Medical Interventions for Children

Medical interventions for overweight/obese children (body mass index [BMI] above the 95th percentile) and children at risk for overweight/obesity (BMI above the 85th percentile but below the 95th percentile) begins with a clinical assessment, identification of the causes of weight gain, and changes in diet, physical activity, and lifestyle. When comorbidities pose significant health risk or if stabilizing or reducing fat mass in obese children through lifestyle changes is unsuccessful, further medical investigation and intervention are warranted. The targets of medical interventions of childhood obesity are to address causes of weight gain, prevent weight gain, initiate weight loss, and to treat the comorbidities.

Children's and adolescents' BMI should be attained during routine health visits, and the BMI should be plotted on the Centers for Disease Control and Prevention (CDC) age-for-BMI percentile charts. Information from a medical, family, nutrition, and physical activity history of obese children or children at risk for overweight/obesity will help determine the causes of obesity. Obesity is caused by a complex interplay of many factors, including genetic predisposition or abnormalities; environmental forces on nutrition and physical activity; sedentary behaviors; and medical reasons, such as disturbances to the hypothalamus (a region in the brain) or medications that stimulate weight gain. By understanding the reasons for obesity, further evaluation and recommendations can be made.

Screening for comorbidities, such as hypertension (high blood pressure), dyslipidemia (blood lipid abnormalities), nonalcoholic steatohepatitis (inflammation of the liver due to increased fat production and retention in liver cells), impaired glucose tolerance, and Type 2 diabetes (an inability to properly use insulin) may be indicated if the child has a BMI above the 95th percentile. Further reasons to screen for comorbidities include having a BMI above the 85th percentile and other comorbidities already present, a family history of comorbidities, or a child from an ethnic population with increased risk of comorbidity. A fasting blood lipids panel, a liver function test, and a glucose tolerance test are all examples of laboratory tests to screen for these comorbidities.

Weight maintenance is encouraged for children and adolescents with a BMI above the 85th percentile to prevent further weight gain. If obese children older than age 2 have a comorbidity or if children older than age 7 have a BMI above the 95th percentile, weight loss is recommended. Weight loss in obese children results in a reduction of fat mass, and many physical improvements throughout the body are attained. Often, weight loss in obese children can be difficult and many individuals undergoing substantial weight loss require the care of many healthcare specialists. The healthcare professionals involved in managing pediatric obesity should include a multidisciplinary team, including pediatricians, nurse practitioners, mental health specialists, nutritionists, endocrinologists, psychiatrists, pediatric geneticists, neurologists, school nurses, surgeons, pharmacists, and others.

Changes in diet, physical activity, and lifestyle are the primary methods to initiate weight maintenance and weight loss. The approach should be individualized; emphasis should be on the benefits of weight loss, setting realistic goals, and assessing motivation [Page 444]of the child and parents/caregivers. Family involvement in weight maintenance or weight loss is paramount, and the plan of action to maintain or lose weight must be catered to the family's willingness to make changes. Nutrition education for the family about portion sizes, caloric content of foods, and food choices are important to prevent hyperphagia (overeating). Emphasis of physical activity, a minimum of 30 to 60 minutes per day of moderate to vigorous intensity, is important for obese children. The choice of activity should depend on the child and his or her environment. Lifestyle changes, such as reducing sedentary activities, are important targets for weight management as well. Weight loss should not exceed two to four pounds per month, and monitoring this change is especially important for adolescents who have not yet achieved their final height.

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