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3. Management and prevention of obesity and its complications in children and adolescents

Jennifer A Batch and Louise A Baur
Med J Aust 2005; 182 (3): 130-135. || doi: 10.5694/j.1326-5377.2005.tb06618.x
Published online: 7 February 2005

Abstract

  • Obesity in children and adolescents has reached alarming levels — 20%–25% of children and adolescents are overweight or obese, and 4.9% of boys and 5.4% of girls are obese.

  • Rates of obesity have increased significantly in Australia from 1985 to 1995, with the prevalence of overweight doubling and obesity trebling.

  • Body mass index (related to reference standards for age and sex) is recommended as a practical measure of overweight and obesity in children, and is used in monitoring individual progress in clinical practice.

  • Obesity in childhood and adolescence may be associated with a range of medical and psychological complications, and can predispose individuals to serious health problems in adult life, including type 2 diabetes, hypertension, dyslipidaemia and non-alcoholic steatohepatitis.

  • Obesity interventions for which there is some evidence include family support, a developmentally appropriate approach, long-term behaviour modification, dietary change, and increased physical activity and decreased sedentary behaviour.

  • Prevention of obesity in children and adolescents requires a range of strategies involving changes in both the microenvironment (eg, housing, neighbourhoods, recreational opportunities) and the macroenvironment (eg, food marketing, transport systems, urban planning).

Behaviour change involving the whole family is more likely to be successful.

The World Health Organization describes the “escalating global epidemic” of obesity as “one of today’s most blatantly visible — yet most neglected — public health problems”.1 Studies of obesity prevalence over time show an increase of 2.3–3.3-fold over about 25 years in the United States and 2.0–2.8-fold over 10 years in the United Kingdom.2

Current estimates in Australian children and young people indicate that 20%–25% are overweight or obese. The 1995 National Nutrition Survey found that 4.9% of boys and 5.4% of girls were obese, and two other studies in 1997 (the New South Wales Schools Fitness and Physical Activity Survey, and the Health of Young Victorians Study) gave similar results.3 There is also evidence that, between 1985 and 1995, the rates of overweight have doubled and those of obesity have trebled.4

Aetiology of obesity: heredity v environment
Genetic factors

Several studies have shown that there is a strong genetic basis to the development of obesity. Obesity appears to be a polygenic disorder, with many genes currently linked or associated with a predisposition to excess adiposity.6 At least five single-gene mutations causing human obesity that present in childhood have been identified. These are rare and all are associated with severe and very early onset obesity, and should prompt referral for further assessment.

Environmental factors

Sedentary behaviour: Physical inactivity is a major element in the development of obesity in westernised societies — in children and adults alike. International studies have shown that television viewing is associated with an increased incidence of new cases of obesity, as well as with a decrease in success rates for obesity intervention.7 Television viewing exposes children to food marketing, increases opportunities for snacking on high-energy foods and drinks, decreases opportunities for physical activity, and reinforces sedentary behaviour. There are as yet no clear data linking viewing of interactive videos, or using computers or other electronic media, with the development of obesity, although they are likely to be associated.

Dietary intake: The increased prevalence of obesity in recent decades may have partly resulted from an increased consumption of high-fat foods or sweetened drinks, although the evidence for a clear effect of diet is not strong. In young children, parental influence on food selection is strong. In older children and adolescents peer influence is also important. Less desirable meal patterns, such as frequent snacking, also appear to be related to established obesity.

Other risk factors for obesity in childhood and adolescence include:

  • Early infant feeding: Breastfeeding is possibly protective for the development of obesity.8

  • Parental obesity, eating patterns, and attitudes: Parental obesity more than doubles the risk of adult obesity among both obese and non-obese children.9 Dietary disinhibition in the mothers of preschoolers is associated with subsequent excess weight gain in their daughters,10 and a 6-year outcome study of children showed that parental dietary disinhibition is associated with greater increases in body fatness.11 Parents who strongly encourage their children to eat have heavier children.12

  • Early adiposity rebound: Earlier adiposity rebound is associated with increased body fatness in adolescence.

  • Socioeconomic status: In some developed countries, poorer children or those who live in rural settings are more at risk of obesity, whereas in countries undergoing economic transition childhood obesity is associated with a more affluent lifestyle and with living in urban regions.

  • Ethnicity: Data from the United States show that there is an increased risk of obesity in Native Americans and Hispanic Americans compared with white Americans, although these differences may be largely related to differences in socioeconomic status.

  • Underlying medical disorders: Secondary obesity may occur with medical conditions, including hypothyroidism, hypercortisolism, growth hormone deficiency and hypothalamic damage.

  • Prescription drugs: Some drugs may contribute to obesity. These include glucocorticoids, antipsychotic drugs (eg, risperidone) and some antiepileptic medications.

Complications of obesity

Childhood obesity is a chronic paediatric disease with possible immediate and long-term complications involving many body systems (Box 1). The National Health and Medical Research Council (NHMRC) Clinical practice guidelines for the management of overweight and obesity in children and adolescents13 provides a comprehensive review of the complications of childhood and adolescent obesity. We will briefly discuss insulin resistance and type 2 diabetes, and steatohepatitis.

Steatohepatitis

Non-alcoholic steatohepatitis (NASH) was first described in 1979 in adults. NASH also occurs in childhood, but is less well characterised. Liver biopsies from obese prepubertal children with NASH may show fatty change, inflammation and fibrosis, with progression to necrosis and cirrhosis.15 Most cases of paediatric NASH are described in older children and adolescents. Elevated serum transaminase levels should raise suspicion of NASH in an obese child or adolescent. If NASH is suspected, referral to a centre specialising in the management of childhood obesity is recommended.

Obesity interventions: the evidence

Established obesity in children and adolescents has proven difficult to treat. A recent Cochrane review of the management of obesity in children and adolescents has shown that there are a limited number of randomised controlled trials.20 Common strategies in the treatment of paediatric obesity for which there is at least some evidence are given in Box 5.

Conventional management of childhood obesity
Developmentally appropriate approach

Treatment of preadolescent obesity with parents as the exclusive agents of lifestyle change appears more effective than targeting the child alone.22 There has been some success with separate sessions for adolescents and parents and structured programs flexible enough to allow input from adolescents.23 There have even been short-term positive outcomes with a phone- and email-based program for adolescent weight management.24

Dietary change

There is some concern that rigid restriction or control of a child’s food intake may trigger disordered eating or, in the young child, reduction in linear height growth. Less prescriptive, lower-energy diets are now used, with an emphasis on all members of the family moving to healthier eating patterns.25 The aim is to provide a flexible program to help the family and the child to make sustainable changes in food choices and eating habits. In general, dietary interventions should emphasise energy reduction, lower-fat food choices, increased vegetable and fruit intake, healthier snacks and decreased portion sizes. Water should be used as the main beverage, and drinks with high sugar content, including soft drinks and fruit drinks, should be limited. The effect of these interventions should be a reduction in total energy intake by reducing the energy density of the diet. Changes in eating habits, shopping practices and types of food for the whole family will support a child’s ability to self-regulate his or her food intake.

Evidence-based practice tips


Levels of evidence (I–IV) are derived from the National Health and Medical Research Council’s system for assessing evidence.35

Intervention type and setting

Several types of interventions have been used to treat childhood obesity: individual counselling sessions, group programs, and sessions given by different types of healthcare professionals.2 Interventions have been conducted in different settings, including primary care, community health centres, tertiary institutions and holiday camps. There is some evidence for the effectiveness of group programs, holiday camps and email- and phone-based behavioural interventions.24

Non-conventional management of childhood obesity
Drug therapy

Sibutramine (Reductil, Abbott): Berkowitz et al29 performed a randomised controlled trial of sibutramine in 82 adolescents with BMI 32–44. The addition of sibutramine to a comprehensive behavioural program induced significantly more weight loss than the behavioural program and placebo; however, 23/82 required a lower dose and 10/82 ceased treatment because of hypertension.

Orlistat (Xenical, Roche): Short-term studies of orlistat in obese adolescents showed good tolerability and weight loss.30

  • The NHMRC guidelines13 suggest that use of both sibutramine and orlistat in obese adolescents with complications should take place only in a specialist centre, and only when there is a reasonable expectation of benefit over risk.

Metformin: Two recent, small controlled trials of the use of metformin in adolescents with hyperinsulinaemia and obesity but no diabetes found that the metformin group had a reduction in hyperinsulinaemia and a modest weight loss compared with the non-metformin group.31,32

  • The NHMRC guidelines13 state that metformin has a potential role in therapy in these adolescents, and that metformin therapy should be considered in obese adolescents with significant hyperinsulinaemia and a family history of diabetes.

Obesity (bariatric) surgery
  • The NHMRC guidelines13 consider bariatric surgery as a last possible option in a severely obese adolescent with obesity-related comorbidity. Assessment for suitability and continuing postoperative care in an experienced weight-management service would be mandatory.

Prevention of obesity

A recently published Cochrane review of interventions for preventing obesity in children concluded that there are “limited high quality data on the effectiveness of prevention programs”.33 However, the published studies do highlight the potential of combining a reduction in sedentary behaviour and an increase in physical activity, as well as the utility of a school-based setting.

The randomised-controlled-trial approach may be inappropriate for large-scale or comprehensive obesity-prevention studies. New approaches to assessing the effectiveness of “real world” obesity-prevention interventions are being developed. Several community-based interventions aimed at preventing obesity and incorporating such approaches are currently under way in a number of countries, including Australia and New Zealand.

Swinburn et al34 introduced the concept of the obesogenicity of modern environments, with the influences promoting the development of obesity operating on micro- and macroenvironmental levels, and having physical, economic, political and sociocultural aspects. Elements in the microenvironment that influence physical activity and food intake include settings where people live, work and study; community facilities (shopping malls, clubs, churches); food retailers and outlets (supermarkets, canteens, lunch bars, restaurants); recreational facilities (parks, pools, gyms); type of neighbourhood (street safety, cycle paths, footpaths); and access to local primary healthcare.

At the macroenvironmental level (ie, beyond the sphere of influence of individuals) factors affecting dietary intake and physical activity include food production, importation, marketing and distribution; urban and rural development (town planning); transport systems (public transport); and health systems. Assessing the environment of a given community using this framework indicates the opportunities for preventive strategies. As yet, there are few successful examples of multifaceted, large-scale interventions to guide obesity-prevention programs. Such interventions need to be supported by adequate resourcing and significant community ownership.

3 Assessment of the obese child or adolescent

History

General history

  • Pregnancy details and birthweight, including maternal gestational diabetes

  • Early medical history

  • Ethnicity

Weight history

  • History of development of obesity, including onset and duration

  • Pubertal history

  • Impact of obesity on the young person’s life and on the family

Complication history

  • Psychological effects of obesity, including teasing and bullying

  • Presence of sleep apnoea/disturbed sleep

Asthma

  • Specific symptoms, such as knee or hip pain

  • Menstrual history (girls)

  • Exercise tolerance

Family’s weight and metabolic history

  • BMI or BMI percentile for first-degree relatives

  • Relative weights of other family members

  • Family history, including obesity, type 2 diabetes, cardiovascular and cerebrovascular disease or obstructive sleep apnoea

Lifestyle history

  • Daily physical activity, including sports participation

  • Daily sedentary activities (eg, TV, video games, computer use)

  • Dietary history, including normal meal pattern, fast-food intake and snacks

Examination

  • Height

  • Weight

  • Waist circumference*

  • Pubertal stage (according to Tanner)16,17

  • Blood pressure (use appropriate-sized cuff and age norms)18

  • Acanthosis nigricans (Box 2)

  • Hepatomegaly

  • Striae, intertrigo

  • Gait and mobility

Physical examination findings requiring further assessment:

  • Short stature

  • Abnormal physical stigmata

  • Associated intellectual disability

  • Visual disturbance and headache (may be a sign of central nervous system lesion)


* Waist circumference can be used as a proxy for abdominal obesity, with its increased risk of metabolic complications. There are no specific cut-off points for waist circumference for age to categorise abdominal obesity in children and adolescents. However, if the waist circumference of a child or adolescent falls above the acceptable waist circumference cut-off points for adults19 (increased risk: men > 94 cm, women > 80 cm), then the child can be readily classified as having abdominal obesity. This imperfect, but practical, approach will, of course, lead to an underestimation of abdominal obesity in paediatric patients. Waist circumference may be most useful in clinical assessment of individual patients when measured serially and used to monitor change over time.

For most overweight children, investigations are not necessary. However, if a child or adolescent is very obese, has a family history of metabolic disease, or a history and examination suggesting the presence of complications of obesity, then a fasting lipid profile, fasting levels of insulin and glucose, and liver function tests (to assess the presence of non-alcoholic steatohepatitis) should be considered. Endocrinological tests are not required, unless there is other evidence of endocrine disease or short stature. Consider referral for review at a specialist centre.

Case study — a 5-year-old overweight child

A mother brings her 5-year-old daughter to you because of concerns about the girl’s significant overweight. The girl is an only child who lives with her mother and maternal great-grandmother and has no contact with her father.

The mother’s pregnancy was complicated by gestational diabetes and hypertension. The child’s birthweight was 3.7 kg.

The child’s past medical history has been unremarkable, apart from mild asthma (currently not requiring treatment). The mother has made some unsuccessful attempts to modify the child’s dietary intake over the past two or more years.

Several family members are obese, including the mother, maternal aunt, maternal grandmother and many family members on the father’s side of the family. There is also a family history of type 2 diabetes (mother had gestational diabetes; maternal great-grandmother has type 2 diabetes).

The girl is in pre-school and has swimming and judo lessons each week, but otherwise plays quietly on her own as no playmates live nearby. She does not watch much television, although the TV is on while the family eats.

Her dietary intake includes three serves of fruit juice per day, a large-size serve for the evening meal, very few vegetables and some high-fat snacks during the day.

The girl appears well and happy. Her weight is 36.2 kg (> 97th percentile); height, 111.2 cm (75th percentile); and BMI, 29.3 kg/m2 (> 95th percentile for age). Her waist circumference is 80 cm. Apart from obesity, there are no abnormal findings on examination. Her blood pressure is 100/60 mmHg.

Management

You arrange to see the mother, on her own, initially monthly, to support her in making whole-family lifestyle changes.

  • The mother makes several sustainable changes to her daughter’s food intake (water as a beverage; smaller-sized serves for the evening meal; healthier snack options, including cut-up raw fruit and vegetables).

  • The family no longer watches television while eating the evening meal.

  • The family buys a dog, and the child and her mother take it for regular walks.

  • The child commences school and thus has more opportunities for regular play with her peers.

At the 15-month review, the girl’s weight is now 37.4 kg (still > 97th percentile, but only a 1.2 kg weight gain in 15 months); height, 119.9 cm (75th percentile); and BMI, 26.0 kg/m2 (> 95th percentile, a 3.2-unit decrease). Her waist circumference remains at 80 cm. While still obese, the girl’s rate of weight gain has decreased and her BMI has fallen dramatically.

You continue to see the mother on a 2- to 3-monthly basis to provide further support for long-term lifestyle change.

  • Jennifer A Batch1
  • Louise A Baur2

  • 1 Department of Endocrinology and Diabetes, Royal Children’s Hospital, Brisbane, QLD.
  • 2 The Children’s Hospital at Westmead and Discipline of Paediatrics and Child Health, University of Sydney, Sydney, NSW.



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