Managing childhood obesity requires commitments from family, community, public policy
The worldwide prevalence of excess body weight in school-aged children is on track to reach 268 million by 2025 if current trends continue, and 91 million of these will have obesity, according to a report published in Pediatric Obesity. In 2013, 223 million children had overweight or obesity, and an estimated 41 million of these were aged younger than 5 years.
Experts warn that obesity in childhood not only increases the likelihood of obesity in adulthood, but also increases the likelihood of comorbidities attributable to obesity, such as elevated blood pressure, cardiovascular disease and type 2 diabetes.
“Becoming obese very early in life is almost certainly going to be more problematic than becoming obese later in life because we’re not very good at changing the trajectory of body weight,” Dennis M. Bier, MD, professor of pediatrics-nutrition at USDA/ARS, Children’s Nutrition Research Center at Baylor College of Medicine, told Endocrine Today. “We’re already dealing with a level of complications in childhood and adolescence that we formerly saw only in adults. The longer a child has obesity that persists into adult life, the more problematic the complications are going to be.”
But how to reverse obesity among children and adolescents is unclear. Although behavioral interventions have shown some short-term and long-term success, randomized controlled trials in children with long-term outcomes are lacking, particularly those starting in very young children.
“What we know is that, in a very oversimplified way (which is now under critique because of its simplifications), the correctional algorithm for reducing obesity is to eat less and exercise more,” Bier, who is an Endocrine Today Editorial Board member, said. “But this requires behavioral changes that are very difficult to institute and maintain over a long period of time.”
Thomas Inge, MD, PhD, FACS, FAAP, agrees. “For teenagers, in particular, the lifestyle interventions and even drug treatment have not been great, and most of the evidence for adolescents [suggests] that there is not good treatment that allows a teenager who has gained considerable extra weight to actually reverse it,” Inge, who is director of the division of pediatrics surgery and director of adolescent metabolic and bariatric surgery at the Children’s Hospital Colorado, told Endocrine Today. “It turns out that once obese, the biology of weight regulation works to oppose even the best efforts to lose weight and keep it off. In addition, there are other powerful forces in the environment, including our food system and lack of availability of exercise opportunities, to overcome once the obesity problem has emerged.”
Prevention is first step
Because achieving effective, long-lasting weight loss is extremely difficult after obesity occurs, the recently released Endocrine Society pediatric obesity guideline identifies prevention as key to obesity management. This can be addressed by “promoting a healthful diet, activity and environment,” according to the authors.
The U.S. Preventive Services Task Force recommends that health care providers screen all children aged 6 years and older for obesity and refer appropriate children for intensive counseling and behavioral interventions that promote weight loss.
According to Stephen R. Daniels, MD, PhD, chair of the department of pediatrics at University of Colorado School of Medicine, and pediatrician-in-chief and L. Joseph Butterfield chair in pediatrics at Children’s Hospital Colorado, screening for obesity is something every pediatrician and family physician should be doing.
Childhood obesity is currently defined as BMI at or above the 95th percentile for children and adolescents of the same age and sex. Obesity screening may include evaluation for obesity-related conditions, such as dyslipidemia, which the Endocrine Society guideline advises for children and adolescents with BMI at least in the 85th percentile for age and sex.
However, delaying screening until age 6 years may be too late to prevent obesity, according to Bier.
“The real action may be happening between birth and ages 3 to 5 years,” he said. “The problem in the childhood obesity field is that the data for the period from breast-feeding to age 3 years are poor. Few are based on systematic scientific data, and it is likely that it is in this critical developmental time period that things are happening that we may not be able to reverse later.”
The guideline recommends further that children with obesity onset before age 5 years, extreme hyperphagia or other clinical findings of genetic obesity syndromes or a family history of extreme obesity receive specific genetic testing.
Treatment options limited
“The field of pediatric obesity treatment has been dominated, as it should be, by thinking about nonsurgical methods of treatment, starting with prevention of the problem entirely and then moving to a behavioral-style management in order to improve control of excess weight gain,” Inge said.
Pharmacotherapy should be reserved for children and adolescents with obesity in whom a formal intensive lifestyle modification program has not halted weight gain or improved comorbidities, according to the guideline.
Two medications are approved for weight loss in children: metformin, which received FDA approval in 2000 for children aged 10 years and older with type 2 diabetes, and orlistat (Xenical, Hoffmann-La Roche; Alli, GlaxoSmithKline), a drug that blocks fat absorption, which received FDA approval in 2003 for children aged 12 years and older.
However, “even in the best studies, [orlistat] does not result in a tremendous amount of weight loss,” Daniels said. “We’re dealing with a situation where there are not any well-studied, very effective medications to use for weight management in children.
“The history of weight management medications is an unfortunate one,” Daniels said. “It is littered with drugs that people thought had a lot of promise but ended up having a lot of adverse effects. ... There is always hope that there will be some pharmacological approaches, but at the moment, there just aren’t any that people are excited about.”
The Endocrine Society guideline recommends weight-loss surgery only for certain patients with advanced pubertal development, extreme obesity and favorable family support. Surgery is indicated only for those adolescents near or at completion of growth with a BMI greater than 40 kg/m2 or BMI greater than 35 kg/m2 accompanied by mild to moderate obesity-related comorbidities.
In a study published in Lancet Diabetes and Endocrinology, Inge and colleagues evaluated data from the Follow-up of Adolescent Bariatric Surgery at 5 Plus Years (FABS-5+) study on participants aged 13 to 21 years who underwent Roux-en-Y gastric bypass (RYGB) for clinically severe obesity.
“Patients in the first year lost about one-third of their weight after RYGB,” Inge said. “We checked back in on them an average of 8 years later, and remarkably they were still maintaining about 28% weight loss. So, for the most part, these long-term data show us that surgery allows one to significantly reduce weight and keep it off.”
Inge added that one of the major reasons adolescents do not opt for bariatric surgery is the perception of its risks.
“The fact that you could have a surgical complication that requires more surgery, the idea that you will need to change your eating choices, is intimidating for some,” Inge said. “Many times, it takes a while before people can wrap their head around the fact that it is a problem that won’t go away if nothing is done. In fact, the data would suggest the long-term mortality risk for being even just overweight as a teenager is quite measurable.”
Surgical delay also poses health risks, according to Inge.
“I don’t think the public knows that there is a finite window of opportunity to effectively reverse severe obesity,” he said. “The long-term outcomes are showing us that the best time to operate is when the BMI is less than 50 kg/m2 if we want to have the best chances of reversing severe obesity.”
Family, peer effects on obesity
The heritability of obesity is extremely high. The relative odds of a child developing obesity if one parent is obese are about threefold and increases to about 15-fold when both parents are obese, according to Bier.
“If you’re obese as a child, the odds are that you are going to be obese as an adult,” he said. “Most individuals who are lean throughout adult life do not have parents with obesity and were not obese as children. On the other hand, a majority of obese adults have at least one parent with obesity. What we know is that obesity is highly heritable. A significant amount of the heritability reflects gene variations. However, we now know that epigenetic alterations of gene expression also contribute significantly to heritability estimates. Genes do not operate in the absence of the environment; if your genetic risk is high, an adverse environmental risk will magnify the risk for an adverse outcome.”
In 2016, a conference supported by the Agency for Healthcare Research and Quality, the American Academy of Pediatrics Institute for Healthy Childhood Weight and The Obesity Society was held to make recommendations for specific lifestyle modification treatments. The consensus report stated that children should have access to specific multicomponent interventions that include dietary modifications, physical activity changes, behavior strategies and active parental involvement.
“Children’s weight-related behaviors exist in the context of their home and family environment,” Denise E. Wilfley, PhD, Scott Rudolph university professor at Washington University School of Medicine, St. Louis, told Endocrine Today. “By including parents in their child’s treatment, the goal is to capitalize on this parental influence to promote healthier behavior choices and maximize health outcomes for both parent and child. Parent weight loss in family-based behavioral treatment has been shown to predict [a child’s] weight loss, highlighting the important relationship between parent and child weight.”
According to the consensus report, family-based behavioral treatments that include active parent involvement result in superior child weight outcomes compared with interventions in which a parent does not participate. Family-based interventions include behavior changes to improve nutrition or dietary behaviors, promote physical activity and reduce sedentary behaviors for children as well as their parents who have overweight or obesity. They also encourage healthy peer relationships.
“In a family-based behavioral treatment, families are encouraged to establish healthy peer networks and to disentangle socializing from unhealthy activities,” she said. “In an effort to improve children’s confidence in their ability to relate positively to peers, family-based behavioral treatment also includes training in pro-social techniques for dealing with teasing and cognitive-behavioral techniques to improve body image and self-esteem.
“Peer interactions are naturally reinforcing to children, and good peer relationships have a positive influence on overall quality of life. When peers are supportive of healthy energy–balance behaviors, weight-loss maintenance efforts are enhanced,” Wilfley said.
Difficulties families face in adopting and maintaining lifestyle changes for their children with obesity are compounded by difficulties in accessing treatment.
“When you screen for something, you have to be able to do something about it,” Daniels said. “We’re doing better at recognizing obesity, measuring height and weight, calculating BMI percentile and then using that as the way to decide on treatment, but there are still barriers for many children with overweight and obesity to get appropriate treatment.”
Questions of who should disseminate weight counseling and behavioral intervention programs, and how to train them, pose one barrier, according to Stephen R. Cook, MD, MPH, associate professor, department of pediatrics, University of Rochester Medical Center.
“It’s not a part of formal behavioral therapy approaches that I’ve seen and not formally part of the medical school education and curriculum,” he said. “The Academy of Nutrition and Dietetics has probably gone the farthest to try to create training models, but it’s not part of the formal residency or clinical-hour internships in behavioral health that’s available.”
Another barrier is paying for treatment.
“Even though a good portion of children’s hospitals try to offer some type of obesity service, they might have to scale back or close the program or service because of the lack of reimbursement,” Cook said. “Obesity is the only chronic condition that affects a significant number of children that is not paid for formally. Why would a hospital, children’s hospital or pediatrics department set up a service, which is not going to be cheap, when there is not even a guaranteed payment?”
Daniels added that payment may depend on individual insurance plans. For example, Medicaid coverage varies from state to state.
“Now having said that, I’ve been doing this for a while, and there was a time when we started focusing on clinical programs for obesity when essentially every insurance company had an exclusion for treatment of obesity,” he said. “Back then, 15 to 20 years ago, insurance companies saw obesity as more of a cosmetic problem than a medical problem. We’ve made a lot of progress since then, and there is much more recognition that this is an important medical problem and that it should be dealt with in childhood. Overall, we have a better situation than we used too, but still it could be better.”
The Affordable Care Act requires private insurance plans to cover evidence-based screening and counseling programs for children that have an “A” or “B” rating by the USPSTF.
“However, despite substantial evidence that obesity warrants early and comprehensive treatment and is mandated by the Affordable Care Act, many insurers do not provide coverage for childhood obesity treatment,” Wilfley said. “When coverage is offered, it is often limited in scope and does not support treatments of adequate duration or breadth to effectively impact childhood obesity.”
“We need to think about how to change our environment to help kids so that the healthier decision is the easier decision to make,” Daniels said. “We need neighborhoods that encourage physical activity. We need neighborhood organizations like the YMCA and Boys & Girls Clubs of America and other things to help with this. We need ways of helping families make better choices about the food they buy and consume. We need the food industry to help with those decisions that people make.”
Ellen L. Connor, MD, co-author of the Endocrine Society guideline, agrees. Obesity prevention and healthy lifestyle require large-scale public health changes in diet and physical activity, Connor, who is a pediatric endocrinology professor at the University of Wisconsin School of Medicine and Public Health, Madison, told Endocrine Today.
“These are things that need to happen on a societal level,” she said. “Avoidance of obesity is not something that we can just prescribe and expect a family to do without societal, federal and global support.”
According to the guideline, despite the increase in research on pediatric obesity during the past decade, further study is still needed for the genetic and biological factors that may increase risk for weight gain and influence response to interventions.
Bier agrees. “There are likely very early periods in fetal, neonatal or early postnatal life where the biological regulatory responses that deal with food intake, appetite, satiety and the metabolic events following macronutrient ingestion become fixed, so to speak, and thus become much harder to alter later because the pathways of development have been altered in some permanent way,” he said.
Epigenetic studies in mice are revealing ways in which feeding or hormonal exposures during critical periods of development permanently affect neural connections governing appetite and satiety, for example.
“We don’t know for sure that similar events occur in humans, but the proof of principle has been established,” Bier said. “Thus, while we don’t know yet the full extent of these processes in human infants, there is every reason to believe that the earlier you can achieve a beneficial effect on obesity, the more likely you will have success in the long term.” – by Amber Cox
- CDC. About Child and Teen BMI. Available at: www.cdc.gov/healthyweight/assessing/bmi/childrens_bmi/about_childrens_bmi.html. Accessed March 3, 2017.
- Hayes J, et al. Oral T-OR-2034. Presented at: ObesityWeek 2016; Oct. 21-Nov. 4, 2016; New Orleans.
- Inge TH, et al. Lancet Diabetes Endocrinol. 2017;doi:10.1016/S2213-8587(16)30315-1.
- Lobstein L, Jackson-Leach R. Pediatr Obes. 2016;doi:10.1111/ijpo.12185.
- Styne DM, et al. J Clin Endocrinol Metab. 2017;doi:10.1210/jc.2016-2573.
- U.S. Preventive Services Task Force. Pediatrics. 2010;doi:10.1542/peds.2009-2037.
- Wilfley DE, et al. Obesity. 2016;doi:10.1002/oby.21712.
- For more information:
- Dennis M. Bier, MD, can be reached at USDA/ARS Children’s Nutrition Research Center, Baylor College of Medicine, 1100 Bates St., Houston, TX 77030; email: email@example.com.
- Ellen L. Connor, MD, can be reached at University of Wisconsin School of Medicine and Public Health, 750 Highland Ave., Madison, WI 53726; email: firstname.lastname@example.org.
- Stephen R. Cook, MD, MPH, can be reached at the University of Rochester Medical Center, 601 Elmwood Ave., Box 643, Rochester, NY 14642; email: email@example.com.
- Stephen R. Daniels, MD, PhD, can be reached at the Children’s Hospital Colorado, 13123 E. 16th Ave., B065 Aurora, CO 80045; email: firstname.lastname@example.org.
- Thomas Inge, MD, PhD, FACS, FAAP, can be reached at the Children’s Hospital Colorado, 13123 E. 16th Ave., Box 323, Aurora, CO 80045; email: email@example.com.
- Denise E. Wilfley, PhD, can be reached the Washington School of Medicine, Department of Psychiatry, 660 S. Euclid Ave., St. Louis, MO 63110; email: firstname.lastname@example.org.
Disclosure: Bier reports having served as a consultant to various food companies in the past, most recently for Ajinomoto Co., Conagra Foods, Novartis International AG, Pfizer and Soremartec Ferrero Group. Inge reports having served as a consultant to Standard Bariatrics. Connor, Cook and Daniels report no relevant financial disclosures. Wilfley reports having served as a consultant for Shire Pharmaceuticals and Sunovion Pharmaceuticals.