Obesity in Children

Overview

Obesity is defined as a body mass index (BMI), determined by plotting on BMI growth curves, at or above the 95th percentile. Overweight is defined as a BMI between the 85th and 95th percentiles. For children and teens, BMI is age- and sex-specific. Every effort should be made during childhood and adolescence to help patients avoid becoming at risk for overweight or obesity. If overweight or obese, clinicians should not wait to address issues until adulthood because lifestyles and habits are more difficult to change then and the pathophysiologic changes associated with overweight and obesity are established. Clinical approaches involve family-focused communication, education, motivation, and lifestyle interventions.

“Handing families a list of recommended eating and activity habits, as if it were an antibiotic prescription for obesity, fits into traditional medical training, but such an approach is rarely effective.” [Barlow: 2007]

Other Names & Coding

Adolescent obesity Childhood obesity Overweight

ICD-10 coding

Z68.5x, Body mass index pediatric

Z71.3, Dietary counseling and surveillance

Z71.82, Exercise counseling

E66.xx, Overweight and obesity

E66.0x, Obesity due to excess calories

E66.3, Overweight

Each “x” in the codes above indicates the need for an additional digit that indicates percentile range for BMI (Z68) or root cause and/or severity (E66). See ICD-10 for Body Mass Index (icd10data.com) and ICD-10 for Overweight and Obesity (icd10data.com) for details.
Note: The Affordable Care Act stipulates that obesity screening and counseling be covered benefits under insurance plans that are not exempt.

Prevalence

Since 1980, the prevalence of childhood obesity has more than tripled. [Fryar: 2014] About 1:5 (18.5%) children who are 6-19 years old has obesity, and the prevalence increases from younger children (18.4%) to adolescents (20.6%). [Robert: 2014] Non-Hispanic black and Hispanic-origin groups have higher rates of obesity than other race and non-Hispanic origin groups. The results of the National Health and Nutrition Examination Survey, 1999-2016 are shown below:
Prevalence of childhood obesity in the United States by sex and age, 2015–2016 1 Significantly different from those aged 2–5 years

Past studies have been criticized because they involved primarily middle class white children, ages 8 -12 who are seen in obesity clinics. [Gilles: 2008] [Jelalian: 2007] [Hughes: 2008] There are few studies on specific minority populations that may be at a higher risk for obesity due to ethnic and cultural influences, although it has been suggested that African American children have greater lean mass than their Caucasian peers. [Freedman: 2009]

Genetics

Advances in gene-identification techniques have led to a greater understanding of the variations in genes that are likely to cause most cases of obesity. For example, Genome-Wide Complex Trait Analysis (GCTA) can be used to estimate the genetic influence on accumulating excess adipose tissue that is attributable to additive genetic effects from common single nucleotide polymorphisms (SNPs) across the entire genome. [Llewellyn: 2013] In adult studies, the estimated influence is 10%-16.5%, compared to 30% in children. [Yang: 2011] [Vattikuti: 2012] [Llewellyn: 2013] This suggests that the additive genetic effect from common SNPs on obesity may be higher in children. GCTA cannot be used to predict the risk of obesity for an individual.
It is extremely rare for a mutation of a single gene to cause obesity. There have been <80 cases of obesity worldwide attributable to mutations of 7 distinct genes (e.g., complete leptin deficiency, complete leptin receptor deficiency). [Yanovski: 2018] Variations of the FTO gene can influence eating and satiety in obese children. [Epstein: 2010] Melanocortin 4 receptor (MC4R) mutations, found in 4%-6% of morbid obesity cases, are the most common genetic cause of obesity. These patients present with early onset morbid obesity, increased fat mass, hyperphagia, hyperinsulinemia, and mild hypothalamic hypothyroidism. Children with proopiomelanocortin (POMC) defects, which result in disruption of the melanocortin signaling and cause dysfunction of the hypothalamic-pituitary-adrenal axis, can present with abnormal thyroid levels. [Sothern: 2006] Genetic syndromes associated with childhood obesity include Prader-Willi syndrome, Turner syndrome, and Laurence-Moon-Bardet-Biedl syndrome.
Findings such as developmental delay, short stature/delayed growth, dysmorphic features, abnormal or absent genitalia, and digital anomalies should raise suspicion of an underlying genetic disorder. [Lönnqvist: 1995] [Sothern: 2006]

Prognosis

Childhood obesity is associated with a spectrum of complications that may affect short- and long-term physical and mental health. Common comorbid conditions include hypertension, type 2 diabetes, sleep apnea, polycystic ovary syndrome (PCOS), asthma, liver and gallbladder disease, and orthopedic problems. [Daniels: 2006] [Hughes: 2008] Obese children may have weaker immune systems and increased risk of chronic illnesses. [Herrera: 2004] Obese children are at greater risk than their non-obese peers of becoming obese adults. [Jelalian: 2007] Prognosis often depends on the effectiveness of treatment, when treatment begins, and the support of the family.

Practice Guidelines

Several clinical practice/expert consensus guidelines that have been published since the 2007 guideline [Barlow: 2007]. All of these guidelines offer similar recommendations:

Avoid sugar-sweetened beverages / calorie-dense, nutrition–poor foods.
Eat fruits and vegetables in place of juice.
Engage in 60 minutes of moderate-vigorous physical activity at least 5 days/week.
Limit screen/sedentary time to less than 2 hours/day (No screen time for children younger than 2 years).

Practice Guidelines

Styne DM, Arslanian SA, Connor EL, Farooqi IS, Murad MH, Silverstein JH, Yanovski JA.
Pediatric Obesity-Assessment, Treatment, and Prevention: An Endocrine Society Clinical Practice Guideline.
J Clin Endocrinol Metab. 2017;102(3):709-757. PubMed abstract / Full Text

Daniels SR, Hassink SG.
The Role of the Pediatrician in Primary Prevention of Obesity.
Pediatrics. 2015;136(1):e275-92. PubMed abstract

Centers for Disease Control & Prevention.
Prevention Strategies & Guidelines.
U.S. Department of Health and Human Services; (2018) https://www.cdc.gov/obesity/resources/strategies-guidelines.html. Accessed on October 2018.
A collection of guidelines and recommended strategies to prevent obesity.

Roles of the Medical Home

Effective identification and treatment of childhood obesity require that primary care clinicians routinely screen children for obesity risk using BMI measurements and percentiles. [Barlow: 2007] Non-judgmental conversations about weight should occur early since lifestyles that contribute to obesity begin as young as age 4. [Ruxton: 2004] Counsel parents/guardians of children younger than 4 years to create a healthy eating environment with access to vegetables, fruits, whole grains, low-fat/non-fat dairy products, lean meats, beans, lentils, and plenty of drinking water. Clinicians can recommend that sugar-sweetened beverages be limited (or eliminated) from the diet and that there be no screen time for kids younger than 2 years and no more than 2 hours per day of screen time for children older than 2 years. Encourage kids to find fun activities to do with family members or on their own that involve movement.
When counseling patients and families, clinicians should use language that creates concern (“unhealthy weight”) and is not stigmatizing (“fat” or “obese”). [Pont: 2017]Clinicians assist with setting realistic, achievable goals and monitoring behaviors targeting change. Clinicians should expect imperfect adherence and communicate positive messages focused on long-term progress. The medical home may suggest involvement of a dietician or a weight specialist, behavior specialist, exercise specialist, or bariatric medicine specialist and coordinate the care provided.

Clinical Assessment

Overview

The history and physical of the obese child, as well as of family members, help the clinician assess contributing factors and formulate a plan for achieving healthier weight.

Pearls & Alerts for Assessment

TSH is a low-yield test.

Hypothyroidism is a rare cause of obesity.

Insulin is a low-yield test

The Endocrine Society recommends against measuring insulin concentrations when evaluating children and adolescents for obesity. [Styne: 2017]

Screening

For the Condition

BMI screening is still considered the standard of care and the most useful tool in identifying obesity. While BMI does not measure fat mass, it correlates well and is a good indicator of health risk. [Hughes: 2008] The tri-ponderal mass index (TMI) may emerge as a new estimate of obesity for youth 8-17 years old. It is calculated as weight (kg)/height (m)3 and does not require calculating a percentile. TMI >16.0 kg/m3 for boys and >16.8 kg/m3 for girls may be a quick way to determine if further calculation of BMI and BMI percentile is appropriate. [Peterson: 2017] The Portal's Childhood Obesity Screening & Prevention page provides additional screening tools.

Of Family Members

While screening of family members is not essential for the diagnosis of childhood obesity, it can provide clues for how to help patients and family members change their lifestyle, which is the key to successful treatment.

For Complications

The National Heart, Lung, and Blood Institute recommends for children with a BMI ≥95th percentile an annual fasting lipid profile beginning at age 2 years.
The 2018 American Diabetes Association recommends annual screening for type 2 diabetes or prediabetes in asymptomatic children and adolescents ≥10 years with a BMI >85th percentile for age and sex plus 1 or more additional risk factors: 1) maternal history of diabetes or gestational diabetes mellitus during the child’s gestation; 2) family history of type 2 diabetes in first- (parent, sibling) or second-degree relative (grandparent); 3) race/ethnicity (Native American, African American, Latino, Asian American, Pacific Islander); and 4) Signs of insulin resistance or conditions associated with insulin resistance (acanthosis nigricans, hypertension, dyslipidemia, polycystic ovary syndrome, or small-for-gestational-age birth weight) and an annual fasting glucose beginning at age 10 years.HgA1C, or fasting plasma glucose, or 2-hour plasma glucose during a 75g oral glucose tolerance test can be used to test for prediabetes or diabetes.[American: 2018]
All children, regardless of weight status, should have annual blood pressure measurement beginning at 3 years of age.[National: 2012] The Endocrine Society Pediatric Obesity Guidelines recommend screening for mental health issues and counseling as indicated. Some screens to consider are:

Patient Health Questionnaire-9 (PHQ-9) ( 40 KB): Nine-question depression screen with scoring information that can be used with adolescents 13-17 years old. Select language and "Go to the Selected Screener" for a PDF download.
Adolescent Binge Eating Scale (ADO-BED) Questionnaire ( 268 KB): A 5-item, questionnaire developed to identify obese adolescents at risk for binge eating disorder

The Endocrine Society Pediatric Obesity Guidelines do NOT recommend routine laboratory evaluations for endocrine etiologies of pediatric obesity unless the patient’s stature and/or height velocity are attenuated (assessed in relationship to genetic/familial potential and pubertal stage). They also do NOT recommend measuring insulin concentrations when evaluating children or adolescents for obesity. [Styne: 2017]

Diagnostic Criteria

The definitions of overweight and obesity are based on BMI, derived from the child’s height and weight:

BMI = (Weight [lb] / Height [inches] x Height [inches]) x 703

In children older than age 2, clinicians should use BMI percentiles specific to the age and sex of the child. [Hassink: 2010] BMI percentiles are derived from NHANES data collected prior to 1980, when the prevalence of obesity was 5%. See Clinical Growth Charts (CDC & WHO).

Clinical Classification

Overweight is defined as a BMI between the 85th and 95th percentiles. Children with a BMI ≥95th percentile meet criteria for obesity. Additional classifications for children who have BMI >97th percentile may be useful for those in need of more aggressive treatment. [Hughes: 2008]

Medical Conditions Causing Obesity in Children

Excess caloric intake and sedentary behaviors are the most common causes of childhood obesity. There is a growing body of literature that describes the association between the death of a parent or hardship due to family income with childhood obesity. [Hemmingsson: 2018] Also, history of sexual and physical abuse during childhood increases risk of severe obesity in adulthood. [Rehkopf: 2016] [Hemmingsson: 2014] [Richardson: 2014]
Rare causes of childhood obesity include:

Cushing syndrome (obesity resolves with treatment)
Hypothyroidism
Polycystic ovary syndrome (PCOS)
Insulinoma
Growth hormone deficiency
Hypothalamic disorders
Congenital leptin deficiency
Medications (insulin, thiazolidinedione, antipsychotics, antidepressants)
Genetic causes:
- Down syndrome: While obesity is not a defining factor of Down syndrome, obesity can occur later in adolescence as a result of inactivity. The Medical Home Portal's Down Syndrome module provides diagnosis and management information.
- Fragile X syndrome: The Medical Home Portal's Fragile X Syndrome module provides diagnosis and management information.
- Prader-Willi syndrome (hypotonia, hypogonadism, hyperphagia, cognitive impairment, morbid obesity): The Medical Home Portal's Prader-Willi Syndrome module provides diagnosis and management information.
- Laurence-Moon Bardet-Biedl syndrome (polydactyly, renal anomalies, retinitis pigmentosa, cognitive impairment, truncal obesity)
- Cohen syndrome (microcephaly, hypotonia, short stature, truncal obesity, ocular anomalies, neutropenia)
- Biemond syndrome (diabetes mellitus, polydactyly, coloboma, facial abnormalities, hypogonadism)

Comorbid & Secondary Conditions

Obese youth are more likely than healthy-weight children to have risk factors for cardiovascular disease and mental health problems. In a population-based sample of children with obesity who were 5-10 years old, 58% had 1 cardiovascular risk factor and 25% had 2. [Hughes: 2008] Cardiovascular risks include increased left ventricular mass and decreased cardiac function with abnormal endothelial function, elevated blood pressure (4.5 times more likely), and abnormal lipid levels (2.4 - 7.1 times more likely). [Hughes: 2008]
In addition, obese children are more likely than non-obese children to develop: [Hughes: 2008] [Daniels: 2005] [Dietz: 2005]

Type 2 diabetes mellitus
Hyperinsulinemia and increased insulin resistance (12.6 times more likely)
Metabolic syndrome (18%-50% compared to <1% in children of healthy weight)
Bone and joint problems
Sleep apnea
Social and psychological problems (stigmatization, poor self-esteem, anxiety, and depression) [Nemiary: 2012] [Melnyk: 2006]

Obese adolescents are more likely to develop heart disease and diabetes as adults. [Hughes: 2008]

History & Examination

Current & Past Medical History

Ask about: [Barlow: 2007]

Sleep patterns (duration, snoring, nocturnal binge eating, nocturia)
Physical limitations due to orthopedic problems
Mood
Eating patterns (focus on history of dieting and binge-eating)
In female adolescents, the regularity of periods and the presence of hyperandrogenism (acne, hair distribution on body, hair loss on head, deeper voice)

Psychological conditions may include: [Herrera: 2004]

Social stigma
Low self-esteem
Poor parent-child interaction
Behavior problems
Binge eating
Depression

A high BMI in children 5-10 years old predicts lower self-esteem 4 years later. [Hughes: 2008] Obese children and adolescents endure social stigma; After success in weight management programs, improvements in self-esteem, body image, behavior, and quality of life occur. [Nemet: 2005]

Family History

Ask about:

Obesity
Cardiac events (before age 55 years in men, before age 65 years in women)
Type 2 diabetes mellitus
High blood pressure
Hypercholesterolemia

These family conditions may confer increased risk for the child or may affect family functioning. [Barlow: 2007]

Pregnancy/Perinatal History

Ask about maternal or gestational diabetes or other complications of pregnancy that may contribute to obesity (hypertension, impaired intrauterine growth, small or large for gestational age). [Barlow: 2007]

Maturationalprogress

Short stature or abnormal growth patterns should trigger consideration of endocrine or genetic causes of obesity.

Social & Family Functioning

For insight into dietary and activity patterns, assess in detail: [Barlow: 2007]

Eating behaviors and physical activity patterns:
- Self-efficacy and readiness to change
- Specific dietary practices
  - Frequency of eating outside the home at restaurants or fast food establishments
  - Excessive consumption of sweetened beverages
  - Consumption of excessive portion sizes for age
- Additional dietary practices:
  - Excessive consumption of 100% fruit juice (more than 6 oz. per day), soda, punch, and other sugar-sweetened drinks
  - Breakfast consumption (frequency and quality)
  - Excessive consumption of foods that are high in energy density
  - Low consumption of fruits and vegetables
  - Meal frequency and snacking patterns (including quality)
Physical activity patterns:
- Self-efficacy and readiness to change
- Environment and social support and barriers to physical activity
- Amount of exercise (60 minutes of moderate to vigorous physical activity per day)
- Amount of sedentary behavior, including hours of screen time (viewing television, watching DVDs, playing video games, and using a smartphone)

Physical Exam

Physical Examination Findings in Obesity Assessment and Possible Causes (AAP), Table 6 in [Barlow: 2007], details the physical exam by system and offers explanations for findings.

General

Assess for dysmorphic features associated with syndromes that include obesity.

Vital Signs

Check blood pressure and heart rate.

Growth Parameters

Record height and weight, BMI and BMI percentile for age and gender.

Skin

Examine skin for signs of acanthosis nigricans, striae, or manifestations of hyperandrogenism (hirsutism, moderate acne) in females.

HEENT/Oral

Assess for ocular abnormalities, such as retinitis pigmentosa, coloboma microcephaly, and facial abnormalities. Assess for large tonsils that may cause obstruction and enamel erosion that may be evidence of purging.

Chest

Examine breast for pubertal staging in girls or evidence of pseudogynecomastia in boys.

Heart

Assess for point of maximal impulse (PMI), rate, rhythm, and the presence of murmurs.

Abdomen

Evaluate for enlarged liver.

Genitalia

Assess pubertal staging and hypogonadism in males.

Extremities/Musculoskeletal

Examine the musculoskeletal system focusing on skeletal deformities and limitation of motion and polydactyly.

Testing

The Endocrine Society Guidelines recommend the following screening procedures for comorbidities: [Styne: 2017]

Prediabetes - HgA1c (annually)
Diabetes mellitus – HgA1c (annually) or fasting plasma glucose (annually)
Dyslipidemia – fasting lipids (annually)
Prehypertension/hypertension – blood pressure measurement at every visit
Non-alcoholic fatty liver disease (NAFLD) – ALT (annually)
Polycystic ovarian syndrome (PCOS) – Free and total testosterone and sex hormone binding globulin (SHBG)
Obstructive sleep apnea – if positive history, refer for nocturnal polysomnography, if not available overnight oximetry
Psychiatric comorbidities – assess at each visit. if positive history, refer to a mental health specialist. See Patient Health Questionnaire-9 (PHQ-9) ( 40 KB) and select language and "Go to the Selected Screenner" for a PDF download.

Laboratory Testing

Consider:

HgA1C (annually)
Fasting lipids (annually)
CMP (annually)
Free and total testosterone and sex hormone binding globulin (SHBG) – as appropriate to make diagnosis of PCOS

Other Testing

Developmental evaluation is appropriate if there is suspicion of delay.

Specialty Collaborations & Other Services

Nutrition Assessment Services (see ID providers [1])

Refer at onset (or during the first appointment with a patient with obesity) to receive counseling regarding diet and assist with diagnosing eating disorders.

Developmental Assessments (see ID providers [136])

Refer for evaluation when an underlying developmental condition is suspected.

Medical Genetics (see ID providers [3])

Refer for evaluation when obesity is most likely due to genetic disorder, birth defect, or other developmental disability.

Biochemical Genetics (Metabolics) (see ID providers [2])

Refer for evaluation when obesity is most likely due to genetic conditions, including chromosomal disorders, single gene disorders, and recognizable syndromes.

Pediatric General Surgery (see ID providers [1])

Refer for evaluation for surgical intervention if the patient is 10-19 years of age and meets criteria for class II Obesity (BMI >120% of 95th percentile) AND co-morbidity; or class III obesity (>140% of 95th percentile).

Treatment & Management

Overview

Expert committee members of the European Society of Endocrinology and the Pediatric Endocrine Society produced a clinical practice guideline for the assessment, treatment, and prevention of pediatric obesity, which replaced the long-standing 2007 guideline. See "Systems" section, below, for specific referral parameters. [Styne: 2017]
Highlights of recommendations:

Calculate BMI and BMI percentiles for children and adolescents >2 years of age. Obesity is defined as a BMI ≥95th percentile for age and sex; extremely obese is a BMI ≥120% of the 95th percentile or ≥35 kg/m2.
Evaluate all children and adolescents with a BMI ≥85th percentile for potential comorbidities.
Consider metabolic and bariatric surgery for youth with obesity who are 10-19 years old.
Do NOT routinely perform laboratory evaluations for endocrine etiologies (including thyroid) of pediatric obesity unless the patient’s stature and/or height velocity are attenuated (assessed in relationship to genetic/familial potential and puberty stage).
Do NOT measure insulin concentrations when evaluating children or adolescents for obesity.
Avoid the use of obesity medications in children and adolescents <16 years of age who are overweight but not obese.

Clinicians should prescribe and support healthy eating and physical activity habits:

Avoid calorie-dense foods (e.g., sugar-sweetened beverages, fast foods, calorie-dense packaged snacks).
Enjoy whole fruits rather than fruit juices.
Engage in at least 20 minutes (optimally 60 minutes) of vigorous physical activity at least 5 days per week.
Reduce screen time to increase opportunities for physical activity.
Use comprehensive behavior-changing interventions (e.g., school or community-based programs) and family-centered lifestyle modifications.
Encourage breastfeeding for numerous health benefits.

Specific counseling by the primary care clinician depends upon the child’s age and BMI, as well as the parents’ weight status and involvement. Weight Goals and Intervention Stages (AAP), Table 8 in [Barlow: 2007], makes recommendations for specific goals and interventions according to age and BMI categories.

Pearls & Alerts for Treatment & Management

Contraception may be less effective and exacerbate obesity

Transdermal combined hormonal contraception is less effective in girls with obesity and intramuscular depo-medroxy progesterone acetate (Depo-Provera) may exacerbate obesity. Better options include long-acting reversible contraceptives such as the subcutaneous progestin-containing implantable rod (Nexplanon) or the levonorgestrel intrauterine device (Mirena, Skyla, or Kyleena). Alternatives include combined oral contraceptives or an intra-vaginal ring (NuvaRing). Contraception & Menstrual Management provides more detail about options and side effects.

Replace simple carbohydrates with healthier options

Examples are consuming brown rice instead of white rice, corn chips instead of potato chips, whole-grain bread instead of white bread, fruit instead of cookies, and water instead of soda.

Behavioral therapy

Behavioral therapy has been shown to be more effective than cognitive behavioral therapy in helping children with obesity.

Metabolic and bariatric surgery

MBS is now considered a safe and effective intervention for adolescents with class II and class III obesity because it can reduce the risk of persistent obesity and the resulting significant comorbidities and improve quality of life. [Pratt: 2018]

How should common problems be managed differently in children with Obesity in Children ?

Growth or Weight Gain

Monitor children and adolescents who are still growing (have not completed puberty) for appropriate height growth. To avoid nutritional deficiencies that impair normal height growth, maintain or decreased weight gradually,

Development (Cognitive, Motor, Language, Social-Emotional)

Developmental problems should not be managed differently in children and adolescents with obesity. Children with developmental problems may be at greater risk for having obesity; promote healthy lifestyle behaviors with these children and their families.

Viral Infections

Excess adipose tissue is associated with increased systemic inflammation and decreased immune function. Childhood obesity may reduce the immune system responsiveness to vaccines and microorganisms. Infection with adenovirus-36 may increase risk for obesity; at this time, there is no treatment or prevention for this infection. [Atkinson: 2011] [Sabin: 2015]

Bacterial Infections

Children and adolescents with obesity are more likely than those with a normal weight to develop bacterial infections due to impaired immune function. Obesity is a risk factor for developing a surgical site infection. [Blackwood: 2017]

Prescription Medications

The Pediatric Pharmacy Advocacy Group recommends weight-based dosing for prescription and over-the-counter medications in patients younger than 18 years who weigh less than 40kg (88lb) unless the recommended adult dose for the specific indication is exceeded. [Matson: 2017]

Common Complaints

Children and adolescents with obesity may complain, more frequently than those without obesity, of joint and muscle pain/discomfort, abdominal pain, heartburn, fatigue, shortness of breath, low self-esteem, depressed mood, and anxiety. They are more likely to be bullied, and therefore are more likely to avoid school and other social activities to avoid being bullied. [Beck: 2016]

Systems

Mental Health/Behavior

Behavioral Therapy
Behavioral therapy is the most used psychosocial modality for initiating change in obese children and it has been proven successful in adults. [Gilles: 2008] Behavior modification techniques typically address improving diet, increasing physical activity, and decreasing sedentary behavior. [Gilles: 2008] Specific methods include self-monitoring, praise and modeling, reinforcement, and contracting. [Saelens: 2007] Success has also been found with contingency-management therapy (highly effective treatment for substance use and related disorders) and controlling the environment (e.g., food and screen). [Saelens: 2007] Behavioral therapists theorize that obesity results from the lack of ability to control food intake; the use of food as a reward or punishment may contribute. This innate ability is lost by about age 10 or 11.
Behavioral therapy may be more effective than cognitive therapy in very obese children (BMI >97th percentile). [Ruxton: 2004] [Herrera: 2004] Approaches that target specific cognition, such as problem solving, have been used to enhance self-control and adherence to diet and exercise programs. [Gilles: 2008] A meta-analysis found cognitive-based therapies were not beneficial for weight-loss programs and may detract from behavioral components. [Gilles: 2008] For some children, particularly when there is comorbid depression/anxiety or a binge-eating disorder, referral to an experienced behavioral health specialist may be beneficial.
Inpatient or residential behavioral modification programs, such as intensive weight loss camp, can have dramatic results. In 1 study, weight loss after 1 year of behavioral modification in an inpatient setting resulted in a 50% decrease of excess body weight. One-third of those patients demonstrated continued weight loss and weight maintenance up to a year after completed treatment. [Latzer: 2009] However, the program cost and requirement that patients be removed from their natural environment are barriers for many families. The choice of control groups in these studies has been poor for comparison of outcomes, which threatens external validity. [Latzer: 2009]
Psychiatric Disorders
Binge eating disorder (BED) and loss of control eating disorder (LOC-ED) are seen in 5%-30% of obese children and adolescents. [Jelalian: 2007] Children more commonly experience LOC-ED. Children and adolescents with LOC-ED experience weight gain and emotional distress. Screen children and adolescent with obesity for adolescent BED using the Adolescent Binge Eating Scale (ADO-BED) Questionnaire ( PDF Document

268 KB) . [Chamay-Weber: 2017]

Specialty Collaborations & Other Services

Behavioral Therapies (see ID providers [31])

Families with children <10 years old may benefit from a behavioral program that offers child and family counseling focusing on learning new skills, problem solving, and managing feelings.

Family Counseling (see ID providers [66])

There is some evidence that family-based therapy with appetite awareness training is superior to family-based therapy. [Njardvik: 2018]

Nutrition/Growth/Bone

Even though controversy exists regarding the ideal diet for children, most researchers agree that providing nutritional education instead of a prescribed diet leads to more informed decisions by patients and families and better compliance. Children are encouraged to consume a planned diet, in portions appropriate for dietary/caloric intake recommendations, with 3 daily meals and 1-2 snacks that contain balanced macronutrients. The plan suggests eating low energy-dense foods with high water and fiber content, such as fruits and vegetables, and avoiding calorie-containing beverages. [Barlow: 2007] MyPlate (USDA) gives ideas for how to develop healthier eating habits and emphasizes creating plates of food with 1/2 vegetables and fruit, 1/4 grains, and 1/4 lean protein.

Specialty Collaborations & Other Services

Nutrition Assessment Services (see ID providers [1])

Refer families to nutrition counseling to assist in treating eating disorders and teaching healthy living habits.

Recreation & Leisure

A non-randomized controlled trial that looked at changes in weight status and cardiovascular risk factors found positive effects from exercise, such as reduced adiposity and insulin resistance, increased fitness and activity level, improved cardiac risk factors. These changes were sustained 12 months after the intervention ended. [Hughes: 2008] Even modest exercise, such as walking, can improve health outcomes, although encouraging children to reduce the amount of time they participate in sedentary activities is often more effective than encouraging physical activity. [Nowicka: 2007] Overweight children are more likely to engage in physical activity if they feel it is non-competitive, fun, and that they can go at their own pace. [Latzer: 2009]
Current recommendations for pediatric patients include reducing screen time (<2 hours per day) and encouraging spontaneous play (at least 1 hour per day). Children and parents should be educated about practical ways to meet physical activity goals, such as breaking up an hour of activity into smaller increments, taking up a hobby that helps with staying active, participating in a sport, and attending physical education classes at school. Clinicians should also talk with families about being patient in the development of skills and the significance of the involvement of family and friends. [Nowicka: 2007]
Conditions associated with childhood obesity that can affect exercise goals include:


Condition	Treatment Goal
Sleep problems (≥50% among adolescents with severe obesity) [Kalra: 2005]	Removal of tonsils and adenoids if obstructive sleep apnea; evaluation for continuous positive airway pressure therapy during sleep [Barlow: 2007]
Asthma (can be confused with poor physical conditioning) [Ford: 2005]	Treatment is no different from that for healthy-weight children [Ford: 2005]
Musculoskeletal discomfort and increased risk for fractures [Taylor: 2006]	Early intervention (including physical therapy, when indicated) [Taylor: 2006]
Depression [Ford: 2005]	Refer to a specialist as needed [Ford: 2005]

Specialty Collaborations & Other Services

Rec Centers, Parks, Zoos & Museums (see ID providers [19])

Recommend community recreation centers that offer physical and educational opportunities for children, teens, and the family. This is one way for families to be physically active together at least once a week.

Family

Parent-only or parent-plus-child interventions for weight management are typically more effective than child-only interventions when children are ≤13 years old. For adolescents, who tend to be more independent, clinicians should discuss health behaviors directly with them and encourage parents to make the home environment as healthy as possible. [Sothern: 2006]
While some controversy exists about the best way to incorporate family and peers in pediatric obesity treatment, parental modeling is a powerful predictor of a child’s weight change. [Epstein: 2010] [Wilfley: 2007] A meta-analysis suggests that success is more likely when parental involvement is combined with behavioral modification. Education needs to target both children and parents with reinforcement, as this leads to better short- and long-term outcomes, especially if the parent is overweight or obese. [Sothern: 2006] [Jelalian: 2007] Involvement of peers, especially in adolescent years, produces increased self-esteem and promotion of teamwork. [Jelalian: 2007] Clinicians can provide age-specific information about parenting actions. Recommendations need to take into account cultural values and beliefs.

Specialty Collaborations & Other Services

Behavioral Therapies (see ID providers [31])

Offers various child and family counseling focusing on learning new skills, problem solving, and managing feelings.

Pharmacy & Medications

Although weight loss medications usually are not used in children and adolescents, in some cases, they may be considered for adolescents. Two medications are FDA approved for weight loss in adolescents: Orlistat and phentermine.

Orlistat (Alli is over the counter and Xenical is by prescription) inhibits pancreatic lipase, which results in the loss of triglycerides in the feces. It is FDA approved for children ≥12 years old. To date, 5 randomized controlled trials have been conducted; 4 had favorable results and 1 reported no change between the treatment and control group. The risks and side effects of treatment are generally diarrhea and flatulence in those who consume higher quantities of fat. The studies found that the low-fat diet required to avoid side effects of the medication is difficult to maintain long term. [Latzer: 2009]
Phentermine (available by prescription) only is approved for use in individuals ≥17 years old for a 12-week period. Adverse effects include tachycardia and elevated blood pressure. There are limited data on its efficacy in adolescents.

Medications that are not approved for weight loss but are approved for other indications and may result in weight loss include:

Bupropion may be an excellent option for treating adolescent with co-existing depression because it has the added potential to decrease impulsive eating and diminish appetite.
Metformin is used by some clinicians to aid weight management; however, this medication is considered “weight neutral” and is probably most effective as an adjunct to increased physical activity and reduced simple carbohydrates in those with severe insulin resistance.
Topiramate is used in combination with phentermine (Qsymia) as an adjunct to a reduced-calorie diet and increased physical activity for chronic weight management in adults ≥18 years old with an initial BMI of ≥30 kg/m2 or ≥27 with comorbidity.
Thyroid hormone should only be used with a diagnosis of hypothyroidism and with laboratory findings consistent with hypothyroidism. Never use thyroid hormone to treat obesity. Likewise, stimulant medications used to treat ADD/ADHD have not been demonstrated to be effective weight-loss medications, and they have the potential to cause tachycardia and hypertension.
Stimulants are the first-line medical treatment for ADHD and are known to have side effects that often result in appetite suppression and weight loss in patients with ADHD. However, stimulant medications have not been demonstrated to be effective weight-loss medications, and they have the potential to cause tachycardia and hypertension as well as risks of drug diversion.

There are FDA-approved weight-loss medications for adults ( ≥18 years old) with obesity who have an initial BMI of ≥30 or ≥27 with comorbidity. All are indicated as an adjunct to a reduced-calorie diet and increased physical activity for chronic weight management.

Belviq (lorcaserin) should be discontinued if a patient has not lost at least 5% of baseline body weight by week 12. Belviq is not recommended for pediatric patients.
Contrave (naltrexone + bupropion) has a black-box warning because it contains bupropion, an antidepressant that may increase risk of suicidal thoughts and behavior in children, adolescents, and young adults. Contrave is not recommended for pediatric patients.
Saxenda (liraglutide) is indicated as an adjunct to a reduced-calorie diet and increased physical activity for chronic weight management in adult patients (≥18 years old) with an initial BMI of 30 or 27 with comorbidity. Saxenda is associated with increased risk of thyroid C-cell tumors. Saxenda is not recommended for pediatric patients.

Surgery

Metabolic and bariatric surgery (MBS) is an extreme intervention that may prevent the continuation of comorbid conditions into adulthood. The Association for Metabolic and Bariatric Surgery recommends that children and adolescents 10-19 years of age should be considered as candidates for MBS if they have a BMI >120% of 95th percentile with comorbidity or a BMI >140% of 95th percentile. [Pratt: 2018] Contraindications to MBS include medically correctable causes of obesity, ongoing substance abuse problem (within the preceding year), medical/psychiatric/psychosocial or cognitive condition that prevents adherence to postoperative dietary and medication regimens, and current or planned pregnancy within 12-18 months of the procedure. MBS is now considered a safe and effective intervention for adolescents with class II and class III obesity because it can reduce the risk of persistent obesity and the resulting significant comorbidities and improve quality of life. [Pratt: 2018]

Specialty Collaborations & Other Services

Weight Loss Programs (see ID providers [0])

No Related Issues were found for this diagnosis.

Ask the Specialist

How do I address these concerns without offending parents?

A beginning statement may be, “Your child’s BMI is at the ____th percentile. Do you have any concerns about that?”

Do insurances pay for obesity services?

The Affordable Care Act stipulates that obesity screening and counseling be covered benefits under insurance plans that are not exempt. Depending on the insurance plan, children may be able to get these services at no cost to families. See Help Your Child Stay at a Healthy Weight - Healthfinder.gov.

Resources for Clinicians

On the Web

The Portal's page about Childhood Obesity Screening & Prevention has information and for clinicians.
Helpful Books

Goran MI, Sothern MS.
Handbook of Pediatric Obesity: Etiology, Pathophysiology, and Prevention.
Boca Raton: CRC Press / Taylor & Francis Group; 2005. 1574449125
Features contributions from leading experts on childhood obesity at the social, behavioral, environmental, metabolic, and genetic levels.

Sothern MS, Gordon ST, von Almen TK.
Handbook of Pediatric Obesity: Clinical Management.
Boca Raton, FL: CRC Press/Taylor & Francis; 2006. 1574449133
Compilation of management, medical, nutrition, psychological, and physical activity facts, models, theories, interventions, and evaluation techniques regarding management of pediatric obesity.

Web Resources

Guidelines for Physical Fitness (CDC)
Physical activity guidelines for adults and children; Centers for Disease Control and Prevention.

Obesity Statistics (CDC)
Statistics regarding childhood obesity and educational resources for patients; Centers for Disease Control and Prevention.

Pediatric Obesity Clinical Resources (Obesity Medicine Association)
Links to algorithms and related information from the AAP, USDA, CDC, and more.

Helpful Articles

PubMed search for articles within the last year about pediatric obesity

Pont SJ, Puhl R, Cook SR, Slusser W.
Stigma Experienced by Children and Adolescents With Obesity.
Pediatrics. 2017;140(6). PubMed abstract
Discusses the prevalence and adverse effects of weight stigma on pediatric patients and their families and provides 6 clinical practice and 4 advocacy recommendations regarding the role of pediatricians in addressing weight stigma.

National Heart, Lung, and Blood Institute Expert Panel.
Integrated guidelines for cardiovascular health and risk reduction in children and adolescents.
National Institutes of Health. NIH Publication No. 12-7486; October 2012. / http://www.nhlbi.nih.gov/guidelines/cvd_ped/peds_guidelines_full.pdf
Addresses the major population-based risk factors for cardiovascular disease in a single evidence-based set of guidelines.

Society for Adolescent Health and Medicine.
Preventing and Treating Adolescent Obesity: A Position Paper of the Society for Adolescent Health and Medicine.
J Adolesc Health. 2016;59(5):602-606. PubMed abstract / Full Text
Expert consensus and evidence to increase professionals' ability to prevent, screen, treat, and advocate effectively for obesity prevention and healthy weight promotion.

Baker JL, Farpour-Lambert NJ, Nowicka P, Pietrobelli A, Weiss R.
Evaluation of the overweight/obese child - practical tips for the primary health care provider: recommendations from the Childhood Obesity Task Force of the European Association for the Study of Obesity.
Obes Facts. 2010;3(2):131-7. PubMed abstract / Full Text
Simple and practical tools for the identification and management of children with, or at risk of, overweight and obesity in the primary care setting.

Clinical Tools

Growth/BMI Charts

WHO and CDC Growth Charts (CDC)
WHO growth standards for infants and children ages 0 to 2 years of age in the U.S and CDC growth charts for children and youth ages 2-19; Centers for Disease Control and Prevention.

BMI Percentile Calculator for Children and Teens (CDC)
The calculator provides BMI, BMI-for-age percentile, and an easy-to-read interpretation. Results can also be viewed on a CDC BMI-for-age growth chart; Centers for Disease Control & Prevention.

Toolkits

Healthy Care for Healthy Kids Obesity Toolkit for Practitioners (NICHQ)
Clinical tools related prevention, assessment and diagnosis, management and treatment, and community resource to help clinicians with the care of children who are overweight or at-risk for being overweight; National Institute for Children’s Health Quality.

Childhood Obesity Resource (NACHC) ( PDF Document 2.3 MB)
A toolkit with obesity prevention, assessment, and management information that includes BMI and blood pressure charts, patient and family questionnaires, algorithms and checklists, coding and billing tools, logs and trackers; developed by the Obesity Society and National Association of Community Health Centers.

Other

Weight Goals and Intervention Stages (AAP)
A table that includes goals and interventions according to age and BMI categories; from the Expert Committee Recommendations Regarding the Prevention, Assessment, and Treatment of Child and Adolescent Overweight and Obesity: Summary Report; American Academy of Pediatrics.

Adolescent Binge Eating Scale (ADO-BED) Questionnaire ( PDF Document 268 KB)
10-question screen developed to identify obese adolescents at risk for binge eating disorder (BED)

Patient Health Questionnaire-9 (PHQ-9) ( PDF Document 40 KB)
Nine-question depression screen in many languages with scoring information that can be used with adolescents 13-17 years old. Questions based on DSM-IV diagnostic criteria for major depressive disorder. Select a language and "Go to Selected Screener" for a PDF download.

Patient Education & Instructions

BAM! Body and Mind (CDC)
Learn about nutrition, physical activity, stress, and safety, or diseases through interactive, online activities. Designed for youth 9–12 years old and their teachers and parents; Centers for Disease Control and Prevention.

Resources for Patients & Families

Childhood Obesity (FAQ)

Information on the Web

MyPlate (USDA)
Offers personalized eating plans and interactive tools to help plan and assess food choices; US Department of Agriculture.

Let's Move! (obamawhitehousearchives.gov)
Resources for families, parents, children, communities, and health care providers for providing healthy food in schools, improving access to healthy, affordable foods, and increasing physical activity; First Lady Michelle Obama’s initiative for healthy families.

Rudd Center for Food Policy and Obesity
Nonprofit research center dedicated to combating obesity and improving nutrition.

Behavior, Environment, and Genetics in Causing Obesity (CDC)
How genes may play a role in the development of obesity; Public Health Genomics / Centers for Disease Control and Prevention.

Nutrition & Fitness (KidsHealth)
Nutrition, fitness, and overall health information for parents, kids, teens, and educators. Includes recipes, safety tips, and discussion of feelings; sponsored by the Nemours Foundation.

Bright Bodies Program
Weight management program for children ages 7-16. Includes recommendations for education, exercise, and lifestyle modification; Yale Center for Clinical Investigation and Pediatric Endocrinology, Yale School of Medicine.

Weight-Control Information Network (WIN)
Up-to-date, science-based information on weight control, obesity, physical activity, and related nutritional issues; National Institute of Diabetes and Digestive and Kidney Disease (NIDDK).

Robert Wood Johnson Foundation for Childhood Obesity
Improving the nation’s nutrition through access to healthy food and health policy.

Ending the Food Fight: Guide Your Child to a Healthy Weight in a Fast Food/ Fake Food World
A book, containing a nine-week program offering the tools -- including tasty recipes, motivational tips, and activities -- that can help families prevent the kitchen table from becoming a battleground.

Live Well (Intermountain Healthcare)
Education for families about healthy lifestyles; Intermountain Healthcare.

About BMI for Children and Teens (CDC)
Answers to frequently asked questions about BMI such as how it is calculated, what percentiles mean, and how children BMIs differ from adult BMI calculators; Centers for Disease Control and Prevention.

Studies/Registries

Adolescent Weight Control Registry (WCDRC)
Registry for adolescents; Weight Control and Diabetes Research Center.

Pediatric Obesity (clinicaltrials.gov)
Studies looking at better understanding, diagnosing, and treating this condition; from the National Library of Medicine.

Services for Patients & Families in Idaho (ID)

Service Categories	NW		NM	NV	OH	RI
Behavioral Therapies	1	9	20	1	31	34
Biochemical Genetics (Metabolics)	1	1	2	1	3	3
Developmental Assessments	1	104	6	1	35	55
Family Counseling		1	23		40	77
Medical Genetics	1	2	5	1	4	8
Nutrition Assessment Services			3	1	2	5
Pediatric General Surgery		4	5		4	2
Rec Centers, Parks, Zoos & Museums	3	10	80	3	21	67
Weight Loss Programs						2

For services not listed above, browse our Services categories or search our database.

* number of provider listings may vary by how states categorize services, whether providers are listed by organization or individual, how services are organized in the state, and other factors; Nationwide (NW) providers are generally limited to web-based services, provider locator services, and organizations that serve children from across the nation.

Authors & Reviewers

Initial publication: May 2014; last update/revision: October 2018

Current Authors and Reviewers:

Author:	Nicole Mihalopoulos, MD, MPH
Contributing Author:	Jennifer Goldman, MD, MRP, FAAP

Authoring history

2014: first version: Amber Baker, DNP/FNP-c^A; Nicole Mihalopoulos, MD, MPH^R

^AAuthor; ^CAContributing Author; ^SASenior Author; ^RReviewer

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