With the number of children with obesity at epidemic levels, clinicians need to redouble prevention efforts — and even get involved in advocating policies to fight obesogenic environments.
Prevention is the best hope for combating pediatric obesity because current treatments are limited in efficacy, according to a new Endocrine Society guideline.
“Intensive, family-centered lifestyle modifications to encourage healthy diets and activity remain the central approach to preventing and treating obesity in children and teenagers,” says Dennis M. Styne, MD, chair of pediatric endocrinology at the University of California Davis Health System in Sacramento. Styne chaired the task force that wrote “Pediatric Obesity — Assessment, Treatment, and Prevention: An Endocrine Society Clinical Practice Guideline.”
- Prevention through the well-known lifestyle modifications of a healthy diet and physical exercise remain the best hopes for stemming the epidemic of obesity in childhood because the effectiveness of treatment is limited
- Pediatric comorbidities of obesity are common and should be screened for in a methodical fashion — but endocrine causes of obesity are rare and should only be tested for in cases of attenuated growth.
- The response to pediatric obesity cannot be limited to the clinician’s office, but requires the promotion of societal changes and policies that encourage better diets and more active lifestyles for the entire family.
Childhood obesity is at an epidemic level, affecting 17% of U.S. children between the ages of two and 19 years, so Society leaders wanted to ensure that clinicians had access to the most current information on effective treatments. “Since the Society last issued a pediatric obesity guideline in 2008, there have been more than 1,700 publications on childhood obesity which require attention, so we revised the guideline using the best information available,” Styne says. “There is new information on genetic causes of obesity, psychological complications associated with obesity, surgical techniques, and medications available for the most severely affected older teenagers. The guideline offers information on incorporating these developments into patient care.”
“This epidemic is not going to be solved in a clinician’s office. This problem spans the cities and countries in which children live. It spans public policy, advertising, and all of the things in our daily life that affect the child. Only a political and society-wide change will lead to the diminution of this epidemic.” – Dennis M. Styne, MD, chair, of Pediatric Endocrinology, University of California Davis Health System, Sacramento
The guideline suggests that in addition to BMI, physicians should also “use clinical judgment, because some children will be obese even though their BMI value is below the 95th percentile. You have to examine the child. You can’t just use a number,” Styne says.
New and Noteworthy
Some of the noteworthy new recommendations concern fatty liver disease, fasting insulin tests, and genetic testing.
Physicians should test for comorbidities associated with obesity — with fatty liver disease being among the most common — but clinicians need to be aware of the difference between adult and younger patients. Styne says that physicians need to pay attention to the alanine aminotransferase (ALT) value but be aware that “the standards for children are lower than the standards for adults. The guideline recommends 25 U/L as the cut-off value for boys and 22 U/L for girls, and that is substantially below what you are going to find on your electronic medical record,” Styne says.
The guideline recommends against the common practice of using fasting insulin levels for the diagnosis of comorbidities, particularly insulin resistance, because the test lacks diagnostic value. That finding might surprise some clinicians, according to David B. Allen, MD, professor of pediatrics at the University of Wisconsin School of Medicine and Public Health, Madison. Allen was not on the guideline committee but reviewed it for the Endocrine Society. That measurement “has almost worked its way into standard practice as a way of screening kids for evolving insulin resistance. When the committee looked at the evidence, they felt confident that there was so much variability in this measurement and so little correlation with actual diabetes risk, they recommended that it not be used for routine diagnosis,” Allen says.
Another new suggestion concerns genetic evaluation. The guideline suggests “genetic testing in patients with extreme early onset obesity (before five years of age) and that have clinical features of genetic obesity syndromes (in particular extreme hyperphagia) and/or a family history of extreme obesity.”
The Politics of Prevention
“Prevention is the key to this epidemic, because we have limited tools that have long-term effectiveness to treat children who become obese,” Styne says, so the guideline emphasizes the importance of changing the child’s environment. “This epidemic is not going to be solved in a clinician’s office. This problem spans the cities and countries in which children live. It spans public policy, advertising, and all of the things in our daily life that affect the child. Only a political and society-wide change will lead to the diminution of this epidemic.”
“Unless we reduce the toxicity of the environment for people that are susceptible to obesity, our ability to alter this trajectory is going to be very limited. The sobering underlying message of these guidelines is that part of the work of our profession as endocrinologists must be to step into the policy arena.” – David B. Allen, MD, professor of pediatrics, University of Wisconsin School of Medicine and Public Health, Madison
Allen says that this guideline differs from the previous guideline in “the degree to which the recommendations step into the arena of public health. There are recommendations for policy-driven changes that are necessary to create a healthier environment for children, such as the limitation of access to sweetened beverages and the building of community environments that allow children to safely move around,” he says. “Unless we reduce the toxicity of the environment for people that are susceptible to obesity, our ability to alter this trajectory is going to be very limited. The sobering underlying message of these guidelines is that part of the work of our profession as endocrinologists must be to step into the policy arena.”
Research Hopes for the Future
“It is hard to comprehend how much work went into this guideline,” Allen says. “This was at least three years of work by this task force to do a very systematic, evidence-based analysis of the treatment studies that have been done.”
Despite this accumulation of studies since the previous guideline, the task force notes that there is still a dearth of information on an effective response to the growth in the prevalence of obesity: “Continued investigation into the most effective methods of preventing and treating obesity and into methods for changing environmental and economic factors that will lead to worldwide cultural changes in diet and activity should be priorities.”
Seaborg is a freelance writer based in Charlottesville, Va. He wrote about the Endocrine Society’s new Clinical Practice Guideline on treating hypothalamic amenorrhea in the June issue.
Cosponsored by the European Society of Endocrinology and the Pediatric Endocrine Society, the guideline was published in the March 2017 Journal of Clinical Endocrinology & Metabolism and is available online.
- Youthful patients with a BMI great than or equal to the 85th percentile should be evaluated for related conditions such as dyslipidemia, fatty liver disease, and diabetes.
- However, laboratory evaluations to look for endocrine etiologies of pediatric obesity should only be performed in patients whose height or growth rate is less than expected based on age and pubertal stage. “It is not usually an endocrine problem that causes obesity,” Styne says.
- “We caution against the use of medication unless the child is over 16 years of age,” Styne says. The only medication approved for use in children under 16 is not very effective.
- Evidence is accumulating that bariatric surgery can be effective in the most seriously affected teenagers who have failed at lifestyle modification, so the document delineates its appropriate use. The guideline recommends that surgery should be performed only by experienced teams with resources for long-term follow-up, and only in patients who are physiologically mature and late in their pubertal development. Ten years ago, surgery in adolescents seemed “incredibly radical” Allen says, but with the growing number of youth having obesity, “in this day and age it has to be considered, and may have some value.”
- Physicians should promote healthy eating habits such as avoiding calorie-dense, nutrient-poor foods (such as sugar-sweetened beverages) and consuming whole fruits rather than juices. Children should engage in at least 20 minutes — and optimally 60 minutes — of vigorous physical activity at least five days a week.