Prevention and Management of Overweight and Obesity in Children and Adolescents

Table 3. Recommendations

A.   prevention of overweight and obesity in children and adolescent

N

Health questions

Source Guideline

Recommendations

Quality of evidence

Strength of Recommendation

A1

What are preventative methods for early prevention of overweight and obesity in children and adolescent by pediatricians, primary health care professionals, in outpatient clinics and primary health care facilities

WHO 2017

A1

• Exclusive breastfeeding is recommended for up to 6 months.

• Avoid excessive weight gain and/or increased weight-to- length ratio from the very first months of life.

• Solid foods and beverages other than breast milk or infant formulas should be introduced no earlier than 4 months and no later than 6 months

• Protein intake should be limited to less than 15% of the daily energy intake.

• Reduction of lipid intake to percentages indicated for adults is not recommended.

• Sweetened drinks should be avoided.

Moderate

Strong

Table 4. Recommendations

B. Diagnosis of overweight and obesity in children and adolescent.

N

Health questions

Source Guideline

Recommendations

Quality of evidence

Strength of Recommendation

B1

In overweight and obese infants, children and adolescents without co-morbidities, how can the healthcare provider diagnose the cause using history taking appropriate determination of the etiology?

Australian 2013

B1.

1-Developmental history:

➡️ Age.

➡️ Type of delivery, birth weight and length, gestational age at birth, maternal gestational diabetes.

➡️ Infant feeding, including duration of breastfeeding and /or formula.

➡️ Growth and development (e.g. age at which the child walked, talked).

2-Physical and mental health.

➡️ Weight history including previous weight management interventions, previous and current eating behaviours, recent weight gain.

➡️ Physical conditions associated with overweight (e.g. joint problems).

➡️ Physical disability affecting mobility.

➡️ Mental health (e.g. depression, anxiety, low self-esteem, eating disorder) and social experience (e.g. isolation, bullying).

➡️ Family history of obesity, type 2 diabetes, gestational diabetes, hypertension, dyslipidaemia, cardiovascular disease, sleep apnoea, polycystic ovary syndrome, bariatric surgery, eating disorders.

➡️ Medications that may contribute to weight gain (e.g. glucocorticoid, psychoactive agents).

➡️ Sleeping routine and presence of snoring.

➡️ Menstrual history for girls.

3- Health behaviours

➡️ Dietary intake (especially high intake of sugar-containing drinks and high-energy foods, and low intake of fruit and vegetables).

➡️ Previous and current dietary behaviours—for example, recurrent episodes of dieting, signs of pathological hyperphagia (such as eating large portions very quickly, being difficult to distract from food) and signs of disordered eating (such as binge eating).

➡️ Dietary patterns, for example, eating breakfast and regular meals, snacking, eating prepared foods outside the home (eating out, take-away).

➡️ Levels of physical activity and sedentary activity (e.g. hours spent in screen-based activities per day) (e.g. time spent being active, active transport, time spent outside, participation in structured exercise).

➡️ Family body-image behaviours (e.g. body perceptions, body checking and avoidant behaviours, body-related thoughts and beliefs, distress associated with body weight or shape, family talk and modelling related to body weight and shape).

4- Comorbidities

➡️ Is the person on medications associated with weight gain?.

➡️ Is fitness level sufficient for moderate-intensity activity?.

➡️ Is mobility impaired (e.g. due to obesity or comorbidities)?.

➡️ Is activity impeded by disability?.

➡️ Is lifestyle change impeded by disability?.

➡️ Has the person experienced life stressors (e.g. abuse, trauma, grief)?.

➡️ Is the person experiencing symptoms of depression?.

➡️ Is the person experiencing or at risk of an eating disorder?

Moderate

Strong

B2

In overweight and obese infants, children and adolescent's without co-morbidities, how the healthcare provider diagnose the cause, using general and focused examination for appropriate determination of etiology

Korean 2019

Australian 2013

B2

I- Anthropometric parameters: Weight, length/height, Waist and hip circumference are useful surrogates in estimating visceral fat.

• Children <24 months of age diagnosed as overweight if their weight for length is above the 95th percentile on the WHO Growth Charts

• Children and adolescents >2 years of age diagnosed with overweight when the BMI is above the 85th but less than the 95th percentile for age and sex, and obesity when the BMI is above the 95th percentile.

• A waist- to-height ratio of ≥ 0.5 may be useful in predicting cardiovascular risk and is easy to calculate.

II- Obesity focused clinical signs:

Clinical assessment aims to identify possible causes for overweight or obesity, and indicators of comorbidities

1- Cutaneous examination:

➡️  Acanthosis nigricans (velvety, light brown-to-black markings usually on the neck, under the arms or in the groin.

➡️ Intertrigo.

➡️ Hirsutism/acne from androgen excess: a sensitive examination of the status of excess hair in females.

➡️ Striae when associated with obesity are lighter and narrower. But if darker and wider in child with short stature with hypertension, screen for Cushing’s.

 2- Pubertal or tanner staging.

3- Skeletal problems:

➡️ If knee or hip pain, exclude slipped capital femoral epiphysis,

➡️  Pes planus (flat feet).

➡️  Genu valgum (knock knee).

➡️ Bowed tibias

4- Cardiac: measure blood pressure (with appropriate cuff size)

5- Respiratory examination: if in doubt refer

6- Abdominal examination- exclude hepatomegaly.

Low

Low    

Weak (conditional)

Weak (conditional)

B3

In overweight and obese infants, children and adolescents without co-morbidities, what are the basic laboratory tests requested by the health care provider to assess the case.

B3

· Complete blood count

• Lipid profile
• 25 hydroxy vitamin D level.
• Iron profile

Good Practice Statement

B4

When and to whom should the healthcare provider refer to overweight and obese infants, children and adolescents without co-morbidities?

Australian 2013

B4

The healthcare provider should refer overweight and obese infants, children and adolescents if upon examination there are red flags suggestive of endocrine, genetic, neurologic manifestations or evidence of co-morbidities

Moderate

Strong

Table 5. Recommendations

C. Management of overweight and obesity in children and adolescent

N

Health questions

Source Guideline

Recommendations

Quality of evidence

Strength of Recommendation

C1

Role of diet intervention for management of children and adolescent obesity without comorbidities by pediatricians, primary health care professionals, in outpatient clinics and primary health care facilities

Australian guidelines (2013)

C1.

• Regular meals including breakfast and snacks

• Healthy high nutritive value food

• Eat meals as family

• Provide a calculator for daily caloric, macro and micronutrients need depending on weight and age (difficult to interpret).

• We can use my plate as an easier alternative method. (5 meals per day, 3 hours apart, each meal is balanced containing one portion of protein, carbohydrate, vegetables and fruits each).

Moderate

Strong

C2

Role of lifestyle modification for management of children and adolescent obesity without comorbidities by pediatricians, primary health care professionals, in outpatient clinics and primary health care facilities

Australian (2013)

Korean 2019

Korean 2019

For children and adolescents who are overweight or obese, recommend lifestyle change including reduced energy intake and sedentary behavior, increased physical activity and measures to support behavioral change.

Focus lifestyle programs on parents, carers and families.

• Encourage moderate and physical activities

• Increase daily activities (walking to school)

• Be involved in sport team

• Parents should be active with the child (playing, walking)

• Be role model by being active themselves

• Avoid controlling or restricting to the child’s food intake

• Avoid using food as rewards

• Comfort the child with attention instead of food

• Decrease time –screen-based activities

• Separate eating from watching tv or computer

Physical activity

1. Active moderate to vigorous activity for at least 20 min/day to 60 min/day, 5 days/week

2. Programmed exercise targeting decreasing body fat

3. Increasing daily physical activities

Behavioral changes

1. Recommend family-based approach to adapt healthier habits and decrease parental obesogenic lifestyle pattern

2. Decrease sedentary time, nonacademic screen time, digital activities 1-2 hr/d

3. Adequate sleep pattern

4. Setting realistic goals for change

5. Development of public health interventions to control overweight and obesity in children with lower socioeconomic status

Moderate

Low

High

High

Strong

Weak (conditional)

Strong

Strong

C3

What is the pharmacological role in management of children and adolescent  obesity

Australian (2013)

C3

• Drug treatment is not generally recommended for children younger than 12 years.
• In children aged ≥ 12 years, treatment with orlistat is recommended only if physical comorbidities (such as orthopedic problems or sleep apnea) or severe psychological comorbidities are present.
• Treatment should be started in a specialist pediatric setting, by multidisciplinary teams with experience of prescribing in this age group
• Orlistat acts by inhibiting pancreatic lipase and increasing fecal losses of triglyceride

Low

Weak (conditional)

C4

What is the role of bariatric Surgical procedure referral in adolescent obesity ?

Australian (2013)

Korean 2019

C4

• For post-pubertal adolescents with a BMI > 40 kg/m2(or > 35 kg/m2 with obesity-related complications), laparoscopic adjustable gastric banding via specialist bariatric/pediatric teams may be considered if other interventions have been unsuccessful in producing weight loss.

• Bariatric surgery should only be undertaken by a highly specialized surgical team within the framework of a multidisciplinary approach.

Aim (how to detect TTT success)

1.BMI 85-94 (overweight):

Weight maintenance until BMI < 85 (for all age group 2-18 years).

2.BMI 95-98 (obesity)

•  2-5 -years: maintain weight until BMI <85 or weight loss not more than 0.5 kg/month (assess that adequate energy diet is obtained)

• 6-18years: weight loss not more than 0.9 kg/month

3. BMI >/ 99(severe obesity):

• 2-5 years: gradual weight loss not more than 0.5 kg/month.

• 6-18 years: gradual loss of weight not more than 0.9 kg/month

Low

Moderate

Weak (conditional)

Strong