Obesity in children

Overview 
Theory 
Diagnosis 
Management 
Follow up 
Resources 

Effective treatment strategies for childhood obesity are important, since children with obesity tend to become adults with obesity, and they have significant health risks related to the obesity.[39][59] While still growing, some overweight children may be able to maintain or reduce their rate of weight gain, thereby allowing normal growth and development while lowering their BMI percentile.

Treatment modalities include healthy lifestyle modifications (e.g., dietary changes, increases in physical activity, and decreases in sedentary behaviors), pharmacotherapy, and metabolic/bariatric surgery.[3][59][85][86][87] [ ] There is evidence that more intensive interventions such as pharmacotherapy and metabolic/bariatric surgery are more effective.[86][88][89]

The American Academy of Pediatrics (AAP) recommends that medications should be offered to adolescents 12 years or over with obesity, in line with indication and risks, alongside lifestyle and behavior treatment. The use of medications can also be considered in children with obesity 8-11 years with other risk factors, however evidence is currently insufficient in children under 12 years.[3]

The AAP also outline criteria for consideration for pediatric metabolic and bariatric surgery as a BMI of ≥40 kg/m² or 140% of the 95th centile for age and sex (whichever is lower), or if there are comorbid conditions a BMI ≥35 kg/m² or 120% of the 95th centile for age and sex (whichever is lower); age is not included as a sole determinant of eligibility for surgery but data is limited in the younger age group and therefore additional research is needed particularly for recommendations to be made for children ages 12 years and younger.[3]

Although research into obesity in children is growing, there remain many barriers to delivery of effective obesity treatment. One review of Cochrane reviews found that interventions for treating children and adolescents with overweight and obesity were less likely to be undertaken in culturally diverse populations, in those with complex health needs or disabilities, nor in those living with social disadvantage, all of which might make adherence to standard therapies more challenging.[90] This should be taken into consideration when considering the individual management of patients. Additionally interventions should be financially sustainable, and should utilize innovative strategies in order to keep children and their families engaged throughout the process.[86]

Lifestyle modification

Lifestyle modification is one of the cornerstone treatments for all children with a body mass index (BMI) ≥85th percentile.[3] [ ]

Lifestyle modification includes education around diet and physical activity, plus behavioral therapy, so that children and their families can make and sustain changes.[3][57][84]

Lifestyle interventions lead to significant weight loss and improved cardiometabolic parameters, compared with no treatment: BMI (-1.25 kg/m², 95% confidence interval [CI] -2.18 to -0.32) and BMI z score (-0.10, 95% CI -0.18 to -0.02).[87]

Intensity of lifestyle modification treatment is variable but the main factor found to contribute to effectiveness is the intensity (or dose) of the intervention, measured in hours of face-to-face contact. The number of hours delivered is directly proportional to the likelihood that a child will experience a reduction in BMI.[3] For example, the US Preventive Services Task Force found that ≥52 hours per year was associated with a difference in change in BMI z-score from baseline of -0.31, while 26 to 51 hours was associated with a difference in change in BMI z-score from baseline of -0.17 (this was 0.01 for 6 to 25 hours and -0.09 for 1 to 5 hours, respectively).[82] It may be delivered through regularly scheduled visits in primary care, with assistance from dieticians and clinicians with experience in behavior change/motivational interviewing, or through weekly visits to a dedicated pediatric weight management team, or as an in-hospital/residential program. Escalation to more intensive weight management programs depends on the child's age, response to treatment, risk factors, and motivation, among others.[3]

In-hospital lifestyle modification programs may be effective for children with obesity susceptibility gene loci, indicating the importance of addressing environmental, social, and behavioral factors.[91]

It is imperative that the parents and family also adopt healthy lifestyle habits and shared decision making for the child to have success with weight maintenance or weight loss.[3][92]

Diet

Children should be encouraged to eliminate sugar-sweetened beverages, decrease portion sizes, and limit both energy-dense and fast foods.[3][59][93][94][95][96][97] Eliminating sugar-sweetened beverages from the diet has been shown to significantly reduce caloric intake and obesity.[3][95]

Diets rich in fruits and vegetables should be suggested, and healthy food choices should be offered in the school.[94] Family meals should be encouraged. More frequent family meals are associated with a higher intake of fruits and vegetables, and a lower intake of fast food and takeout food, in US adolescents.[98] If possible, unhealthy foods should be removed from the home.

US nutritional guidelines encourage all children to consume nutrient-dense foods, including fruits, vegetables, wholegrains, beans, peas, lentils, eggs, seafood, unsalted nuts and seeds, fat-free and low-fat dairy products, and lean meats (prepared without added sugar, salt, and saturated fats).[97]

Advise regular meals to avoid grazing and snacking, and provide education on portion control.[84]

Physical activity

Children should be encouraged to get at least 60 minutes of physical activity per day.[3][93][97][99] The activity should be age appropriate and fun for the child, to encourage compliance.[58] Play activities such as climbing or playing catch or tag are encouraged. Physical activity improves cardiovascular fitness, muscle fitness, weight status, and bone health. It has additional benefits for cognition and behavior: increased physical activity has been associated with better academic performance, reduced risk of smoking, and reduced risk of depressive symptoms.[58]

Family involvement in promoting physical activity is encouraged. Parents and caregivers have an essential role in modeling healthy behaviors and setting realistic goals.[58]

Television viewing and other discretionary screen time (e.g., computer and video games, internet) should be limited. The American Academy of Pediatrics recommends no media use in children under the age of 18 months, a 1 hour limit for ages 2-5 years old and a parent-monitored plan for media use in older children.[3] The American Heart Association recommends:[100]

Removing screens from bedrooms and during meals
Encouraging daily device-free social interactions and outdoor play
Supporting parents to enforce limitations on screen time and to set a healthy example of screen-based behavior.

Children with obesity often experience personal barriers to movement and exercise, including mobility barriers. Therefore, tailoring and adapting pediatric exercise interventions will often be necessary, particularly for those that report musculoskeletal pain, high rates of fatigue, urinary incontinence, skin chafing, or have impaired motor skills or other conditions (e.g., muscular dystrophy, immobility, etc).[8]

Behavioral therapy

Support to make and sustain changes in the child's and family's behavior is a key component of lifestyle modification.[3][57][84]

Components of behavioral therapy may include:[3][8][57][84]

Identifying eating cues such as boredom, stress, loneliness, or screen time
Goal setting
Rewards for reaching goals
Self-monitoring behavior
Involving parents/caregivers in modeling desired behaviors.

There is moderate-quality evidence that multidisciplinary interventions, combining diet, physical activity, and behavioral components, reduce weight in adolescents who are overweight or have obesity, compared with no intervention or usual care.[101] [ ]

The effect of family- and parent-based weight loss treatments on child weight loss were compared in a randomized trial of 150 children with obesity or who were overweight (8 to 12 years old) and their parents, over a period of 24 months. Weight loss treatment was delivered in 20 one-hour group meetings with 30-minute individualized behavioral coaching sessions over 6 months, with or without the child present. Parent-based treatment was shown to be noninferior to family-based weight loss treatment.[102]

Motivational interviewing

A patient-centered counseling style which focuses on shared decision making and the patients’ self identified motivations for change, in contrast with a more traditional healthcare professional led approach. It aims to result in a particular behavior change, such as reducing intake of a particular food or having more meals together as a family. Motivational interviewing consists of four processes:

Engaging: establishing a relationship and collaborative role; understanding patient issues
Focussing: identifying appropriate strategies to change weight
Evoking: highlighting motivations for change; empowering patients to make change
Planning: completing effective plans for change; appropriately managing relapse

Psychosocial comorbidities

Associated psychosocial problems (e.g., bullying, teasing, low self-esteem) or psychiatric conditions (e.g., anxiety, depression) should be sought and treated.[84]

Pharmacotherapy

Following conservative measures, treatment may include medication, with ongoing intensive lifestyle modification support. The American Academy of Pediatrics (AAP) recommends that pharmacotherapy should be offered to adolescents 12 years and over with obesity, in line with indication and risks, alongside lifestyle and behavior treatment. The use of medications can also be considered in children with obesity 8-11 years with other risk factors, however evidence is insufficient in children under 12 years.[3]

Orlistat

Inhibits fat absorption through the inhibition of enteric lipase, and is approved for children ≥12 years of age.[103]
In clinical trials of orlistat in adolescents, BMI change ranged from -0.55 kg/m² up to -4.09 kg/m².[104]
Adverse effects include steatorrhea, fecal urgency, and flatulence, which limits its use in children.[3]

Liraglutide

Glucagon-like peptide-1 (GLP-1) agonists decrease hunger by delaying gastric emptying and by acting on targets in the central nervous system.
Liraglutide is approved in the US and Europe for chronic weight management in children 12 years and older with obesity (i.e., body weight above 60 kg and an initial BMI corresponding to ≥30 kg/m² for adults by international cutoffs), in addition to a reduced-calorie diet and increased physical activity.
One randomized controlled trial found that liraglutide plus lifestyle therapy is more effective for weight loss than placebo plus lifestyle therapy.[105] In the study of 251 adolescents with obesity, conducted over 3 years, 43% of participants in the liraglutide plus lifestyle therapy group achieved a 5% reduction in body mass index (BMI), and 21% achieved a 10% reduction in BMI. In the placebo plus lifestyle therapy group, 19% of participants achieved a 5% reduction in BMI, and 8% achieved a 10% reduction in BMI.[105]

Semaglutide

Another GLP-1 agonist which is approved in the US and Europe for chronic weight management in children 12 years and older with an initial BMI ≥95th percentile for age and sex as an adjunct to diet and exercise.
One phase 3 clinical trial including 201 participants (all except one with BMI ≥95th percentile) demonstrated a 16% decrease in BMI in treated participants as compared to the placebo group after 68 weeks. At the end of the study, 73% of those treated with semaglutide lost at least 5% of their starting body weight.[106]
Common adverse effects include nausea, vomiting, and diarrhea.

Metformin

Metformin inhibits hepatic gluconeogenesis and is commonly used in the treatment of type 2 diabetes mellitus (DM) in children 10 years and older. The evidence for effectiveness of metformin for weight loss in children is conflicting and is not approved for the treatment of obesity in children.[3] Some studies demonstrate the benefit of adding metformin in mitigating the weight gain seen in children and adolescents.[88][107] Those studies that did demonstrate effect typically included higher doses, more intensive lifestyle adjunct treatment and use in children with more severe obesity and/or a secondary diagnosis.[3]
One systematic review investigated the efficacy of metformin in treating obesity in children without type 2 DM. At 6 months, children prescribed metformin experienced an average BMI reduction of -1.38 kg/m² (95% CI -1.93 kg/m² to -0.83 kg/m²). However, reduction in BMI was considered to be modest, and metformin was not clinically superior to other options for treating childhood obesity.[108]
A subsequent randomized controlled trial reported a decrease in BMI with metformin, compared with placebo, in prepubertal children, but not in pubertal children.[109] Further, larger studies are required.
The AAP suggests that metformin can be considered as an adjunct to intensive health behavior and lifestyle treatment when other indications for use of metformin are present.[3]

Phentermine/topiramate

Phentermine is an anorectic that decreases appetite and topiramate is an anticonvulsant with weak carbonic anhydrase inhibitor activity that induces weight loss. Although the precise mechanism of action in weight loss is currently unknown, it has been hypothesized to be secondary to dopamine, GABA and glutamate alterations.[110][111]
The combination of phentermine/topiramate is approved in the US for the treatment of obesity in adolescents (12-17 years old) with an initial BMI in the 95th percentile or greater standardized for age and sex.
A study of the pharmacokinetic and pharmacodynamic properties of a fixed-dose combination of phentermine/topiramate conducted in adolescents with obesity demonstrated statistically significant weight loss.[112][113] However, adverse effects include depression and difficulties with concentration and memory, which may limit its usefulness in adolescents. Topiramate can cause fetal harm in pregnant women, and has been demonstrated to show an increase in oral clefts with first trimester exposure to topiramate.[114]

Metabolic/bariatric surgery

Treatment for children with severe obesity may include bariatric surgery, with ongoing intensive lifestyle modification support with or without medication.

Guidelines suggest that surgery is considered in children with BMI ≥40, or BMI ≥35 with clinically significant comorbidities.[3][115] Clinically significant comorbidities include: obstructive sleep apnea, type 2 diabetes mellitus, idiopathic intracranial hypertension, nonalcoholic fatty liver disease, Blount disease, slipped capital femoral epiphysis, GERD, and hypertension.[115]

Surgery does not negatively impact pubertal development, and therefore a specific Tanner stage and bone age should not be considered a requirement for surgery.[116]

Numerous risk factors associated with cardiovascular disease have been shown to improve among adolescents with severe obesity undergoing bariatric surgery. Increased weight loss, female sex, and younger age predict a higher probability of resolution of specific cardiovascular risk factors.[117] Clarifying predictors of change in these risk factors may help identify patients and optimize the timing of adolescent bariatric surgery to improve clinical outcomes.[117]

One study that modeled the effect of adolescents with or without a psychiatric diagnosis found no association between preoperative psychiatric diagnoses and postsurgical weight loss outcomes.[118] The results of this study suggest that psychiatric problems should not necessarily be a contraindication to surgery. Bariatric surgery has been associated with improvement in quality of life and depression.[119]

The surgical approaches used most often are the Roux-en-Y gastric bypass and vertical sleeve gastrectomy - also known as laparoscopic sleeve gastrectomy.[115] One prospective cohort study found that long-term follow-up (7 to 10 years) after vertical sleeve gastrectomy in children and adolescents demonstrates durable weight loss, maintained comorbidity resolution, and unaltered growth.[120] Surgery should only be performed by an experienced surgeon who works with a team capable of following the patient for long-term nutritional or psychosocial issues.

Outcomes of bariatric surgery in the adolescent population are being studied vigorously.[121][122]

Overweight children (BMI ≥85th to 94th percentile)

All children and their families should be supported to make lifestyle modifications.[3][57][84]

Children who have remained at the same BMI percentile over several years, and who do not have other medical risks or family history of obesity, may be at lower risk of excess body fat, as BMI is only an indirect measure of adiposity. The goal of treatment is weight velocity maintenance (or weight maintenance after linear growth is complete) and close assessment for increasing BMI percentiles or development of other risk factors.[64]

Children with additional risk factors (e.g., family history of type 2 diabetes, nonwhite race, and/or conditions associated with insulin resistance such as acanthosis nigricans, polycystic ovary syndrome, hypertension, or dyslipidemia) should receive more intensive lifestyle modification therapy.

Age <6 years[64][85]

The goal of treatment is weight maintenance or slow weight gain
Healthcare professionals should treat overweight comorbidities concurrently
Motivational interviewing is recommended
Intensive health behavior and lifestyle treatment should be considered. It is most effective with at least 26 hours of face-to-face, family-based, multi-component treatment over 3-12 months.

Age 6 to 12 years[64][85]

The goal of treatment is weight maintenance
Healthcare professionals should treat overweight comorbidities concurrently
Motivational interviewing is recommended
Intensive health behavior and lifestyle treatment is recommended. It is most effective with at least 26 hours of face-to-face, family-based, multi-component treatment over 3-12 months.

Age 12 to 18 years[64][85]

The goal of treatment is weight maintenance or gradual weight loss
Healthcare professionals should treat overweight comorbidities concurrently
Motivational interviewing is recommended
Intensive health behavior and lifestyle treatment is recommended. It is most effective with at least 26 hours of face-to-face, family-based, multi-component treatment over 3-12 months.

Children with obesity (BMI ≥95th percentile) and children with severe obesity (BMI ≥120% of 95th percentile)

All children and their families should be supported to make lifestyle modifications.[3][57][84] Escalation to more intensive weight management programs depends on the child's age, response to treatment, risk factors, and motivation among others.[3]