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Obesity in Children

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Obesity in Children, Childhood Obesity, Pediatric Obesity, Overweight Child

  • See Also
  1. Obesity
  • Epidemiology
  1. Number of obese children and adolescents in U.S. trippled between 1980 and 2000
  2. Prevalence in U.S. (2020)
    1. Overweight between age 2 to 19 in 2020: 19.7% (was 12% in 1994)
    2. Severe Obesity overall: 6.1%
    3. Age
      1. Age 2 to 5 years: 13%
      2. Age 6 to 19 years: 22%
    4. Race
      1. Mexican American: 26.2%
      2. Non-hispanic black: 24.8%
      3. Non-hispanic white: 16.6%
    5. References
      1. Hu (2022) JAMA Pediatr 176(10):1037-9 +PMID: 35877133 [PubMed]
  • Causes
  • Secondary Causes of Childhood Obesity (<10% of cases)
  1. Hypothyroidism
  2. Cushing's Syndrome (Hypercortisolism)
  3. Primary Hyperinsulinism
  4. Pseudohypoparathyroidism
  5. Hypothalamic abnormality
  6. Genetic Syndromes with Intellectual Disability
    1. Prader-Willi Syndrome
    2. Laurence-Moon or Bardet-Biedl Syndrome
    3. Borjeson-Forssman-Lehmann Syndrome
    4. Cohen Syndrome
    5. Ruvalcaba Syndrome
    6. Familial Lipodystrophy
  7. Genetic Syndromes without Intellectual Disability
    1. Alstrom Syndrome
    2. Turner's Syndrome
    3. Beckwith-Wiedemann Syndrome
    4. Sotos' Syndrome (cognitive delay may be present)
    5. Weaver Syndrome
  • Risk Factors
  1. Obesity Risk increases with television viewing time
    1. Lowest Prevalence for <1 hour/day: 8% Obesity
    2. Highest Prevalence for >4 hours/day: 17% Obesity
    3. Crespo (2001) Arch Pediatr Adolesc Med 155:363 [PubMed]
  2. Obesity in child's parent
  3. Decreased Physical Activity
    1. Physical Activity is inversely related to Obesity
  • Evaluation
  1. See Cardiac Risk Factors
  2. See Daily Energy Allowance
  3. Blood Pressure
  4. Body Mass Index (BMI) for age
    1. See Body Mass Index
    2. BMI 85 to 95%: Overweight
    3. BMI 95 to 120%: Obesity
    4. BMI >120%: Severe Obesity (or BMI>35 kg/m2)
  • Labs
  1. Lipid profile
  2. Indications for suspected secondary cause evaluation
    1. Short Stature (<5th percentile)
    2. Minimal to no Family History of Obesity
    3. Intellectual Disability
    4. Delayed Bone Age
    5. Physical findings suggest secondary cause
  • Complications
  1. See Obesity Risk
  2. Slipped Capital Femoral Epiphysis
  3. Tibia vara
  4. Adult Obesity (high risk)
    1. Kvaavik (2003) Arch Pediatr Adolesc Med 157:1212-18 [PubMed]
  5. Medical Conditions
    1. Hypertension
    2. Diabetes Mellitus
    3. Metabolic Syndrome
    4. Hyperlipidemia
  • Management
  • Lifestyle
  1. See Prevention measures below
  2. Lifestyle modification is indicated and the base for all weight loss strategies
  3. Significant Obesity (BMI>95%) is an indication for Intensive management
    1. More moderate changes in Exercise and diet are unlikely to significantly modify Obesity
  4. Set reasonable weight loss goal
    1. Monthly: 1 to 4 pound loss
    2. Month 3 to 6: 5 to 10 pound loss
  5. Employ 5-2-1-0 approach to lifestyle change
    1. Fruits and vegetables 5 or more
    2. Maximum recreational Screen Time limited to 2 hours or less
    3. Physical Activity of 1 or more hours per day
    4. Sugary drinks per day 0
    5. Adequate sleep
  6. Establish Dietary Guidelines
    1. See Food Pyramid
    2. Calculate Daily Energy Allowance
    3. Approximate a 500 calorie deficit per day
  7. Establish regular Exercise
    1. Exercise in addition to school physical education
    2. Home Exercise for more than 30 minutes/day
  8. Behavior Modification
    1. Stimulus control
    2. Modify eating habits
    3. Attitude change
    4. Reward positive new behaviors
  9. Involve family in Weight Reduction program
    1. Parent nutritional counseling
    2. Family activity
    3. Family television viewing limited
  1. Indications
    1. Age >12 years with severe, refractory Obesity
    2. Consider in age>8 years old
  2. Specific Medications (with FDA approval in children)
    1. See Obesity Medication
    2. Phentermine (age >=16 years)
    3. Orlistat (age >= 12 years)
      1. Poorly tolerated with leaking of greasy, foul smelling stools
    4. Phentermine/Topiramate (Qysmia) age >= 12 years (Teratogenic, withdrawal risk)
      1. BMI decreased >8% at 52 weeks on moderate dose (>10% on high dose)
      2. Kelly (2022) NEJM Evid 1(6):10.1056 +PMID: 36968652 [PubMed]
    5. Liraglutide 3 mg (age >= 12 years)
      1. BMI decreased >4% at 52 weeks
      2. However, weight gain is significant on stopping (likely applies to GLP1 Agonist)
        1. BMI returns to 1% below Placebo at 6 months after stopping medication
        2. Kelly (2020) N Engl J Med 382(22):2117-8 +PMID: 32233338 [PubMed]
    6. Semaglutide 2.4 mg (age >= 12 years)
      1. BMI decreased >16% at 68 weeks
      2. Nausea and Vomiting occurs in 36 to 42% of patients
      3. Weghuberj (2022) N Engl J Med 387(24):2245-57 +PMID: 36322838 [PubMed]
    7. Setmelanotide (age>= 6 years)
  1. Indications: Age >=13 years
    1. BMI >40 kg/m2 or 140% of 95th percentile
    2. BMI >35 kg/m2 or 120% of 95th percentile AND significant comorbidity
      1. Youth Onset Type 2 Diabetes Mellitus (Y-T2DM)
      2. Obstructive Sleep Apnea (AHI >5)
      3. Blount's Disease
      4. Significant Gastroesophageal Reflux Disease
      5. Nonalcoholic Steatohepatitis (NASH)
      6. Slipped Capital Femoral Epiphysis (SCFE)
      7. Idiopathic Intracranial Hypertension (IIH)
  2. Additional Requirements
    1. Obesity refractory to other intensive weight management (lifestyle, medications)
    2. Supportive family environment
    3. Capable and willing to follow postoperative nutritional guidelines
    4. Committment to comprehensive pre- and postoperative medical and psychologic evaluations
  3. Bariatric Surgery Procedures in Teens
    1. Sleeve Gastrectomy
    2. Roux-en-Y gastric bypass
  4. Adverse Effects
    1. See Bariatric Surgery
    2. Associated Vitamin Deficiency, decreased Bone Mineral Density
    3. Reintervention rates approach 25%
  5. Efficacy
    1. Significant sustained weight loss and clearance of comorbidities
  6. References
    1. Inge (2019) N Engl J Med 380(22):2136-45 + PMID: 31116917 [PubMed]
    2. Beamish (2023) J Clin Endocrinol Metab108(9):2184-92 +PMID: 36947630 [PubMed]
  • Prevention
  1. Provide balanced diet (see Food Pyramid)
    1. Maximize child's Dietary Fiber intake
    2. Eat 5 or more fruits and vegetables per day
  2. Eliminate excessive fat and sugars
    1. Limit fat calories to <30% of total calories
    2. Replace whole milk with skim milk at age 2 years
    3. Avoid fast-food and "junk-food" (e.g. potato-chips, twinkies)
    4. Avoid sugar-sweetened drinks (e.g. Gatorade, soda, fruit drinks)
    5. Limit high calorie foods in home
  3. Encourage healthy eating behaviors
    1. Eat meals as a family at least 5 days per week
    2. Limit eating out (esp. fast food restaurants)
    3. Do not skip breakfast
    4. Use appropriate food portions
    5. Food should not be used to comfort or reward child
    6. Treats should not be used to reward finishing a meal
    7. Child does not need to "clean plate": stop with satiety
  4. Encourage activity
    1. Limit television, computer and video games to 2 hour or less per day
    2. Do not keep a television in the child's room
    3. Foster active play and family Exercise for >30-60 minutes per day
  • Prognosis
  1. Children with Obesity will continue with Obesity as adults in 82% of cases
    1. Juonala (2011) N Engl J Med 365(20):1876-85 +PMID: 22087679 [PubMed]
  2. Longterm multisystem complications of Childhood Obesity and the associated Youth Onset Type 2 Diabetes Mellitus (Y-T2DM)
    1. Y-T2DM is associated with longterm Hypertension, Chronic Kidney Disease and Hyperlipidemia in >50%
    2. Bjornstad (2021) N Engl J Med 385(5):416-26 +PMID: 34320286 [PubMed]
  • Resources
  1. Shapedown Pediatric Obesity Program (Ages 6 to 20)
    1. http://www.shapedown.com
    2. Phone: 415-453-8886
  2. Children's Hospital of Pittsburgh
    1. http://www.chp.edu/clinical/03a_weightmanage.php
  • References
  1. (2023) Presc Lett 30(6): 33
  2. Kreipe (1998) Adolescent Health Update 10(2):1-8
  3. Kumar (2024) Mayo Clinic Pediatric Days, attended lecture 1/17/2024
  4. Moran (1999) Am Fam Physician 59(4):861-8 [PubMed]
  5. Rao (2008) Am Fam Physician 78(1): 56-66 [PubMed]
  6. Spiotta (2008) Am Fam Physician 78(9): 1052-8 [PubMed]
  7. Williams (1997) Ann N Y Acad Sci 817:225-40 [PubMed]