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Written By: Jackie Ballou Erdos, MS, RD, CSSD, Registered Dietitian & Owner, Balancing Act Nutrition, New York, NY
Reviewed by William A. Neal, MD, professor emeritus, pediatrics (cardiology), West Virginia University, Morgantown, WV

It’s been close to a decade since The Endocrine Society’s guidelines on pediatric obesity1 have been updated. For many clinicians, the latest revisions—from the European Society of Endocrinology and the Pediatric Endocrine Society, and funded by the Endocrine Society—are long overdue.
“Childhood obesity is not something that can be prevented in the doctor’s office, it’s prevented in the community in which the child lives,” says Dennis M. Styne, MD, Yocha Dehe Chair of Pediatric Endocrinology and a professor of pediatrics at the University of California, Davis. As chair of the task force that established the new guidelines, Dr. Styne has emphasized the need to form alliances among government officials, the education sector, urban development groups, and healthcare professionals.
What are the new recommendations?

In addition to strategic partnerships, the new guidelines encourage breastfeeding, given its many well-established benefits, yet with the caveat that the relationship between breastfeeding and obesity prevention is less clear than was once thought. As Dr. Styne explains, “We absolutely recommend breastfeeding. But unfortunately, several studies have suggested that maybe it isn’t the one unequivocal way to prevent obesity.”
Not surprisingly, Dr. Styne and his guidelines co-authors also continue to recommend decreasing or eliminating intake of sugar-sweetened beverages, and limiting juice intake to 4 to 6 ounces a day for children 6 months to 6 years old, and 8 to 12 ounces daily for kids 6 years and older. Whole fruit is preferred over juice, and 5 to 7 servings of fruits and vegetables per day are encouraged.2

Further, the guidelines recommend increasing the number of opportunities for children to be active. The authors acknowledge that technology, and with it, screen time, has increasingly become a part of everyday life. They endorse the practice of offsetting time spent being sedentary with physical activity, and prescribe a more moderate recommendation, given that the condition of obesity itself makes it more difficult to be active.2 While 60 minutes of vigorous physical activity 5 days per week is ideal, an initial goal of 20 minutes 3 to 5 days per week may be more realistic as a starting point, and has been shown to yield metabolic benefits.2
Rest is critical, too. Obtaining adequate sleep (8 to 11 hours a day) of good quality is a new prevention strategy recommended in the 2017 guidelines. As Dr. Styne explains, “If you don’t sleep enough, you’re more insulin-resistant and it affects your carbohydrate metabolism in an adverse manner.”2
Reducing stress and addressing dysfunctional family dynamics are also emphasized in the guidelines as important obesity-prevention tactics.2 Add to that school- and community-based interventions that employ specific behavior change strategies as part of childhood obesity-prevention measures.
Guidelines for screening young patientsThe guidelines recommend using body mass index (BMI) to diagnose childhood obesity. Although imperfect and limited in the information it provides, BMI is easily calculated and is still a useful tool, Dr. Styne believes.

Styne says diagnosing pediatric obesity and assessing the child for comorbidities early on are paramount. The 2017 guidelines recommend evaluating children and adolescents as young as 2 years old with a BMI greater than or equal to the 85th percentile (defined as overweight) for obesity-related comorbidities.2
The updated guidelines also include new benchmarks for alanine aminotransferase (ALT) levels, which are used to monitor the risk of non-alcoholic fatty liver disease (NAFLD). “We’re worried about a boy having a value over 25 and a girl having a value over 22,” Dr. Styne says.
What about evaluating young patients for diabetes?

“The hemoglobin A1c in a teenager isn’t necessarily as accurate as in the adult in diagnosing diabetes,” Dr. Styne says. The authors of the 2017 guidelines acknowledge that an international expert committee recommended in 2009 that the same diagnostic criteria for diabetes using HbA1c levels be applied to adolescents, but caution clinicians that this recommendation is based on adult studies only. Other pediatric studies, the authors go on to say, have shown that HbA1c isn’t a good indicator of prediabetes or diabetes (underestimating the incidence of both), and note that in high-risk youths, there’s good support for using other tests in combination with HbA1c when making a diagnosis (such as a fasting, random, or oral glucose tolerance test).2 The guidelines also steer clinicians away from testing insulin levels, given that there are no clear diagnostic criteria for insulin resistance, and that temporary insulin resistance commonly accompanies the conclusion of puberty.

In addition to diabetes and NAFLD, the authors encourage screening patients with a BMI greater than or equal to the 85th percentile for dyslipidemia, hypertension, polycystic ovary syndrome, obstructive sleep apnea, and psychosocial problems.2
Assessment of endocrine and genetic disorders is also covered in the guidelines. “An endocrine evaluation isn’t so important unless you have clear evidence of an endocrine problem, or the child’s growth is attenuated,” Dr. Styne says. “However, there are genetic causes of obesity which can be diagnosed. At present it’s about 7% of the most extreme obesity [cases].” Specifically, the guidelines recommend a genetic evaluation for patients younger than 5 years of age with extreme obesity (BMI >120% of the 95th percentile) accompanied by genetic obesity syndrome characteristics (such as food-seeking behaviors or hyperphagia), with or without a history of family members with extreme obesity.2

Treatment options can vary widely
“Lifestyle [modification] is most important for prevention, and it’s the most important method of treating obesity,” Dr. Styne stresses. Dietary changes endorsed by the guidelines are in agreement with recommendations set forth by the American Academy of Pediatrics and the U.S. Department of Agriculture, such as reducing intake of fast food, salty or fatty processed foods, added sugars, and high-fructose corn syrup, while increasing intake of fruits and vegetables. The guidelines also encourage educating families about portion control and strategies to address common eating cues, such as boredom and stress.2
Dr. Styne’s team recommends resources published by dietitian and family therapist, Ellyn Satter, to help clinicians and families navigate struggles at the dinner table. “Dietitians are an incredibly important resource,” Dr. Styne says.

Treatment guidelines for physical activity mirror prevention recommendations,2 and Dr. Styne says working with communities and schools to increase safe opportunities for children to be active is key to helping families meet physical activity goals. Additionally, the authors recommend limiting nonschool-related screen time to 1 to 2 hours per day.2
Screening for psychosocial comorbidities and making appropriate referrals to mental health professionals—as well as working with the entire family to support effective parenting styles and communication methods—is at the foundation of treating this chronic condition, per the guidelines.2 Notably, children with obesity have reported quality of life scores similar to those of patients with diabetes and cancer, and are at higher risk for anxiety, depression, eating disorders, substance abuse, and low self-esteem, underscoring the need for a sensitive approach.2

When is surgery warranted?
The new guidelines also discuss pharmacotherapy and bariatric surgery as treatment options. “We caution against the use of medications approved for adults in children under 16, and we recommend that no one do it [prescribe anti-obesity agents] unless they have experience in the area, as children are not the same as adults,” Dr. Styne says.
Regarding weight loss surgery, the authors of the new guidelines state bariatric surgery may be indicated in patients who meet certain criteria, including: Tanner stage 4 or 5 in puberty; BMI >40 kg/m2, or BMI >35 kg/m2 with major comorbidities; patients whose weight and comorbidities have failed to improve with intensive lifestyle intervention; those who have undergone psychological assessment and have been deemed appropriate for surgery; and patients who are prepared to undertake necessary long-term lifestyle changes post-surgery.2 These recommendations align with best practices put forth by the American Society for Metabolic and Bariatric Surgery.3
Though clinicians play an important role in preventing, diagnosing, and treating pediatric obesity, Dr. Styne stresses that health professionals can’t succeed alone. “There’s a lot of work to be done,” he says. “Everyone has to play a role, including policy makers, politicians, and education professionals.”
Originally Published on 03/27/2017: http://www.medpagetoday.com/resource-center/Advances-in-Weight-Management/Pediatric-Obesity-Guidelines/a/64156?xid=NL_MPT_weight_management_2017-04-01&eun=g1143694d0r

 

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