II. Epidemiology
- Number of obese children and adolescents in U.S. trippled between 1980 and 2000
-
Prevalence in U.S. (2020)
- Overweight between age 2 to 19 in 2020: 19.7% (was 12% in 1994)
- Severe Obesity overall: 6.1%
- Age
- Age 2 to 5 years: 13%
- Age 6 to 19 years: 22%
- Race
- Mexican American: 26.2%
- Non-hispanic black: 24.8%
- Non-hispanic white: 16.6%
- References
III. Causes: Secondary Causes of Childhood Obesity (<10% of cases)
- Hypothyroidism
- Cushing's Syndrome (Hypercortisolism)
- Primary Hyperinsulinism
- Pseudohypoparathyroidism
- Hypothalamic abnormality
-
Genetic Syndromes with Intellectual Disability
- Prader-Willi Syndrome
- Laurence-Moon or Bardet-Biedl Syndrome
- Borjeson-Forssman-Lehmann Syndrome
- Cohen Syndrome
- Ruvalcaba Syndrome
- Familial Lipodystrophy
-
Genetic Syndromes without Intellectual Disability
- Alstrom Syndrome
- Turner's Syndrome
- Beckwith-Wiedemann Syndrome
- Sotos' Syndrome (cognitive delay may be present)
- Weaver Syndrome
IV. Risk Factors
-
Obesity Risk increases with television viewing time
- Lowest Prevalence for <1 hour/day: 8% Obesity
- Highest Prevalence for >4 hours/day: 17% Obesity
- Crespo (2001) Arch Pediatr Adolesc Med 155:363 [PubMed]
- Obesity in child's parent
- Decreased Physical Activity
- Physical Activity is inversely related to Obesity
V. Evaluation
- See Cardiac Risk Factors
- See Daily Energy Allowance
- Blood Pressure
-
Body Mass Index (BMI) for age
- See Body Mass Index
- BMI 85 to 95%: Overweight
- BMI 95 to 120%: Obesity
- BMI >120%: Severe Obesity (or BMI>35 kg/m2)
VI. Labs
- Lipid profile
- Indications for suspected secondary cause evaluation
- Short Stature (<5th percentile)
- Minimal to no Family History of Obesity
- Intellectual Disability
- Delayed Bone Age
- Physical findings suggest secondary cause
VII. Complications
- See Obesity Risk
- Slipped Capital Femoral Epiphysis
- Tibia vara
- Adult Obesity (high risk)
- Medical Conditions
VIII. Management: Lifestyle
- See Prevention measures below
- Lifestyle modification is indicated and the base for all weight loss strategies
- Significant Obesity (BMI>95%) is an indication for Intensive management
- Set reasonable weight loss goal
- Monthly: 1 to 4 pound loss
- Month 3 to 6: 5 to 10 pound loss
- Employ 5-2-1-0 approach to lifestyle change
- Fruits and vegetables 5 or more
- Maximum recreational Screen Time limited to 2 hours or less
- Physical Activity of 1 or more hours per day
- Sugary drinks per day 0
- Adequate sleep
- Establish Dietary Guidelines
- See Food Pyramid
- Calculate Daily Energy Allowance
- Approximate a 500 calorie deficit per day
- Establish regular Exercise
-
Behavior Modification
- Stimulus control
- Modify eating habits
- Attitude change
- Reward positive new behaviors
- Involve family in Weight Reduction program
- Parent nutritional counseling
- Family activity
- Family television viewing limited
IX. Management: Obesity Medications
- Indications
- Age >12 years with severe, refractory Obesity
- Consider in age>8 years old
- Specific Medications (with FDA approval in children)
- See Obesity Medication
- Phentermine (age >=16 years)
- Orlistat (age >= 12 years)
- Poorly tolerated with leaking of greasy, foul smelling stools
- Phentermine/Topiramate (Qysmia) age >= 12 years (Teratogenic, withdrawal risk)
- BMI decreased >8% at 52 weeks on moderate dose (>10% on high dose)
- Kelly (2022) NEJM Evid 1(6):10.1056 +PMID: 36968652 [PubMed]
- Liraglutide 3 mg (age >= 12 years)
- BMI decreased >4% at 52 weeks
- However, weight gain is significant on stopping (likely applies to GLP1 Agonist)
- BMI returns to 1% below Placebo at 6 months after stopping medication
- Kelly (2020) N Engl J Med 382(22):2117-8 +PMID: 32233338 [PubMed]
- Semaglutide 2.4 mg (age >= 12 years)
- BMI decreased >16% at 68 weeks
- Nausea and Vomiting occurs in 36 to 42% of patients
- Weghuberj (2022) N Engl J Med 387(24):2245-57 +PMID: 36322838 [PubMed]
- Setmelanotide (age>= 6 years)
X. Management: Bariatric Surgery
- Indications: Age >=13 years
- BMI >40 kg/m2 or 140% of 95th percentile
- BMI >35 kg/m2 or 120% of 95th percentile AND significant comorbidity
- Youth Onset Type 2 Diabetes Mellitus (Y-T2DM)
- Obstructive Sleep Apnea (AHI >5)
- Blount's Disease
- Significant Gastroesophageal Reflux Disease
- Nonalcoholic Steatohepatitis (NASH)
- Slipped Capital Femoral Epiphysis (SCFE)
- Idiopathic Intracranial Hypertension (IIH)
- Additional Requirements
- Obesity refractory to other intensive weight management (lifestyle, medications)
- Supportive family environment
- Capable and willing to follow postoperative nutritional guidelines
- Committment to comprehensive pre- and postoperative medical and psychologic evaluations
- Bariatric Surgery Procedures in Teens
- Adverse Effects
- See Bariatric Surgery
- Associated Vitamin Deficiency, decreased Bone Mineral Density
- Reintervention rates approach 25%
- Efficacy
- Significant sustained weight loss and clearance of comorbidities
- References
XI. Prevention
- Provide balanced diet (see Food Pyramid)
- Maximize child's Dietary Fiber intake
- Eat 5 or more fruits and vegetables per day
- Eliminate excessive fat and sugars
- Limit fat calories to <30% of total calories
- Replace whole milk with skim milk at age 2 years
- Avoid fast-food and "junk-food" (e.g. potato-chips, twinkies)
- Avoid sugar-sweetened drinks (e.g. Gatorade, soda, fruit drinks)
- Limit high calorie foods in home
- Encourage healthy eating behaviors
- Eat meals as a family at least 5 days per week
- Limit eating out (esp. fast food restaurants)
- Do not skip breakfast
- Use appropriate food portions
- Food should not be used to comfort or reward child
- Treats should not be used to reward finishing a meal
- Child does not need to "clean plate": stop with satiety
- Encourage activity
- Limit television, computer and video games to 2 hour or less per day
- Do not keep a television in the child's room
- Foster active play and family Exercise for >30-60 minutes per day
XII. Prognosis
- Children with Obesity will continue with Obesity as adults in 82% of cases
- Longterm multisystem complications of Childhood Obesity and the associated Youth Onset Type 2 Diabetes Mellitus (Y-T2DM)
- Y-T2DM is associated with longterm Hypertension, Chronic Kidney Disease and Hyperlipidemia in >50%
- Bjornstad (2021) N Engl J Med 385(5):416-26 +PMID: 34320286 [PubMed]
XIII. Resources
- Shapedown Pediatric Obesity Program (Ages 6 to 20)
- http://www.shapedown.com
- Phone: 415-453-8886
- Children's Hospital of Pittsburgh
XIV. References
- (2023) Presc Lett 30(6): 33
- Kreipe (1998) Adolescent Health Update 10(2):1-8
- Kumar (2024) Mayo Clinic Pediatric Days, attended lecture 1/17/2024
- Moran (1999) Am Fam Physician 59(4):861-8 [PubMed]
- Rao (2008) Am Fam Physician 78(1): 56-66 [PubMed]
- Spiotta (2008) Am Fam Physician 78(9): 1052-8 [PubMed]
- Williams (1997) Ann N Y Acad Sci 817:225-40 [PubMed]