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may include liver ultrasound, an oral glucose tol- erance test, more detailed endocrine assessment and polysomnography.
Treatment Strategies
Systematic reviews of pediatric obesity treatment show that lifestyle interventions can lead to im- provements in weight and cardiometabolic out- comes [7, 8] . While there is no evidence to sup- port one specific treatment program over anoth- er, meta-analyses show that family-targeted behavioral lifestyle interventions can lead to a
mean BMI reduction of 1.25 to 1.30 when com- pared with no treatment or usual care [8] . The longer the duration of treatment, the greater the weight loss observed [8] . Lifestyle interventions also lead to improvements in low-density lipo- protein cholesterol, triglycerides, fasting insulin and blood pressure up to 1 year from baseline [8] .
Some of the challenges of treatment are that
‘real-world’ obesity clinics are often more poorly resourced than in clinical trials, and clinic pa- tients may be more socially disadvantaged, or have a broader range of comorbidities, than those who take part in trials, making treatment adher- ence more difficult.
Table 1. Elements of history-taking in obese children and adolescents
General history Prenatal and birth – history of gestational diabetes and birth weight Infant feeding – duration of breastfeeding
Current medications – glucocorticoids, some antiepileptics and antipsychotics
Weight history Onset of obesity and duration of parental and child concerns about their weight
Previous weight management interventions Previous and current dieting behaviors Complications
history
Psychological – bullying, poor self-esteem, depression Sleep – snoring, symptoms suggestive of sleep apnea Exercise tolerance
Specific symptoms related to gastroesophageal reflux, gallstones, benign intracranial hypertension, orthopedic complications, enuresis, constipation
Menstrual history (girls) Family history Ethnicity
Family members with a history of: obesity, type 2 diabetes, gestational diabetes, cardiovascular disease, dyslipidemia, obstructive sleep apnea, polycystic ovary syndrome, bariatric surgery, eating disorders
Lifestyle history Diet and eating behaviors – breakfast consumption, snacking, fast-food intake, beverage consumption, family routines around food, binge eating, sneaking food
Sedentary behavior – daily screen time; numbers of televisions, gaming consoles, computers and smart phones in the bedroom and home; pattern of screen time
Physical activity – after school and weekend recreation, sports participation, transport to and from school, family activities Sleep – duration and routines
Koletzko B, et al. (eds): Pediatric Nutrition in Practice. World Rev Nutr Diet. Basel, Karger, 2015, vol 113, pp 163–167 DOI: 10.1159/000360331
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However, the broad principles of management are well recognized [1–4, 7, 8] : management of obesity-associated comorbidities; family involve- ment; a developmentally appropriate approach;
long-term behavior modification; dietary change;
increased physical activity; decreased sedentary behaviors; a plan for longer-term weight mainte- nance strategies; and consideration of the use of pharmacotherapy and other nonconventional therapies.
Elements of Treatment
Family Focus
Many clinical trials show that family-based inter- ventions can lead to long-term relative weight loss, i.e. from 2 to 10 years. Parental involvement when managing obese preadolescent children ap- pears vital, although there are more limited data on management of adolescents.
A Developmentally Appropriate Approach
For preadolescent children, weight outcomes may be improved with a parent-focused interven- tion, without direct engagement of the child [9] . There are more limited data on the treatment of adolescent obesity than on younger children, and especially on interventions that would be sustain- able in most health care settings. Generally, pro- vision of at least some separate therapist session time with the adolescent seems appropriate.
Behavior Modification
Weight outcomes are improved with the use of a broader range of behavior change techniques [1–
4] . One such technique, goal-setting, can include performance goals (such as changing eating or ac- tivity behaviors) or outcome goals (such as spe- cific weight loss). Examples of the former include not buying cookies, or reducing television time to 3 h per day. Another technique, stimulus control, refers to modifying or restricting environmental
Table 2. Physical examination of obese children or adolescents and important physical findings [9, 11]
Organ system Physical findings Skin/subcutaneous
tissues
Acanthosis nigricans, skin tags, hirsutism, acne, striae, pseudogynecomastia (males), intertrigo, xanthelasmas (hypercholesterolemia)
Neurological Papilledema and/or reduced venous pulsations on funduscopy (pseudotumor cerebri) Head and neck Tonsillar size, obstructed breathing
Cardiovascular Hypertension, heart rate (cardiorespiratory fitness) Respiratory Exercise intolerance, wheeze (asthma)
Gastrointestinal Hepatomegaly and hepatic tenderness (nonalcoholic fatty liver disease), abdominal tenderness (secondary to gallstones or gastroesophageal reflux)
Musculoskeletal Pes planus, groin pain, and painful or waddling gait (slipped capital femoral epiphysis), tibia vara (Blount disease), lower-limb arthralgia and restriction of joint movement Endocrine Goiter, extensive striae, hypertension, dorsocervical fat pad, pubertal staging, reduced
growth velocity
Psychosocial Flat affect and low mood, poor self-esteem, social isolation Other – evidence of
a possible underlying genetic syndrome
Short stature, disproportion, dysmorphism, developmental delay
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influences in order to aid weight control, with ex- amples including not eating in front of the televi- sion, or using smaller plates and bowls within the home. A third commonly used technique, self- monitoring, involves the recording of a specific behavior or outcome, such as the use of a food di- ary, daily pedometer measurement of physical ac- tivity, or weekly weighing.
Dietary Change and Eating Behaviors
Treatment programs incorporating a dietary component can be effective in achieving relative weight loss in children and adolescents, although no one dietary prescription appears superior to another [8] . However, dietary interventions are usually part of a broader lifestyle change pro- gram, and are rarely evaluated on their own. The two most commonly reported diets are: (a) the modified stop/traffic light approach, where foods are color-coded on the basis of nutritional value and energy content to indicate those to be eaten freely (green) or more cautiously (amber, red), and (b) a calorie restriction/hypocaloric diet ap- proach. Both diets can lead to sustained weight loss across different settings and age groups [8] . The role of dietary macronutrient modification in the management of obese children and adoles- cents remains unclear.
In general, dietary interventions should follow national nutritional guidelines and have an em- phasis on the following [1–3] :
• Regular meals
• Eating together as a family
• Choosing nutrient-rich foods which are lower in energy and glycemic index
• Increased vegetable and fruit intake • Healthier snack food options • Decreased portion sizes
• Drinking water as the main beverage • Reduction in sugary drink intake
• Involvement of the entire family in making sustainable dietary changes
In advising patients and families on dietary chang- es, is there a risk of an eating disorder developing?
While most people with obesity do not have a binge eating disorder, the latter is more common in people with severe obesity. Further, overweight adolescents are more likely to binge-eat, and child- hood obesity is a risk factor for later bulimia. How- ever, professionally run pediatric obesity programs do not increase the risk of disordered eating and may improve psychological wellbeing [10] . Physical Activity and Sedentary Behaviors In clinical practice, increased physical activity may best result from a change in incidental, or un- planned, activity, such as by walking or cycling for transport, undertaking household chores and playing. Organized exercise programs have a role, with children and adolescents being encouraged to choose activities that they enjoy and which are sustainable. Limiting television and other small- screen recreation to less than 2 h per day is par- ticularly strategic, but may be challenging [11] . Parental involvement is vital and may include monitoring and limiting television use, role-mod- eling of healthy behaviors, and providing access to recreation areas or recreational equipment.
Long-Term Weight Maintenance
In those who undergo an initial weight manage- ment intervention, a period of further therapeutic contact appears to slow weight regain [12] . At present, there is limited evidence to guide the na- ture and type of long-term weight maintenance interventions.
Nonconventional Therapies
There is relatively limited evidence to guide the use of less orthodox treatment approaches such as very-low-energy diets, pharmacological therapy or bariatric surgery in treating severe pediatric obesity. Such therapies should occur on the back- ground of a behavioral weight management pro- gram and be restricted to specialist centers with expertise in managing severe obesity.
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Existing recommendations on management of pediatric obesity suggest that drug therapy (large- ly orlistat, a gastrointestinal and pancreatic lipase inhibitor) can be used in the treatment of severely obese adolescents, in the context of a tertiary care protocol provided by a multidisciplinary care team and incorporating continued diet and activ- ity counseling [1–4] . For obese, insulin-resistant adolescents there may be a role for the use of met- formin, an insulin-sensitizing agent [13] .
The few consensus guidelines for bariatric sur- gery in adolescents have highlighted its use in se- verely obese adolescents, with consideration of the adolescent’s decisional capacity and attainment of physical maturity, as well as the presence of a sup- portive family environment [1, 3, 4, 14, 15] . The need for management in centers with multidisci- plinary weight management teams, for the surgery to be performed in tertiary institutions experi- enced in bariatric surgery and for long-term mul- tidisciplinary follow-up has been emphasized.
Health Service Delivery Issues
Given the high prevalence and chronicity of pedi- atric obesity, there is a need for coordinated mod- els of care for health service delivery. One poten- tial approach, the chronic disease care model, is based upon a tiered level of service delivery relat- ing to disease severity [16] . Thus, while most peo- ple affected by the problem of obesity can be man- aged via self-care or family-based care, with sup- port from primary care or community-based health service providers, there is a need for treat- ment by multidisciplinary care teams, and possi- bly tertiary care clinics, for those who are more severely affected. Individual clinicians should be aware of the presence of other services within their geographic region, and the capacity of these to take referrals or to comanage patients.
target. Arch Pediatr Adolesc Med 2003;
157: 725–727.
12 Wilfley DE, Stein RI, Saelens BE, et al:
Efficacy of maintenance treatment ap- proaches for childhood overweight: a randomized controlled trial. JAMA 2007; 298: 1661–1673.
13 Quinn SM, Baur LA, Garnett SP, Cowell CT: Treatment of clinical insulin resis- tance in children: a systematic review.
Obes Rev 2010; 11: 722–730.
14 Baur LA, Fitzgerald DA: Recommenda- tions for bariatric surgery in adolescents in Australia and New Zealand. J Paediatr Child Health 2010; 46: 704–707.
15 Inge TH, Krebs NF, Garcia VF, et al:
Bariatric surgery for severely overweight adolescents: concerns and recommen- dations. Pediatrics 2004; 114: 217–223.
16 Department of Health: Supporting peo- ple with long term health conditions.
2007. http://www.dh.gov.uk/en/Publica- tionsandstatistics/Publications/Publica- tionsPolicyAndGuidance/Browsable/
DH_4100317.
References
1 Barlow SE; Expert Committee: Expert committee recommendations regarding the prevention, assessment, and treat- ment of child and adolescent overweight and obesity: summary report. Pediatrics 2007; 120(suppl 4):S164–S192.
2 National Health and Medical Research Council: Clinical practice guidelines for the management of overweight and obe- sity in adults, adolescents and children in Australia. 2013. http://www.nhmrc.
gov.au/guidelines/publications/n57.
3 Scottish Intercollegiate Guidelines Net- work: Management of obesity: a nation- al clinical guideline. 2010. http://www.
sign.ac.uk/pdf/sign115.pdf/.
4 National Institute for Health and Clini- cal Excellence: Obesity: guidance on the prevention, identification, assessment and management of overweight and obesity in adults and children. 2006.
http://guidance.nice.org.uk/CG43/
NICEGuidance/pdf/English.
5 Freedman DS, Wang J, Thornton JC, et al: Classification of body fatness by body
mass index-for-age categories among children. Arch Pediatr Adolesc Med 2009; 163: 805–811.
6 Garnett SP, Baur LA, Cowell CT: Waist- to-height ratio: a simple option for de- termining excess central adiposity in young people. Int J Obes (Lond) 2008;
32: 1028–1030.
7 Oude Luttikhuis H, Baur L, Jansen H, et al: Interventions for treating obesity in children. Cochrane Database Syst Rev 2009; 1:CD001872.
8 Ho M, Garnett SP, Baur LA, et al: Effec- tiveness of lifestyle interventions in child obesity: systematic review with meta-analysis. Pediatrics 2012;
130:e1647–e1671.
9 Golan M, Crow S: Targeting parents exclusively in the treatment of child- hood obesity: long-term results. Obesity Res 2004; 12: 357–361.
10 Hill AJ: Obesity and eating disorders.
Obes Rev 2007; 8(suppl 1):151–155.
11 Whitaker RC: Obesity prevention in pe- diatric primary care: four behaviors to
3 Nutritional Challenges in Special Conditions and Diseases
Key Words
Diarrhea ã Nutrition ã Children
Key Messages
• Diarrhea remains one of the leading causes of mor- tality among children under 5 years of age • Risk factors for diarrhea include those related to
poverty, undernutrition, poor hygiene, and under- privileged household conditions making children more at risk of developing infectious diarrhea • Recent evidence suggests that if a range of existing
interventions are scaled up, diarrhea burden can be significantly reduced © 2015 S. Karger AG, Basel
Introduction