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Obesity in Children: A Call to Action

By Sofia Shapiro, MD FAAP | Pediatric Endocrinology & Jaime Tsay, MD | Pediatric Endocrinology

Childhood obesity has become one of the biggest health problems in the United States.  This, in turn, has led to increases in obesity-related complications.  As a result, it is so important to recognize childhood obesity early and treat it before these complications occur.  How do we determine whether a child is obese?  The body mass index (BMI) compares a person’s weight in relation to their height and can be used for children 2 years of age and older.  A child with a BMI between the 85th and 95th percentile for his/her age is considered to be overweight and those with a BMI ? 95th percentile are considered to be obese.

 

Almost one third of children and adolescents in the United States are either overweight or obese!  The prevalence of obesity among children and adolescents tripled from the 1970s to 2000.  Childhood obesity is more prevalent in American Indian, non-Hispanic black, and Mexican American populations.  Having an obese parent also increases the risk of obesity in a child by 2-3 times.  Unfortunately, many obese children eventually become obese adults, but with proper education and changes in lifestyle, this can also be prevented.

 

Obesity in children can be caused by a variety of environmental as well as genetic factors.  Increased availability of unhealthy food choices to children such as sugar-sweetened beverages, unhealthy snacks, and increased portion sizes can lead to excessive caloric intake above a child’s needs.  In addition, we are seeing a more sedentary lifestyle in children with decreased physical activity and increased screen time (TV, smartphones, tablets, video games, etc.).   Decreased amount of overall sleep and even just the presence of a TV in a child’s bedroom, has been associated with higher rates of obesity.   Interestingly, less than 1% of childhood obesity is caused by an endocrine disorder such as hypothyroidism, cortisol excess, or growth hormone deficiency.

 

Treatment of obesity in children is challenging. Aggressive diet and exercise changes have always been the mainstay of therapy. Education about healthier choices, with complex carbohydrates instead of simple sugars, lean protein at every meal, as well as portion control, is the first step. Vigorous exercise of 45 minutes a day is recommended, which is difficult for children and adolescents with severe obesity or special needs, due to deconditioning and lack of motivation. If diet and exercise alone are not successful, medications can be considered. Metformin is the only drug approved for children older than 12 years of age—for those with insulin resistance and pre-diabetes such as metabolic syndrome or Polycystic Ovarian Syndrome. Metformin works by preventing the liver from making extra glucose. Orlistat (Xenical), which has recently been made available as an over-the-counter version “Alli”, is not approved in children. It works by blocking fat absorption; side effects are significant and include greasy stools, flatulence and malabsorption of fat-soluble vitamins. Locarserin (Belviq) is a new appetite suppressant that also has only been approved in adults. One of its more concerning side effects is heart valve problems. Currently, only specialized pediatric weight loss centers offer these two off-label medications, in cases of severe obesity where other treatments have failed, and as a part of a research study and under careful monitoring. Finally, bariatric surgery is now being offered to adolescents with severe obesity who have a BMI of 40 or greater, or those with BMI over 35 with comorbidities such as pre-diabetes, diabetes or polycystic ovarian syndrome.  Specialized centers involve the family into a team of pediatric endocrinologists, surgeons, psychologists and dieticians to treat these adolescents at highest risk. Laparoscopic adjustable gastric banding (LAGB) has been the procedure of choice, and in experienced centers it has been successful.

 

One of the main reasons we try to aggressively prevent and treat obesity is that it carries so many complications with it. Along with well-known risks such as for Type 2 diabetes, heart disease and hypertension, there are numerous others including joint problems, fatty liver disease, and obstructive sleep apnea. Slipped Capital Femoral Epiphysis (SCFE), an orthopedic emergency when the head of the femur bone slips off its shaft, is quite common in obese adolescents during their growth spurt, and requires surgical pinning. Finally, the psychologic ramifications of obesity cannot be overemphasized, where bullying and depression can arise because of one’s weight, can lower a child’s self-esteem, and start a vicious cycle of poor eating choices, less exercise, and worsening obesity. It’s very important to look for and recognize these psychologic concerns, and seek counseling promptly if it’s needed. It takes a team approach of physicians, family members, and school personnel to get involved and be successful in making healthier choices and leading a less sedentary, more active lifestyle.