TORONTO — Diet and exercise remain the first-line treatment for overweight and obese children, according to guidelines on the diagnosis, treatment, and prevention of pediatric obesity developed by the Endocrine Society.
Although selective patients may be candidates for pharmacotherapy or bariatric surgery, lifestyle modification remains the basic treatment modality, said Dr. Gilbert P. August, chair of the expert panel that developed the guidelines.
“Prevention of obesity should be the prime directive,” said Dr. August, a pediatric endocrinologist and professor emeritus of pediatrics at George Washington University, Washington.
At press time, the pediatric obesity guidelines had been submitted for publication. The guidelines include both recommendations and suggestions; suggestions are given in cases where the evidence is weaker. Dr. August offered a preview of the guidelines at the annual meeting of the Endocrine Society.
The prevalence of obesity, defined as having a body mass index (BMI) over the 95th percentile for age and sex, is about 17%, representing a fourfold increase among 6- to 11-year-olds, a threefold increase among 12- to 19-year-olds, and nearly a threefold increase among 2- to 5-year-olds, versus a survey done from 1963 to 1970.
“It is important to look at childhood obesity as a possible precursor of adult obesity and institute corrective measures as soon as possible,” Dr. August said.
The diagnostic recommendations include using the normative percentiles for BMI developed by the Centers for Disease Control and Prevention. The panel also recommended against a routine endocrine evaluation in obese or overweight children unless the growth rate of the child is attenuated.
However, the panel is recommending a referral to a geneticist when the obesity is associated with neurodevelopmental abnormalities. The panel is also suggesting that parents be informed about the possibility of MC4R genetic testing if the child has gained weight from early infancy and is over the 97th percentile for weight at 3 years of age. But keep in mind that test results are positive in only 2%–4% of such children and will not change the treatment, Dr. August said.
Children whose BMIs are above the 85th percentile should be evaluated for comorbidities, according to the guidelines. Screening tests and measurements should include fasting plasma glucose, fasting lipid profiles, blood pressure, and waist circumference.
In terms of treatment, the committee is recommending lifestyle modification as the “cornerstone” for treatment of overweight and obesity in children.
The approach of diet and exercise has a bad reputation, Dr. August acknowledged. There are a number of obstacles to implementing lifestyle approaches effectively, including denial on the part of the family.
Pharmacotherapy can be added after failure of a 6-month trial of diet and exercise in overweight and obese children, the committee suggests. But when considering pharmacotherapy in the overweight child, the child should have significant comorbidities to justify the risk. In addition, the family needs to understand that the medications available have waning effectiveness after 6 months.
The expert panel also suggests the use of bariatric surgery only after failure of a 6-month trial of lifestyle modification with or without a trial of pharmacotherapy in adolescents who have a BMI of over 40 and severe comorbidities. This treatment also can be considered in adolescents with a BMI over 50, Dr. August said.
But the panel adds a number of caveats. For example, the family must undergo psychological evaluation and the surgical team must have adequate pediatric experience and have personnel available capable of handling the metabolic and psychosocial needs of the entire family.
The committee members also suggest that primary care physicians offer more education on obesity and healthy eating.