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ENDO Panel Issues Pediatric Obesity Guidelines

Bruce Goldfarb

Clinicians need to act early to help curb later health problems in an increasing number of overweight children, emphasized a panel of experts at the annual meeting of the Endocrine Society, ENDO 07, held June 2–5 in Toronto. Panelists made that point during a presentation on soon-to-be-published guidelines for treating obesity in pediatric patients.

"It's important to look at childhood obesity as a precursor of adult obesity and institute corrective measures as soon as possible," says panelist Gilbert P. August, MD, a professor emeritus at George Washington University in Washington, D.C.

Studies show a marked increase in the prevalence of pediatric obesity in the U.S., which is presently around 17.1%, according to the panel. Comparisons of recent data with data from 1963–1970 suggest that the rate of obesity has increased almost threefold among children 2–5 years old, fourfold among those 6–11 years old, and threefold among those 12–19 years old, says August.

The panelists found developing sound recommendations for pediatric obesity management to be challenging because of poor-quality clinical research on the issue, says August. In light of this, he says, the guidelines, in many cases, offer suggestions rather than recommendations.

BMI GUIDANCE

The guidelines cite the Centers for Disease Control and Prevention (CDC) normative percentiles of body mass index (BMI) as a useful reference point for determining ranges for normal, overweight, and obesity. Obesity is defined as a BMI the 95th percentile, adjusted for age, sex, and ethnic group. Overweight is defined as a BMI in the 85th–95th percentile.

Critics note the CDC tables are based on decades-old measurements that don't factor in the country's expanding girth and its ethnic and cultural diversity. "These are charts from 20 years ago, when kids looked the way they were supposed to look," says panelist Dennis Styne, MD, a pediatric endocrinologist at University of California, Davis.

Still, the CDC tables are widely accepted and publicly available on the Web; they remain clinically useful until other methods of calculating body composition can be implemented in adulthood, according to the panel.

"We admit that the BMI is not an ideal surrogate for fatness," August says. "At present, there is no other gold standard that can take its place."

The guidelines don't recommend routine referral for an endocrine evaluation unless a growth-rate concern exists, but they do recommend referral to a geneticist when obesity is linked with neurodevelopmental abnormalities. The major weight-related endocrine disorders—hypothyroidism and Cushing's disease—are associated with stunted growth, August says.

SPECIFIC RECOMMENDATIONS

Regarding diagnosis, the guidelines suggest evaluating a patient for comorbidities if the BMI is the 85th percentile. Recommended screening tests and measurements include fasting plasma glucose, fasting lipid profile, blood pressure, and waist circumference.

Regarding treatment, the guidelines note:

• Lifestyle modification—diet and exercise—is the foundation for the treatment of obesity. Diet and exercise "works if somebody sticks to it," August says. "It's a sound principle."
  
• Pharmacotherapy may be added to lifestyle modification after a 6-month trial if a child has significant comorbidities. The drugs sibutramine (Meridia, Knoll Pharmaceuticals/Abbott) and orlistat (Xenical, Roche) are approved for treating pediatric patients. Both drugs have side effects and require monitoring by physicians, the panel suggests.
  
• Bariatric surgery involving a pediatric team should be considered only after 6 months of medical management in adolescents with >40 BMI with severe comorbidities, or in patients with >50 BMI. Bariatric surgery is not recommended for preadolescent children with an underlying eating disorder, a psychiatric disorder, or Prader-Willi syndrome. In addition, a patient's family should undergo presurgical psychological evaluation to assess ability to comply with postsurgical management and lifestyle modification efforts. Bariatric surgery is not recommended "if the family has not mastered lifestyle modification," August says. "It's important to emphasize that bariatric surgery is not a cure, but an adjunct to lifestyle modification."
  

Regarding prevention, the guidelines recommend:

• Mothers should breastfeed 6 months. The increased duration of breastfeeding diminishes the odds of obesity later in life, August says.
  
• Patients and families should be educated about portion sizes, which have increased dramatically in many restaurants and homes. "If you're presented with more food, you'll eat more food," says August.
  
• Schools should schedule a period of moderate to vigorous exercise daily and should provide only "nutritionally sound" foods. No sodas, sweetened drinks, or junk foods should be sold during school hours.
  
• Primary care physicians should provide "anticipatory guidance" to families at risk of obesity, diabetes, and cardiovascular disease. Recognizing potential problems early allows parents and health care providers to take preventive steps.
  

Members of the guidelines panel include Ilene Fennoy, MD, of Columbia University in New York; Francine Kaufman, MD, of Children's Hospital of Los Angeles; Robert Lustig, MD, of University of California, San Francisco Children's Hospital; Janet Silverstein, MD, of University of Florida, Gainesville; Phyllis Witzel Speiser, MD, of New York University; and Dennis Styne, MD, of University of California, Davis.

The guidelines will be published in an upcoming issue of the Journal of Clinical Endocrinology and Metabolism.

Footnotes

FYI

More information on calculating body mass index (BMI) for children and teens using the Centers for Disease Control and Prevention normative percentiles of BMI is available at http://www.cdc.gov/nccdphp/dnpa/bmi/childrens_BMI/about_childrens_BMI.htm.

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