Prevention and Management of Overweight and Obesity in Children and Adolescents

Childhood obesity is one of the most serious public health challenges of the 21st century. The prevalence has increased at an alarming rate, affecting many low- and middle-income countries particularly in urban settings.

The increasing prevalence of childhood obesity has led to the emergence of multiple serious obesity-related comorbidities that not only threaten the health of those affected but also promise to place a large strain on the health care system.

For children less than 5 years of age, overweight is weight-for-height greater than 2 standard deviations above WHO Child Growth Standards median; and obesity is weight-for-height greater than 3 standard deviations above the WHO Child Growth Standards median. Children and adolescents aged between 5–19 years, overweight is BMI-for-age greater than 1 standard deviation above the WHO Growth Reference median; and obesity is greater than 2 standard deviations above the WHO Growth Reference median is widely accepted that increase in obesity results from an imbalance between energy intake and expenditure, with an increase in positive energy balance being closely associated with the lifestyle adopted and the dietary intake preferences

Childhood obesity is associated with a higher chance of obesity, premature death and disability in adulthood. But in addition to increased future risks, obese children experience breathing difficulties, increased risk of fractures, hypertension, early markers of cardiovascular disease, insulin resistance and psychological effects.

This guideline focuses on prevention and management of pediatric obesity and complications.

Guideline development process and methods

After reviewing all the inclusion and exclusion criteria and quality appraisal results, the GDG/ GAG recommended using the following source original clinical practice guidelines (CPGs):

1. WHO: Assessing and managing children at primary health care facilities to prevent overweight and obesity in the context of the double burden of malnutrition, 2017,

2. The Clinical Practice Guidelines For The Management Of Overweight And Obesity In Adults, Adolescents And Children In Australia, 2013.

3. Clinical practice guideline for the diagnosis and treatment of pediatric obesity: recommendations from the Committee on Pediatric Obesity of the Korean Society of Pediatric Gastroenterology Hepatology and Nutrition. Korean J Pediatr. 2019 Jan;62(1):3-21.

We conducted Adolopment for these guidelines: (Adoption, Adaptation, and Development)

         -  Adoption for most of the guideline recommendations.

         -  Development of Good Practice Statements

Recommendations and Good Practice Statements (GPS)

This version of the CPG includes recommendations and good practice statements on the following four sub-sections:

A. Diagnosis of pediatric obesity and complications

The guideline covers infants, children and adolescents less than 17 years.

This guideline emphasis on early detection of overweight and obesity & identification of infants, children and adolescents at high risk of developing overweight and obesity.

B. Management of overweight and obesity.

This section includes recommendations and good practice statements on proper management of overweight and obesity in the targeted population. 

C. Prevention of overweight, obesity and future complications.

We can summarize the guidelines’ recommendations for Prevention and Management of Overweight and Obesity in Children and Adolescents in the following:

·  We recommend the following methods for early prevention of overweight and obesity in children and adolescent:

Exclusive breastfeeding is recommended 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.

(Strong recommendation).

·  In overweight and obese infants, children and adolescents without co-morbidities, we recommend that the healthcare provider diagnose the cause using history taking through asking about:

1-Developmental history including

➡️ 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 including

➡️ 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. glucocorticoids, psychoactive agents).

➡️ Sleeping routine and presence of snoring.

➡️ Menstrual history for girls.

3- Health behaviours including

➡️ 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 including

➡️ 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?

(Strong recommendation).

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

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.

(Weak (conditional) recommendation).

· In overweight and obese infants, children and adolescents without co-morbidities, we suggest the following laboratory tests to assess the case:

➡️ Complete blood count.

➡️ Lipid profile.

➡️ 25 hydroxy vitamin D level.

➡️ Iron profile

(Good practice statement).

· We recommend that 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.

(Strong recommendation).

· In children and adolescent obesity without comorbidities we recommend diet intervention for management as follow :

➡️ Regular meals including breakfast and snacks.

➡️ Healthy high nutritive value food.

➡️ Eat meals as family.

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

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

(Strong recommendation).

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

(Strong recommendation).

➡️  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 being 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.

(Weak (conditional) recommendation).

Physical activity :

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

➡️  Programmed exercise targeting decreasing body fat.

➡️  Increasing daily physical activities.

(Strong recommendation).

Behavioral changes :

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

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

➡️  Adequate sleep pattern.

➡️  Setting realistic goals for change.

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

(Strong recommendation).

· We suggest against drug treatment as it 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

(Weak (conditional) recommendation).

· For post-pubertal adolescents with a BMI > 40 kg/m2 (or > 35 kg/m2 with obesity-related complications), we suggest 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.

(Weak (conditional) recommendation).

To detect TTT success, we recommend :

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)

6-18 years: 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

(Strong recommendation).

Guideline Registration

PREPARE (Practice guideline REgistration for transPAREncy), WHO Collaborating Center for Guideline Implementation and Knowledge Translation, EBM Center, University of Lanzhou, Lanzhou, China. Registration Number: ((submitted and in process)). Link: http://www.guidelines-registry.org/