Pediatric obesity

Overview

In the United States, obesity is the most common dietary condition among children and adolescents. Approximately 21-24 percent of American children and adolescents are overweight, and another 16-18 percent are obese; obesity is more prevalent in certain ethnic groups.

Obesity in childhood increases the risk of insulin resistance and type 2 diabetes, as well as hypertension, hyperlipidemia, liver and kidney disease, and reproductive dysfunction. This syndrome also raises the chances of developing adult-onset obesity and cardiovascular disease.

Obesity in children is a complicated condition. Its frequency has risen so dramatically in recent years that many people regard it as a major health risk in the industrialized world. Obesity is becoming more common in all pediatric age groups, both sexes, and various ethnic and racial groups, according to the National Health and Nutrition Examination Survey.

Many variables are thought to have a role in the development of obesity, including genetics, environment, metabolism, lifestyle, and eating habits. However, more than 90% of cases are idiopathic; fewer than 10% are due to hormonal or genetic factors.

 

Pediatric obesity definition

Although the definition of obesity and overweight has evolved through time, it is still characterized as an excess of body fat (BF). There is no agreement on a cut-off point for overweight or obesity in children and adolescents. children aged 5–18 years and classed them as fat if their proportion of body fat was at least 25% for men and 30% for girls, respectively.

The Center for Disease Control and Prevention defined overweight as at or above the 95th percentile of body mass index (BMI) for age and “at risk for overweight” as between 85th to 95th percentile of BMI for age. European researchers classified overweight as at or above 85th percentile and obesity as at or above 95th percentile of BMI. 

Techniques such as BMI, waist circumference, and skin-fold thickness have been widely employed in the therapeutic setting. Although less reliable than research approaches, these methods are adequate for identifying danger. While BMI appears to be adequate for distinguishing adults, it may not be as beneficial in children due to their changing body shape as they grow. Furthermore, BMI does not differentiate between fat and fat-free mass (muscle and bone) and may overstate obesity in large muscular youngsters.

Furthermore, the development process varies between genders and ethnic groups. Studies that employed BMI to identify overweight and obese children based on percentage of body fat reported that this technique of categorization had a high specificity (95–100%) but a low sensitivity (36–66%). While the health implications of obesity are connected to excess fatness, the best technique of categorization should be based on direct fatness assessment.

Although techniques such as densitometry can be utilized in research, they are not appropriate for clinical usage. Bioelectrical impedance analysis (BIA) is commonly employed in big population-based investigations and clinical scenarios. For youngsters, waist circumference appears to be more accurate since it targets central obesity, which is a risk factor for type II diabetes and coronary heart disease.

 

Epidemiology

Pediatric obesity, often known as childhood obesity, is a rising global problem that need attention due to the burden it places on the healthcare system for both children and adults. Obesity among children and adults is mostly caused by the consumption of fatty foods and a high sugar diet, as well as cigarette smoking and a lack of exercise. Obesity affects 34% of children in the United States and is a major public health problem due to the high morbidity and death rates. Medical expenditures for obesity care have risen, accounting for 40% of the healthcare budget in 2006, with billions of dollars spent on health care each year.

 

Etiology 

It is commonly believed that the rise in obesity is caused by an imbalance between energy intake and expenditure, with an increase in positive energy balance being directly related to the lifestyle chosen and food consumption preferences. However, there is mounting evidence that an individual's genetic background has a role in predicting obesity risk.

Parenting style, family factors, and parents' lives all have a role. Environmental factors like as school regulations, demography, and parental work-related pressures all have an impact on eating and physical activity habits.

One of the most important elements investigated as a cause of obesity is genetics. According to some research, BMI is 25–40% heritable. However, in order to alter weight, genetic vulnerability must frequently be combined with other environmental and behavioral variables. Less than 5% of occurrences of childhood obesity are caused by a hereditary component. As a result, while genetics may play a role in obesity development, it is not the cause of the substantial increase in juvenile obesity.

The basal metabolic rate has also been investigated as a potential cause of obesity. The basal metabolic rate, often known as metabolism, is the amount of energy expended by the body during typical resting processes. In sedentary individuals, the basal metabolic rate accounts for 60% of total energy expenditure. Obese people, it has been hypothesized, have lower basal metabolic rates. Differences in basal metabolic rates, on the other hand, are unlikely to be the cause of increased obesity rates.

Youngsters learn by imitating their parents and classmates' food choices, consumption, and readiness to try new cuisines. The availability of and regular exposure to nutritious meals is critical for building preferences and overcoming food aversion.

Mealtime routines are vital since studies show that families that dine together eat more healthful meals. Furthermore, dining out or watching TV while eating is linked to greater fat consumption. The feeding style of the parents is also important.

Government and societal policies may also encourage healthy behavior. According to research, the most significant element in teenage snack selections is flavor, followed by hunger and price. Other studies show that teenagers link junk food with enjoyment, freedom, and convenience, but preferring nutritious food is regarded as unusual.

Dietary variables have been intensively researched for their potential impacts to growing obesity rates. Fast food intake, sugary beverages, snack items, and portion sizes are among the dietary aspects that have been studied.

Fast food intake: In recent years, increased fast food consumption has been related to obesity. Many families, particularly those with two parents who work outside the home, choose these locations because they are often preferred by their children and are both convenient and inexpensive. Fast food restaurants sell foods that are rich in calories but lacking in nutritional value. Research looked at the eating patterns of lean and overweight teenagers in fast food outlets. 

 

History and Physical Examination

Short height or a slow rate of linear development in an obese kid implies growth hormone insufficiency, hypothyroidism, cortisol excess, pseudohypoparathyroidism, or a hereditary disease such Prader-Willi syndrome.

Hypothyroidism is indicated by a history of dry skin, constipation, cold sensitivity, or fatigability. If an obese adolescent develops overt diabetes, polyuria and polydipsia may be observed.

A history of CNS injury (eg, infection, trauma, bleeding, radiation therapy, seizures) supports hypothalamic obesity with or without pituitary growth hormone insufficiency or pituitary hypothyroidism. A history of morning headaches, vomiting, vision abnormalities, and excessive urination or drinking may also indicate that the obesity is the result of a tumor or mass in the hypothalamus.

Selective fat buildup in the neck, trunk, and purple striae indicates an excess of cortisol, especially if the pace of linear development has slowed.

The emergence of indicators of sexual development at a young age shows that the weight increase is the result of premature puberty. Excessive facial hair, acne, and irregular periods in a teenage female, on the other hand, imply that the weight gain may be due to cortisol excess or polycystic ovarian syndrome (PCOS). Obesity can be associated by facial hair, abnormal menstrual cycles, and hypertension.

Clinical clues that suggest a hormonal etiology for childhood obesity include the following:

  • Weight gain out of character for the family
  • Obesity in a short child
  • Progressive weight gain without a comparable increase in linear growth
  • Dry skin, constipation, intolerance to cold, and fatigability
  • History of central nervous system (CNS) damage (eg, trauma, hemorrhage, infection, radiation, seizures)
  • Accumulation of fat in the neck and trunk but not in the arms or legs
  • Purple striae (stretch marks)
  • Hypertension
  • Inappropriate sexual development at an early age
  • Excess facial hair, acne, and/or irregular menses in a teenage girl
  • Headaches, vomiting, visual disturbances, or excessive urination and drinking
  • Treatment with certain drugs or medications

 

Diagnosis

Identify any genetic or hormonal disorders that may be the cause of a child's obesity.

A blood hemoglobin A1c level, as well as fasting and 2-hour post-glucola glucose and insulin levels (to assess glucose tolerance and insulin resistance) are indicated in the assessment of type II diabetes mellitus. Obese children and adolescents with a fasting plasma glucose concentration more than or equal to 86 mg/dL are most likely to have impaired glucose tolerance.

The following laboratory studies may also be indicated in patients with obesity:

  • Fasting lipid panel for detection of dyslipidemia
  • Thyroid function tests
  • Serum leptin
  • Adrenal function testing, where required, can rule out Cushing syndrome.
  • When indicated by clinical history and physical examination, karyotype (using fluorescence in situ hybridization [FISH] for Prader-Willi ).
  • When indicated, growth hormone secretion and function tests are performed.
  • When indicated, reproductive hormones (including prolactin) are measured.
  • Serum calcium, phosphorus, and parathyroid hormone levels are measured to rule out possible pseudohypoparathyroidism.
  • Transaminases (liver function tests) are used to check for non-alcoholic fatty liver disease (non-alcoholic steatohepatitis)

When clinically warranted, acquire MRI of the brain with a focus on the hypothalamus and pituitary gland.

 

Management

In theory, all treatment interventions in the kid with obesity must regulate weight increase and reduce body mass index (BMI) in a safe and effective manner, as well as avoid long-term problems of obesity in childhood and adulthood.

Manage any acute or chronic obesity consequences, and get mental help if you have atypical eating habits or severe depression. Create a care plan that focuses on long-term nutrition and exercise, family support, and avoiding severe weight fluctuations. A collaborative approach to therapy that includes the efforts of nurse educators, nutritionists, exercise physiologists, and counselors is likely to be the most beneficial.

In some circumstances, consultations with a pulmonary (sleep) medicine expert, orthopedist, and/or gastroenterologist may be necessary. Avoid punitive measures and instead promote positive conduct.

Because dramatic BMI reductions are difficult to achieve and maintain in children and adolescents as well as adults, starting counseling and therapy with realistic goals that emphasize gradual reductions in body fat and BMI and weight loss maintenance rather than a rapid return to ideal body weight may be prudent. Body weight loss is followed by a corresponding decrease in energy consumption. As a result, maintaining a certain weight in an obese patient needs a lower calorie consumption than maintaining an equivalent weight in a non-obese patient.

 

Behavioral Treatment

For very obese children, family-based behavioral weight management is beneficial. Children aged 8 to 12 years with an average body mass index (BMI) percentile for age and gender of 99.18 had a substantial decrease in the percentage of overweight children at 6 months when compared to normal care. 

Small but substantial improvements in medical outcomes were reported in extremely obese toddlers aged 6 and 12 months; binge eating influences the first response to family-based behavioral therapy. Children who self-reported binge eating had a 2.6 percent rise in percentage overweight in response to acute therapy, whereas those who did not binge ate had an 8.5 percent drop; however, this difference did not hold during longer-term follow-up.

Children who reported binge eating made up 11.5 percent of the research subjects; they were younger, had more depressed, anxiety, and eating disorder symptoms, and had poorer self-esteem than those who did not report binge eating. 

Any intervention is doomed to fail if family members do not actively participate and support it. The youngster in question may be only one among several obese family members, and successful therapy frequently necessitates a shift in the entire family's eating habits. In certain circumstances, family counseling may be quite effective.

 

Lifestyle Modifications, Exercise, and Physical Activity

Although no one therapy program can be definitively suggested, integrated behavioral lifestyle treatments result in considerable weight loss. Although orlistat and sibutramine (both banned from the US market) can be used as supplements to lifestyle changes, they must be taken with caution.

Tobacco smoking suppresses appetite and is utilized by many adults and teens to avoid or control weight gain. The negative repercussions of smoking obviously exceed the advantages of weight management, and all children and adolescents should be strongly discouraged from smoking. Obese teenagers who stop smoking should take precautions to avoid gaining too much weight.

Physicians and parents should urge children to engage in rigorous physical exercise throughout adolescence and young adulthood, as well as restrict their time spent watching television, watching videos, and playing computer games. Even 20-30 minutes of daily walking can help with weight control.

Exercise minimizes weight gain by increasing energy expenditure and has a positive impact on cardiovascular health, lowering body fat and total cholesterol levels, increasing lean body mass and high-density lipoprotein (HDL) levels, and improving psychological well-being. Controlled trials have shown that lifestyle fitness regimens combined with food limitations promote long-term weight management in children and adolescents.

According to the findings of a comprehensive review and meta-analysis research, exercise referral systems have not been proved to be an effective way of boosting physical activity or lowering depression in sedentary people when compared to normal treatment. More research is needed to determine the impact on health-related outcomes.

 

The World Health Organization released guidelines on sugar intake. 

The guidelines include the following:

  • The World Health Organization recommends limiting your intake of free sugars throughout your life.
  • WHO recommends limiting free sugar intake to less than 10% of total calorie intake in both adults and children.
  • WHO recommends lowering free sugar consumption to less than 5% of total calorie intake. Monosaccharides and disaccharides added by the manufacturer, chef, or consumer to foods and drinks, as well as sugars naturally present in honey, syrups, fruit juices, and fruit juice concentrates, are examples of free sugars.
  • Levels should not be raised in nations with a low consumption of free sugars. Increased intakes of free sugars jeopardize nutritional quality by delivering considerable energy without particular nutrients.
  • These suggestions were based on a comprehensive examination of the research on the association between free sugar intake, body weight, and dental caries.
  • Increasing or decreasing free sugar consumption is related with parallel changes in body weight, and the association exists independent of free sugar intake amount. Excess body weight connected with free sugars intake is the outcome of excessive energy consumption.
  • Fluoride exposure decreases dental caries at a particular age and delays the initiation of the cavitation process, but it does not entirely prevent dental caries, and dental caries advances in fluoride-exposed populations.
  • When alternative options are available, consuming free sugars is not regarded a suitable technique for boosting calorie intake in those with insufficient energy intake.
  • These recommendations do not apply to those who require therapeutic diets, such as for the treatment of severe and moderate acute malnutrition. Separate recommendations for the management of severe and mild acute malnutrition are being established.

 

Reduced Fat and Very Controlled–Energy Diets

In many juvenile patients with mild or moderate obesity, an energy-restricted balanced diet combined with patient and parent education, behavioral change, and exercise can prevent weight gain.

Programs that change eating habits in families are more likely to succeed. According to one research, individuals who participated in 12-week commercial weight-management programs lost more weight than those who got primary care programs, which were more expensive to offer.

Total and saturated fat reductions may be especially beneficial in teenagers who consume a lot of high fat, snack, and packaged fast meals such french fries, pizza, chips, and crackers. Adult studies show that a reduced fat consumption is connected with a lower body weight, BMI, and waist circumference. While comparable findings in children have yet to be validated, a meta-analysis of current pediatric research indicates a clear link between fat consumption and weight increase. 

In the United States, the average diet for children and adolescents comprises roughly 35% fat. The World Health Organization (WHO) recommends limiting fat consumption to 30% of total energy; nevertheless, no data, epidemiologic or experimental, supports the assumption that a reduced-fat but otherwise unrestricted diet is sufficient for significant weight loss in obese persons. A low-fat diet may be more effective for primary or secondary prevention of weight gain in those who have previously been obese, especially if they have a genetic predisposition.

 

Very controlled–energy diets

A protein-sparing modified fast can result in quick weight loss in an inpatient or outpatient context, and it has been used effectively by multiple researchers in children and adolescents with obesity. A year-long study of 73 pediatric patients aged 7-17 years, for example, found significant reductions in the percentage of overweight, total body fat (TBF), body mass index (BMI), total and low-density lipoprotein (LDL) cholesterol, triglycerides, and fasting serum insulin, but no change in fat-free mass. Unfortunately, because this and many other studies paired the diet with behavior change and a strong exercise regimen, measuring the benefits of the diet alone is impossible.

A high-protein diet does not lessen the urge to consume in obese youngsters. Overweight and obese children randomized to one of two isoenergetic diets, a regular 15% protein diet or a 25% protein diet, experienced equal weight reduction, body composition changes, and changes in hunger or mood. Overall, the youngsters dropped 5.2 3 kg of body weight and had a 0.25 lower BMI standard deviation score. However, assessments of desire to eat increased considerably with both diets during the course of the intervention.

In general, very low–energy diets have a high dropout rate and have been linked to lean weight loss, gallstone development, cardiac arrhythmias, and sudden mortality in adults. Furthermore, some research suggests that regaining weight following a strict diet may result in overshoot, with extra weight deposited as a larger percentage of body fat.

Concerns have been raised about the long-term cardiovascular consequences of such weight cycling in adults, but the implications of significant or cyclical weight fluctuations in children and adolescents remain unclear.

More importantly, the long-term consequences of very low–energy diets on adolescent growth and development, as well as later reproductive function, musculoskeletal development, and intermediate metabolism, are unknown. Because of these uncertainties and the challenges associated with sustaining extreme caloric restriction, highly controlled–energy diets cannot be advised for the great majority of obese children and adolescents.

 

Psychopathology – Intensive Intervention

Anecdotal evidence shows that children with significant obesity may develop substantial psychiatric illnesses (e.g., suicidal ideation, manic depression, or other depressive disorders) that need hospitalization or long-term treatment. It is unknown whether the majority of these mental problems predate, cause, or result from obesity or its treatment. Children who undergo obesity treatment programs, like adults, may be at an increased risk of developing psychopathology.

Because many antidepressant drugs, notably tricyclic antidepressants (TCAs), promote hunger and weight gain, treatment of mental illnesses may complicate or worsen issues with weight control. Provide psychologic support to obese patients and send them for psychiatric assessment and care if there is evidence of psychopathology or dysfunction.

As previously said, any therapy intervention in an obese kid or teenager is unlikely to be successful without the knowledge, consent, and active engagement of family members. Family therapy is useful in individuals who are resistant to other therapeutic methods, particularly those who have obese parents.

 

Surgical Intervention

Various bariatric surgical treatments have been employed in adults and certain adolescents (most centers, patients 15 years) with a BMI greater than 40 kg/m2 or weight greater than 100 percent of optimum body weight (IBW).

 

Vertical-banded gastroplasty

Gastric restriction is the most prevalent surgery. Vertical-banded gastroplasty (VBG) involves the creation of a pouch with a capacity of 15-30–mL, which significantly reduces the amount of food that can be taken at any given time. The gastric bypass creates a bigger pouch that drains into the jejunum. As a result, nutrients bypass the duodenum and the majority of the stomach, resulting in dumping syndrome.

The procedure's overall effectiveness is good, with significant weight loss, a reduction in obesity complications, and an increase in life expectancy; however, the procedure has a 1% mortality rate in adults, and complications include encephalopathy, nephrolithiasis, cholelithiasis, protein-losing enteropathy, and other nutritional deficiencies.

 

Laparoscopic adjustable gastric banding

Because of its relative safety and reversibility, laparoscopic installation of an adjustable gastric band (LAGB) has substituted the VBG. The LAGB is used by wrapping a collar around the upper stomach, 1-2 cm below the esophagogastric junction, with an internal, saline-filled balloon. This forms a 30-mL upper gastric pouch, which may be altered by injecting a tiny quantity of saline into a subcutaneous port connected to the balloon.

 

Conclusion 

Childhood obesity has developed as a major public health issue in the United States and across the world. Currently, one in every three youngsters in the United States is overweight or obese. The rising incidence of childhood obesity is linked to the advent of formerly regarded "adult" disorders such as type 2 diabetes, hypertension, nonalcoholic fatty liver disease, obstructive sleep apnea, and dyslipidemia.

Obesity in children is most commonly caused by a positive energy balance caused by caloric intake in excess of caloric expenditure mixed with a genetic propensity to weight gain. The majority of obese youngsters do not have a single underlying endocrine or genetic explanation for their weight increase.

The evaluation of obese children aims to determine the source of weight gain and to screen for comorbidities caused by excess weight. Family-based lifestyle treatments, such as dietary changes and increased physical activity, are the foundation of pediatric weight control. In establishing the beginning stage of therapy, a phased approach to pediatric weight management is advised, taking into account the child's age, the degree of obesity, and the prevalence of obesity-related comorbidities.

Lifestyle therapies have only had a little impact on weight loss, especially in children with severe obesity. There is little data on the efficacy and safety of weight loss drugs in youngsters. In teenagers with extreme obesity, bariatric surgery has been shown to be beneficial in reducing excess weight and alleviating comorbidities. However, research on the long-term effectiveness and safety of bariatric surgery in teenagers is sparse.