Comprehensive, Family-Focused Care Needed to Manage Pediatric Obesity

To most effectively reverse undesirable body weight in children, clinicians will need to employ a multifaceted approach of diet, physical activity, behavior modification, and education, involving the entire family.

With Caroline Apovian, MD, and J. Michael Gonzalez-Campoy, MD, PhD

Not surprising, the best overall approach to reducing excessive body weight in children will be to employ a comprehensive regimen of diet, physical activity, behavior modification, and education.

Obesity is a multisystem disease.1 Current estimates indicate that children are twice as likely to remain obese as adult than those who do not experience undesirable weight gain during childhood.2

Endocrinologists and pediatricians who see children with adiposity-based chronic diseases (ABCD) need evidence-based recommendations if they are to reverse the lifelong biopsychosocial challenges faced by this population. There is an urgent need realize which strategies are effective and consistent with the needs, preferences, and abilities of parents and their children. As such, the Endocrine Society task force was charged with assessing the efficacy of the treatments to date as a basis for formulating clinical guidelines.

While a variety of approaches may improve metabolic and anthropometric outcomes, a multipronged regimen offers the best chance of managing childhood obesity, but various individual interventions may also be successful,3 according to the authors of the Treatment of Pediatric Obesity: An Umbrella Systematic Review. However, the vast majority of data were deemed low quality.

Overall, comprehensive, nonsurgical approaches that combined dietary improvements, a physical activity plan, lifestyle education, and behavioral therapy achieved the best outcomes in terms of weight reduction and improved metabolic metrics, including systolic and diastolic blood pressure and triglycerides.  

Assuring children avoid obesity requires a family-oriented, comprehensive approach of diet, exercise and behavior.

While obesity may originate from poor lifestyle factors, it rapidly becomes an issue of energy-balance dysregulation due to impaired hypothalamic signaling.5 The pediatric guidelines do not give sufficient consideration to the role of genetics as impacted by the environment even as most clinicians recognize the futility of lifestyle changes to reverse obesity.5

Despite these findings, “because of the paucity of treatment options for pediatric obesity, efforts to combat this epidemic should remain focused on prevention,” Caroline M. Apovian, MD, director of nutrition and weight management at Boston Medical Center, told EndocrineWeb.

Guidelines for Prevention of Pediatric Obesity

Focusing on the preventive strategies highlighted in the guidelines,4 clinicians are urged to:

  • Promote and participate in ongoing healthy dietary and activity education of families, and communities including schools.
  • Prescribe and support healthy eating that emphasizes whole fruits rather than juices and other sugar-sweetened beverages, and avoid calorie-dense, nutrient void foods, including highly processed and fast foods.
  • Advise at least 20 minutes, but aiming for 60 minutes, of physical activity most days of the week.
  • Assess sleep patterns to assure adequate, restorative sleep is realized; as well as family stressors, which may hinder successful outcomes.
  • Recommend limits to screen time that does not supersede opportunities for physical activity.

Results of a Systemic Review of Obesity Treatments

Findings from this umbrella review, encompassing 16 published systematic reviews of 133 randomized controlled trials, and 30,445 participants, confirmed that the strongest support exists for a multipronged strategy to reduce body weight in children.3 However, surgery and pharmacotherapy also appear helpful in reducing outcomes such as diabetes and body mass index (BMI), for some children. Only interventions that were maintained for 6 months or more were included in the evaluation.

J. Michael Gonzalez-Campoy, MD, PhD, medical director and CEO of the Minnesota Center for Obesity, Metabolism, and Endocrinology, in Eagan, Minnesota, told EndocrineWeb, the findings from this study are a “welcome addition to the literature that drives home several key points.”

Such as, “childhood adiposity (or, ABCD) with associated clinical manifestations occurring at such young age, creates an increased life-long risk for these patients,” Dr. Gonzalez-Campoy said. “And, as with any other chronic disease, these patients need to be engaged in their care as early in the disease process as possible, and care should be ongoing, for life.”

What’s more, he added, as is true with other pediatric conditions, parental involvement and support is critical to achieving successful lifelong management. “Not only do children need oversight and transportation, but also the financial resources of parents to be able to access the necessary clinical care,” he said, as well as the means to create a supportive home environment.

“Several childhood obesity interventions are effective in improving metabolic and anthropometric measures. A comprehensive multicomponent intervention, however, appears to have the best overall outcomes,” the authors wrote in the Journal of Clinical Endocrinology and Metabolism.  

Among children ages 6-11, obesity more than doubled between 1980 and 2012, climbing from 7% to 18%; among those ages 12-19, obesity quadrupled, from 5% to nearly 21% during the same period.3

Endocrinologists currently lack evidence-based recommendations for the management of obese children. The Endocrine Society convened a task force to develop such guidelines, and the new review is intended to evaluate the strength of evidence regarding the most commonly utilized treatments.  

The Basis for Obesity Interventions

The researchers, from Mayo Clinic, in Rochester, Minnesota, screened 388 systematic reviews, excluding all but 16 studies involving more than 30,000 obese children.3 They used the Grading of Recommendation, Assessment, Development, and Evaluation (GRADE) method to analyze the strength of interventions.

Among their key findings,3 clinicians are urged to focus on 3 strategies:

  1. Physical activity, such as playing sports and getting aerobic exercise, reduced systolic blood pressure and appeared to lower fasting blood glucose. However, exercise alone – without dietary improvements or an educational intervention, for example – lowered blood pressure but not body mass index (BMI).
  2. Surgery led to the steepest losses in BMI.  However, the evidence for surgery, while of moderately high quality, came from a single trial in a small group of children. Moreover, the extent and severity of complications in surgery for this population of patients are not well understood, the authors concluded.
  3. Several medications, including FDA-approved products such as orlistat, can produce substantial reductions in BMI whereas the benefits of metformin, which some clinicians prescribe off-label to counter overweight and obesity are minimal, so the recommendation is that the drug should be used only in children at least 10 years of age or older.

"The authors fell short in citing only a single small study on bariatric surgery in adolescents," said Dr. Apovian, "because this approach offers the best promise for sustained weight loss for a critical and growing number of teens.5,6 We know this from results of the Teen-Longitudinal Assessment of Bariatric Surgery study (Teen-LABS)a multicenter prospective study, which demonstrated a mean weight loss of 27% and remission of type 2 diabetes in 95% of participants, among other invaluable health outcomes."

"Because lifestyle interventions early in childhood may be effective, these should be instituted," she continued. "But for adolescents with severe obesity for whom the usual care has failed, bariatric surgery should be considered before they reach adulthood when some conditions will be much more difficult to reversible."

Focus on Nutrition Intervention, Healthy Eating

 "Every living creature is on a diet. We do not put people on diets—to the public that just means what not to eat. We do use nutritional interventions to modify chronic diseases, so children and their families need to be taught what to eat," said Dr. Gonzalez-Campoy. "By explaining to people how to eat healthily, understand good nutrition, and learn effective meal planning, they will gain the critical components of nutrition intervention, which is needed to prevent and treat overweight and obesity.

In conclusion, the evidence-based guidelines recommend that clinicians adopt strategies to deliver a comprehensive behavior-changing, lifestyle focused intervention to both prevent and manage ABCD that reaches the entire family, not just the child.

"In the absence of sufficient data, we have to individualize care for pediatric patients with or at risk for obesity and act to treat the disease beyond nutrition and physical activity," urged Dr. Gonzalez-Campoy.

To review the full Pediatric Obesity Management Guidelines, go to: J Clin Endo Met.

 This study was partially funded by the Endocrine Society. The authors had no financial conflicts to disclose.

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