Summary of Clinical Practice Guideline for the Evaluation and Treatment of Children and Adolescents with Obesity

Introduction

Obesity is a common chronic disease affecting the health of 14.4 million children and adolescents. Childhood obesity is caused by a complex combination of factors including socioecological, environmental, and genetic influences, which are more prevalent among children who have experienced negative environmental and social determinants of health such as racism, poverty, discrimination, and stigma. Obesity has a lasting impact on a child’s health and quality of life and requires a coordinated approach to care that involves healthcare providers, families, schools, communities, and health policy. A life course approach to identification and treatment, starting as early as possible and continuing through childhood, adolescence, and young adulthood, is important due to the chronic nature of obesity and its long-term negative health effects, morbidity, mortality, and social and economic consequences.

Individuals with overweight and obesity often face weight stigma, which can lead to negative impacts on mental health and prevent them from seeking medical care. Pediatricians and other healthcare providers need to address their own biases and understand the complex factors that contribute to obesity. The use of person-first language and creating a welcoming environment in the clinic can help reduce weight stigma. Adverse childhood experiences (ACEs), such as family violence or financial hardship, have been linked to obesity in children and adolescents, with the number of ACEs increasing the risk of obesity. The mechanisms linking ACEs to obesity include negative health behaviors, chronic stress response, and social disruption. It is important to address ACEs in efforts to prevent and treat childhood obesity.

Prevalence of Childhood Obesity

Obesity is a chronic disease that has serious health and social consequences. Childhood obesity is defined as having a BMI of ≥95th percentile for age and sex. The percentage of US children and adolescents affected by obesity has increased significantly, from 5% in 1963 to 1965 to 19% in 2017 to 2018. Obesity prevalence increases with increasing age, and there are significant trends in obesity in children and adolescents. The COVID-19 pandemic has significantly affected the lives and routines of children and adolescents, and it has doubled the rate of BMI increase compared to the prepandemic period.

Disparities exist among children and youth with obesity, including lower socio-economic status (SES), less access to healthy food options and physical activity, and higher incidence of ACEs. These disparities highlight the burden of obesity in children from families of lower SES and the need to minimize these inequities. Disparities also exist in obesity prevalence across ethnic and racial groups. Mexican American youth and non-Hispanic Black children have a higher prevalence of obesity compared to non-Hispanic white children. Children and youth with special health care needs (CYSHCN) have a higher prevalence of obesity and lower levels of physical activity compared to those with typical growth and development.

BMI as a Clinical Tool

The gold standard for measuring body fat is expensive and difficult to implement, so Body Mass Index  (BMI) is frequently used in clinical practice as an easy and inexpensive tool to screen and diagnose excess body fat. BMI is a reliable measure of underlying adiposity and can track weight status in children and adolescents over time. BMI is often used to evaluate the success of interventions to improve weight status. However, BMI has limitations, such as low sensitivity for detecting excess adiposity and potential inaccuracies in certain racial and ethnic groups. Additionally, children and adolescents with high muscle mass may have a high BMI and be wrongly classified as overweight or obese.

BMI is a commonly used tool to assess weight status in children and adolescents. “Overweight” is defined as a BMI at or above the 85th percentile and below the 95th percentile, while “obesity” is defined as a BMI at or above the 95th percentile. In older adolescents, the adult cutoff of a BMI equal to or greater than 30 kg/m2 can be used to define obesity if this value is less than the 95th percentile BMI for age and sex.

However, BMI has limitations, particularly in detecting excess adiposity, and may not accurately detect meaningful changes in weight status or comorbidity risk over time, particularly for children and adolescents with severe obesity. Therefore, alternative options such as using the degree to which a particular BMI percentile was above the 95th percentile, or the median for age and sex, have been proposed.

The CDC and AAP recommend using specialized growth charts for certain populations, such as those with trisomy 21, but caution that these charts may be limited by small sample sizes. BMI is useful for identifying children with overweight and obesity for appropriate treatment, such as family-based behavioral therapy, which can lead to improvements in weight status and related comorbidities. The USPSTF recommends annual screening for obesity in children and adolescents aged 6 years or older, and offering or referring them to comprehensive, intensive, family-based behavioral treatment to improve weight status.

The authors of the clinical practice guidelines suggest that healthcare providers who specialize in pediatrics should evaluate the child or adolescent’s individual, structural, and contextual risk factors during the initial and ongoing assessments. This will enable them to provide customized and personalized treatment to children or adolescents with overweight or obesity.

Comorbidities of Pediatric Overweight and Obesity

Children and adolescents with obesity are more likely to have health problems and have a greater risk of obesity, illness, and early death in adulthood. The risk of health problems increases with age, severity of obesity, and varies by race and ethnicity. It’s important for healthcare providers to understand the impact of social and environmental factors on obesity and health disparities in different populations.

Evaluation for obesity and related health problems should be done by taking into account patient-specific factors and using input from technical reports and guidelines. Studies on the best age to start evaluation and frequency of testing are limited.

Children with obesity have a higher risk of comorbidities and more severe disease, which may be underestimated. The prevalence of metabolic syndrome and prediabetes is higher among children and adolescents with obesity compared to those with healthy weight. Adolescents with severe obesity may have more aggressive pediatric NAFLD. Although the prevalence of T2DM in children is low, the incidence is increasing at an alarming rate. NAFLD is common in children and occurs more frequently in certain groups. Despite the high prevalence of obesity, the rate of evaluation for obesity or comorbidities in practice is low. While concerns about overtesting and cost are valid, the impact of obesity and comorbidities on morbidity and mortality cannot be ignored.

Laboratory Evaluation Recommendations – Summary

The AAP Expert Committee on Child Obesity recommended laboratory evaluation for children with obesity to detect dyslipidemia, prediabetes, and NAFLD starting at age 10, including fasting lipid panel, fasting glucose, alanine transaminase, and aspartate transaminase levels every 2 years. For children with overweight, the recommendation was only for a fasting lipid panel unless additional risk factors were present. KASs 3 and 3.1 build on these recommendations, considering recent studies, guidelines, and pediatrician and PHCP behaviors while balancing the risks and benefits of evaluation at both individual and population levels.

Key Action Statement (KAS) 3 and 3.1 suggest that it would be more practical and effective to evaluate for lipid abnormalities, abnormal glucose metabolism, and liver dysfunction in children with obesity at the same time, starting at the age of 10. This approach is recommended to make it easier for pediatricians and other healthcare providers to follow the guidelines. The evaluation should include fasting laboratory tests because a fasting lipid panel is still the recommended test to evaluate for dyslipidemia in children and adolescents with overweight and obesity, as explained in the dyslipidemia section.

KAS 3.1 recommends that children between the ages of 2 and 9 with obesity may be evaluated for lipid abnormalities. This recommendation is consistent with the 2011 NHLBI Expert Panel guidelines for cardiovascular health and risk reduction in children and adolescents. Studies have shown that lipid abnormalities occur in children younger than 10 years, especially those with obesity. However, evaluating for abnormal glucose metabolism or liver function may not be necessary for this age group unless there is severe obesity or other risk factors.

KAS 3 recommends that children who are 10 years and older and overweight should be evaluated for lipid abnormalities, but only if they do not have any additional risk factors. For T2DM evaluation, additional risk factors such as family history, gestational diabetes history, insulin resistance signs, and use of obesogenic psychotropic medication need to be considered. Similarly, for NAFLD evaluation, additional risk factors such as family history, central adiposity, insulin resistance signs, prediabetes or diabetes mellitus, dyslipidemia, and sleep apnea need to be considered.

Concurrent Treatment of Obesity and Obesity-Related Comorbidities

Studies have shown that treating obesity and its related conditions concurrently can result in weight loss, prevent further weight gain, and improve comorbidities. Lifestyle treatment, weight loss medication, and bariatric surgery have all been effective in improving comorbidities. Guidelines recommend lifestyle treatment as the primary management for dyslipidemia, T2DM, NAFLD, and HTN. Children who undergo intensive pediatric obesity treatment have shown improvement in cardiometabolic markers. Pediatricians and other healthcare providers should evaluate comorbidities in children with overweight or obesity during wellness checkups and provide guidance on risk factors. The diagnosis of obesity should be conveyed sensitively to avoid any potential harm. Identifying comorbidities can also be a motivating factor for addressing weight concerns in adults. Studies in pediatrics have been inconsistent but suggest that evaluating youth for comorbidities may increase engagement and adoption of healthy choices, leading to weight loss. More studies are needed to draw definitive conclusions about the effects of evaluating families for comorbidities.

Specific Guidelines for Initial Evaluation for Comorbidities

Dyslipidemia

Children and adolescents with overweight and obesity are at increased risk for abnormal lipid levels, especially hypertriglyceridemia and low HDL levels driven by insulin resistance. This type of dyslipidemia is three times more prevalent in overweight and obese children compared to those with a healthy BMI. These cardiovascular risk factors tend to persist into adulthood, emphasizing the importance of early evaluation and counseling on risk-reduction behaviors by pediatricians and other healthcare providers. Risk factors for dyslipidemia include cigarette use, hypertension, diabetes, and a family history of cardiovascular disease. Social factors, such as adverse childhood experiences, are also associated with cardiovascular risk factors and should be taken into account when assessing dyslipidemia in younger children. The 2011 NHLBI Expert Panel on Integrated Guidelines for Cardiovascular Health and Risk Reduction in Children and Adolescents and 2018 American Heart Association and American College of Cardiology Guidelines recommend early evaluation and counseling for children and adolescents with obesity.

According to the 2011 NHLBI expert panel, a fasting lipid panel is recommended for evaluating dyslipidemia in children with overweight and obesity. Fasting for 8 to 12 hours before testing is recommended, as dietary fats and carbohydrates can affect serum triglyceride levels. The non-HDL level, which is total cholesterol minus HDL cholesterol, may be used for nonfasting lipid panel tests, but if it is abnormal (non-HDL ≥145 mg/dL) and/or HDL level is <40 mg/dL, a fasting lipid panel should be obtained for diagnosis. The nonfasting lipid panel is recommended for all children 9 to 11 years old to evaluate for familial hypercholesterolemia. The cut-off criteria for lipids are generally the same across different age groups, except for triglycerides.

Prediabetes and Type 2 Diabetes Mellitus

The incidence of type 2 diabetes mellitus (T2DM) among 10- to 19-year-olds in the United States has been increasing over the years, with rates going up from 9.0 to 13.8 per 100,000 between 2002 and 2015. Prediabetes is also becoming more common among adolescents, with about 1 in 5 adolescents (12-18 years) affected. While T2DM is uncommon among children younger than 10 years, it has been diagnosed in some cases as young as 4 years of age. Therefore, healthcare providers should consider the risk factors and symptoms of altered glucose metabolism in all age groups. Obesity is a significant risk factor for developing prediabetes and T2DM, and healthcare providers should be particularly vigilant when caring for children with obesity, especially if other risk factors are present. Racial and ethnic disparities in the incidence of T2DM are partly due to genetics and social determinants of health.

If a patient presents with symptoms of hyperglycemia, such as polydipsia, polyuria, polyphagia, blurred vision, unexplained weight loss, or fatigue, diagnostic tests for prediabetes and T2DM should be performed. These tests include fasting plasma glucose (FPG), 2-hour plasma glucose after oral glucose tolerance test (OGTT), and HbA1c. There is no consensus on which test is best, and clinicians should be aware of the advantages and limitations of each test and take patient preferences and accessibility into consideration. The OGTT is effective in identifying dysglycemia but may not be readily available or practical in some medical settings. The HbA1c test is easy to obtain and recommended for monitoring prediabetes and glycemic control over time.

However, it has lower sensitivity in children compared to adults, and HbA1c levels can be affected by iron deficiency anemia. Fasting insulin is not recommended for diagnosis. If test results indicate T2DM, treatment should be initiated without the need for a confirmatory test. The cut-off values for pediatric and adult populations are similar, and the HbA1c test is recommended for tracking glycemic control over time.

Hypertension

Children and adolescents with overweight and obesity have a higher prevalence of hypertension (HTN), which increases with increasing BMI percentile. They may also have abnormal diurnal variation in BP, with one-third having a decreased nocturnal BP dip, which increases the potential risk for end-organ damage. HTN during childhood and adolescence increases the risk for adult HTN and cardiovascular disease. Among children with obesity, HTN is associated with vascular changes, increased left ventricular mass, and carotid intima media thickness during childhood. It is therefore important to consistently evaluate for HTN early throughout childhood and adolescence among individuals with overweight and obesity.

Childhood obesity is the biggest risk factor for hypertension. Elevated blood pressure can be observed in early childhood and its prevalence increases with age and BMI. Prevalence of hypertension varies among different races and ethnicities, with non-Hispanic Black and Hispanic youth having the highest rates. Socioeconomic status and adverse childhood experiences are also risk factors for hypertension. Pediatricians and other healthcare providers should inquire about salt and sodium intake, physical activity, and sleep duration and disordered breathing as these factors are associated with childhood hypertension. This aligns with the AAP’s 2017 guideline that recommends frequent monitoring of blood pressure in children with obesity starting from age 3 to facilitate early detection of elevated BP.

Consensus recommendation for other comorbidities

Obstructive Sleep Apnea – The authors of the clinical practice guideline recommend that healthcare professionals who work with children and adolescents with obesity should gather information about their sleep, including symptoms such as snoring, daytime sleepiness, bedwetting, headaches, and difficulty paying attention. This information will help evaluate whether the child may have obstructive sleep apnea (OSA). If the child has obesity and at least one symptom of disordered breathing, a polysomnogram should be conducted to confirm the diagnosis of OSA.

Polycystic ovarian syndrome (PCOS) – The authors of the CPG suggest that pediatricians and other PHCPs should assess the risk for PCOS among female adolescents with obesity by looking for signs of hyperandrogenism (such as hirsutism and acne) and menstrual irregularities.

Depression – pediatricians and other PHCPs should keep a lookout for symptoms of depression in children and adolescents with obesity. They also recommend conducting an annual evaluation for depression in adolescents aged 12 years and older using a formal self-report tool.

Slipped capital femoral epiphysis (SCFE) – pediatricians and other PHCPs should include a musculoskeletal review of systems and physical examination, such as assessing internal hip rotation and gait, when evaluating a child or adolescent with obesity. In cases where a slipped capital femoral epiphysis (SCFE) is suspected, they recommend immediate and complete activity restriction, nonweight-bearing with the use of crutches, and referral to an orthopedic surgeon for urgent evaluation. If an orthopedic surgeon is not available, the PHCP may consider sending the child to an emergency department.

Idiopathic intracranial hypertension – pediatricians and other PHCPs maintain a high level of suspicion for IIH (idiopathic intracranial hypertension) when there are new-onset or progressive headaches in the context of significant weight gain, particularly in females.

Treatment

Some experts have expressed concerns that treating obesity in children may lead to disordered eating patterns and body image issues as they grow older. However, studies have shown that structured and supervised weight management programs actually decrease current and future eating disorder symptoms, such as emotional eating, binge eating, and drive for thinness. These programs have similarities with eating disorder programs, including a focus on promoting healthy eating habits, regular physical activity, and improving self-esteem. Therefore, professional treatment of pediatric obesity can actually reduce the prevalence and risk of eating disorders.

Motivational Interviewing

Motivational interviewing (MI) is a counseling technique that emphasizes identifying and reinforcing a patient’s own motivation for change, instead of prescribing behavior change. The approach is patient-centered, and the focus is on the person responsible for behavior change, which may be the parent or the patient, depending on the age of the patient. MI consists of four processes: engaging, focusing, evoking, and planning. Through engaging, pediatricians evaluate whether to attempt behavior change, while the focusing process identifies behaviors to change collaboratively. The evocation process evaluates the patient’s values and goals, while planning assesses a patient’s knowledge, resources, and support available for a particular strategy. Pediatricians play a critical role in providing support and guidance to collaboratively chosen courses of action, and they can also assess setbacks and relapses and suggest appropriate strategies to get back on track. MI can help identify behavior changes for weight status, such as reducing sugar-sweetened beverages, increasing physical activity, or eating meals together. The approach respects the autonomy of the patient and family and is successful when the family changes the selected behavior.

Pharmacotherapy

According to the CPG, pediatricians and other PHCPs may consider offering weight loss medication to children aged 8 to 11 with obesity, along with health behavior and lifestyle treatment, based on the medication’s indications, risks, and benefits.

Metformin is a medication used to treat type 2 diabetes in patients aged 10 years or older. It has additional uses, such as treating prediabetes, PCOS, and preventing weight gain when used with certain antipsychotic medications, although these uses have not been approved by the FDA. Metformin belongs to a class of drugs called biguanides, and it works by reducing glucose production in the liver, decreasing intestinal glucose absorption, and improving insulin sensitivity. Metformin comes in immediate and extended-release formulations, and the recommended starting dose is 500 mg taken once or twice daily, with gradual increases up to a maximum daily dose of 2500 mg. Possible side effects include bloating, nausea, flatulence, and diarrhea, and these can be dose-dependent. Although lactic acidosis is a rare but serious complication, it occurs very rarely in pediatric populations.

Orlistat is a medication that stops the body from absorbing fats by blocking the enzymes that break down fat in the pancreas and stomach. It is currently approved for use in children who are 12 years or older, with a recommended dose of 120 mg taken three times a day. However, its use is limited in treating pediatric obesity due to side effects such as oily bowel movements, an urgent need to have a bowel movement, and excessive gas, which make it difficult for patients to tolerate. The medication has been approved by the FDA for long-term treatment of obesity in children aged 12 years and older.

Glucagon-like peptide-1 receptor agonists (GLP-1RA) are drugs such as liraglutide, exenatide, dulaglutide, and semaglutide that reduce hunger by slowing down gastric emptying and targeting the central nervous system. The medications are available in oral or subcutaneous injection forms, with some requiring daily or weekly dosing. Two small studies on exenatide, a weekly injection, showed a reduction in BMI in children as young as 8 years but also had significant adverse effects. Exenatide is currently approved for children aged 10 to 17 years with T2DM. A recent randomized controlled trial found liraglutide, a daily injection, to be more effective than placebo in weight loss at 1 year for patients 12 years and older with obesity who did not respond to lifestyle treatment. The recommended starting dose for liraglutide is 0.6 mg per day, with a maximum dose of 3.0 mg per day administered through subcutaneous injection. Adverse effects of GLP-1RA include nausea, vomiting, and a slightly increased risk of medullary thyroid cancer among patients with a family history of multiple endocrine neoplasia. Liraglutide is FDA approved for long-term treatment of obesity (with or without T2DM) in children 12 years and older.

Bariatric Surgery

The most serious types of pediatric obesity, defined as class 2 obesity with a BMI of 35 kg/m2 or greater, or 120% of the 95th percentile for age and sex (whichever is lower), are widely considered to be a “crisis within a crisis.” In addition, severe obesity is associated with the development and worsening of many related health conditions, a decrease in long-term health, and a shortened life expectancy.

Conclusion

Previous clinical guidelines emphasize the importance of providing effective and ongoing obesity treatment for children and families, with the aim of reducing potential harms of disordered eating and improving long-term health outcomes. This guideline stress the need for immediate and intensive obesity treatment for each patient as soon as they are diagnosed with obesity, providing PHCPs with more evidence-based tools than ever before.

References

Sarah E. Hampl, Sandra G. Hassink, Asheley C. Skinner, Sarah C. Armstrong, Sarah E. Barlow, Christopher F. Bolling, Kimberly C. Avila Edwards, Ihuoma Eneli, Robin Hamre, Madeline M. Joseph, Doug Lunsford, Eneida Mendonca, Marc P. Michalsky, Nazrat Mirza, Eduardo R. Ochoa, Mona Sharifi, Amanda E. Staiano, Ashley E. Weedn, Susan K. Flinn, Jeanne Lindros, Kymika Okechukwu; Clinical Practice Guideline for the Evaluation and Treatment of Children and Adolescents With Obesity. Pediatrics February 2023; 151 (2): e2022060640. 10.1542/peds.2022-060640

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