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Patient Guide to the Prevention and Management of Pediatric Obesity

	Why were the guidelines written?

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This patient guide is based on clinical guidelines written to help physicians who are evaluating and treating obese children and adolescents. The number of U.S. youth who are overweight or obese has risen dramatically over the past three decades. Although percentages vary among different ethnic groups, currently about 17% of children are obese. Obesity in children and adolescents leads to a variety of diseases. For example, before the epidemic of obesity, diabetes in adolescents was almost always Type 1 (requiring insulin) but now Type 2 diabetes (usually associated with older adults) accounts for 30% of newly diagnosed cases of diabetes in teenagers. Also associated with obesity are sleep apnea (temporary interruptions of breathing during sleep), high blood pressure, high cholesterol, bone and joint problems, and depression.

	How were the guidelines developed?

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The clinical guidelines were developed after an extensive review of the best human research studies related to the diagnosis, treatment, and prevention of pediatric obesity. An expert panel of The Endocrine Society examined studies that were published in "peer-reviewed" medical journals (i.e., studies that were evaluated by other scientists). The panel rated the quality of the studies and gave the highest rating to randomized (assigned into treatment groups by chance) and placebo-controlled studies.

Once the panel reached an agreement about their "recommendations" and "suggestions," the guidelines were reviewed by the general membership and approved by several of the Society’s committees of The Endocrine Society. The development of these guidelines was not influenced by pharmaceutical or other business concerns.

	How are overweight and obesity diagnosed in children?

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Defining childhood overweight and obesity is difficult. Most definitions of obesity use the body mass index (BMI) to measure body fat. BMI is calculated as weight in kilograms divided by height² in meters; or the weight in pounds times 703, divided by the height² in inches. In adults, a BMI of 25 to 30 is overweight and over 30 is obese. However, BMI varies with age and gender in children, so the BMI is plotted on a curve of normal children to determine overweight or obesity. A BMI-for-age higher than that of 85% of children of similar age indicates overweight; a BMI-for-age higher than that of 95% indicates obesity.

	What should you do if your child is diagnosed as obese?

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Childhood obesity is a serious matter. Having excess fat should not be dismissed as a condition the child will grow out of, something "in the genes," or a merely cosmetic concern. Obese children become obese adults, with increased chance for early death. Your recognition of the problem and support in tackling it are essential to your child’s life and health.

Addressing childhood obesity early will help lead to a healthier and longer life as an adult.

	How is pediatric obesity treated?

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Lifestyle changes

The panel recommended that clinicians prescribe and support lifestyle (diet and activity) changes for the patient, in an age-appropriate manner, and for the entire family.

Healthy eating habits include:

Controlling caloric intake through portion control

Avoiding the consumption of calorie-dense, nutrient-poor foods (e.g., sweetened drinks (such as soda, juice and sports drinks ), most "fast food," and high-calorie snacks such as chips and candy)

Increasing dietary fiber, fruits, and vegetables

Eating regular meals, particularly breakfast, and avoiding "grazing" after school

Energy intake (calories) is only half of the equation governing weight gain; the other half is energy output (physical activity). The panel recommended that children engage daily in 60 minutes of vigorous physical activity, and that they spend no more than 1 to 2 hours daily watching television, playing video games, talking or texting on cell phones, or using the computer for fun.

Psychosocial changes

Parents should promote healthy habits related to diet and activity. For example, it is important for parent to be an example of these healthy lifestyles, avoid overly strict dieting, avoid use of food as a reward or punishment, and try to build children’s self-esteem. A positive approach works best. Parents should encourage healthy eating and regular exercise without developing a fear of food. This is the first step in establishing the behaviors essential to long-term success.

Children, parents and physicians should be partners in the care and treatment of obesity. Healthy eating and regular exercise are key.

Medication

The panel suggested that clinicians consider using medication (in combination with changes in diet and exercise) only if a formal program of intensive lifestyle change has failed to limit weight gain or has failed to improve co-existing medical conditions in obese children (those with a BMI-for-age higher than that of 95% of children). Overweight children (those with a BMI-for-age higher than 85% but lower than 95%) should not be treated with obesity medication unless significant, severe co-existing medical conditions continue despite intensive lifestyle modification. In these children, a strong family history of Type 2 diabetes or the presence of risk factors for cardiovascular disease (e.g., high blood pressure, high levels of "bad" cholesterol, low levels of "good" cholesterol) may support the use of obesity medication.

Obesity medications should be prescribed for children only by doctors who are experienced in their use and are aware of the potential for adverse, possibly dangerous reactions to these drugs. There is no sure-fire, risk-free medication for pediatric obesity and the benefits of any drug used to treat childhood obesity should clearly outweigh its risks. In fact, there are several concerns about using medication:

Obesity medications are not FDA approved for children and younger adolescents.

There are few well-controlled studies on safety and efficacy of medications in children.

After about 6 months, medications lose effectiveness and weight loss levels off.

There is a risk of adverse effects of medications in children.

Surgery

Obesity surgery either reduces the size of the stomach, bypasses the small intestine, or both. Surgery can be effective in selected cases, but serious short- and long-term complications can result-including death. The panel recommended against surgery for pre-adolescents, adolescents who have not attained their final height, for pregnant or breast-feeding adolescents, or for those planning to become pregnant within 2 years of surgery. It recommended that surgery never be performed in adolescents with an unresolved eating disorder, untreated psychiatric disorder, or Prader-Willi syndrome.

The panel also suggested that surgery was appropriate only in a few circumstances where all the following situations apply:

For adolescents who have a BMI over 50 (or over 40 with significant, severe obesity-related diseases) and in whom lifestyle modification and medication have failed.

For adolescents who demonstrate the ability to follow a healthy lifestyle.

After psychological evaluation confirms the stability and competence of the family unit.

There is access to an experienced surgeon in a medical center employing a multidisciplinary team, capable of long-term follow-up of the physical and mental health needs of the patient and family, and the institution is either participating in a study of the outcome of bariatric surgery or sharing data.

What can communities do to help prevent obesity?

Many aspects of American life promote obesity: advertising aimed at children that promotes high-calorie, non-nutritious food and drinks; the popularity of "fast food"; large portions served by restaurants; meal patterns of eating on the run and frequent snacking; and sedentary lifestyle.

The cornerstone of obesity treatment is lifestyle modification. Although sticking to changes in diet and exercise can be successful, the rate of long-term success is disappointing. Therefore, prevention is even more important in controlling the current obesity epidemic. The panel suggested the following actions for parents and clinicians:

Promote and practice healthy dietary and activity habits

Advocate that schools provide 60 minutes of moderate to vigorous daily exercise in all grades, restrict availability of unhealthy food choices, and educate children about making healthy lifestyle choices

Advocate policies to ban advertising of unhealthy foods to children

Advocate community redesign to maximize opportunities for safe walking and bike riding to school, athletic activities, and neighborhood shopping

	What can parents do to help prevent pediatric obesity?

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The panel recommended some specific actions that parents can take to prevent obesity. The panel recommended a minimum of 6 months of breast-feeding. Infants exclusively breast-fed for 3 to 5 months are 35% less likely to be obese when they enter school. Babies should be fed when hungry but should not be forced to finish. Between the ages of 2 and 6 years, children often develop irregular eating patterns. They may want to eat the same foods repeatedly and refuse to try new foods. What is important is that the quality and the overall quantity of the food be appropriate and consist of healthy choices. If young children are allowed to decide when to eat and when to stop without outside interference, they will eat as much as they need.

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