Physician's Weekly Article - New Recommendations for Treating Pediatric Obesity

       The Endocrine Society has released new guidelines for managing pediatric obesity. They stress the importance of making lifestyle modifications, initiating pharmacotherapy in appropriately selected patients, and collaborating towards better prevention efforts.

      During the past 30 years, the prevalence of obesity has nearly quadrupled for children between the ages of 6 and 11 and has tripled for children between the ages of 12 and 19. Rates vary among different ethnic groups, but studies have demonstrated that the overall prevalence of childhood obesity is 17.1%. “The increased prevalence of childhood obesity is particularly important because it’s predictive of adult obesity. It’s also associated with an increased prevalence of type 2 diabetes in adolescents,” explains Gilbert P. August, MD. “This is especially problematic because adult obesity has been associated with cardiovascular disease, diabetes, metabolic syndrome, and hypertension.”

      In 2008, the Endocrine Society identified pediatric obesity as an issue of priority and appointed a task force to formulate evidence-based guideline recommendations. Published in the December 2008 issue of the Journal of Clinical Endocrinology & Metabolism and available online at www.endo-society.org, the guidelines summarize the seriousness of pediatric obesity and children who are overweight. They also address the diagnosis of pediatric obesity, available treatments and when to apply them, and measures to prevent overweight and obesity. “This new guideline provides evidence-based recommendations to prevent and treat this growing epidemic,” says Dr. August, who chaired the guideline task force.

      Identifying Key Objectives

      According to the guidelines, the objective of interventions in overweight and obese patients—regardless of age—is to prevent or ameliorate obesity-related comorbidities. “A major concern regarding the increased prevalence of obesity is its association with cardiovascular risk factors, including hypertriglyceridemia, high LDL cholesterol, low HDL cholesterol, hyperinsulinemia, and hypertension,” Dr. August says. “The prevalence of these risk factors increases with the rise in BMI.” The guidelines note that 19% of children and adolescents with a BMI between the 85th and 94th percentile have two or more cardiovascular risk factors and another 5% have three or more. “The presence of cardiovascular risk factors during childhood can lead to an increased incidence of cardiac events in adulthood,” adds Dr. August.

      Assessing Interventions

      The guidelines note that lifestyle changes are the primary mode of treatment for pediatric obesity (Table 1), but Dr. August says these interventions work best if they are applied before children become obese. “Physicians caring for pediatric patients should be alert to excessive weight gain so that they can take measures to prevent or treat these individuals when they’re overweight but not yet obese. Intensive lifestyle modifications are the key prerequisites for any treatment. Such modifications may include prescribing and supporting a healthy diet, promoting regular physical activity, and modifying behaviors.”

      Pharmacotherapy, in combination with lifestyle modification, is suggested for obese children who have failed a formal program of intensive lifestyle modification alone. It is also suggested for overweight children if severe comorbidities persist despite intensive lifestyle modification. “The key is to make efforts to ensure that the proper support systems at home are in place,” Dr. August says. “Parents of obese children need to be on board with these efforts and be educated on treatment options. Pharmacotherapy for pediatric obesity can help, but it will be effective only if it’s used in conjunction with lifestyle changes.”

      Bariatric surgery is also suggested for adolescents with a BMI greater than 50 kg/m² or a BMI greater than 40 kg/m² with severe comorbidities in whom lifestyle modification and/or pharmacotherapy have failed. “Careful patient selection for bariatric surgery is important, especially in children,” says Dr. August. “Obese children and their parents should receive preoperative psychological evaluations, and patients should demonstrate that they can continue a program of lifestyle modifications after surgery.”

      Prevention Efforts Critical

      Dr. August says it is better to prevent obesity rather than to treat it once it has occurred. “The guidelines detail treatments for pediatric obesity, but also emphasize the importance of prevention [Table 2]. For example, physicians should provide ‘anticipatory guidance’ to at-risk families and inform them about the potential problems that may manifest down the road,” says Dr. August. Recommendations for schools are also included in the guidelines. One recommendation is to promote 60 minutes of moderate to vigorous exercise every day for students in all grades. Another recommendation is that school systems alter the food choices available in their cafeterias. “Physicians can play a key role in these community efforts,” adds Dr. August. “By engaging in the local community, physicians can be proactive in the fight against pediatric obesity.”

      Gilbert P. August, MD, has indicated to Physician’s Weekly that he has or has had no financial interests to report.