Where to Begin With the Extremely Obese Child

Question: How does one treat a 210-lb 12-year-old?

Answer: First, one should obtain a history for risk factors (birth weight, exposure to diabetes in utero, family history, race/ethnicity, serial plot of body mass index [BMI], and past illness and medication history) and assess dietary intake, activity pattern, and sedentary behavior.

A third of obese youth have multiple risk factors for cardiovascular disease and type 2 diabetes.¹ Other possible irregularities include skeletal complications, pseudotumor cerebri, obstructive sleep apnea, polycystic ovary syndrome, nonalcoholic fatty liver disease, and psychosocial disorders. In addition to tests of fasting plasma glucose, lipids, and liver function, a sleep study, skeletal X-rays, serum insulin measurement, free testosterone and leutinizing hormone/follicle-stimulating hormone (LH/FSH) ratio tests, and cranial MRI should be performed as indicated.

CARE PATH

The initial intervention should be nutrition education in the context of a more comprehensive behavior therapy program. According to Stephen Daniels, MD, PhD, and colleagues, there are five guiding principles for treating childhood overweight:² 1) establish individual treatment goals and approaches based on the child's age, degree of overweight, and presence of comorbidities; 2) involve the family or major caregivers in treatment; 3) assess and monitor frequently; 4) consider behavioral, psychological, and social correlates of weight gain in the treatment plan; and 5) recommend dietary changes and increases in physical activity that can be implemented within the family environment and that foster optimal health, growth, and development.

Success has been achieved in limited randomized clinical trials that use behavior therapy. Nutrition education and behavioral techniques of contingency contracting (in which the child earns rewards for meeting short-term goals), self-monitoring of caloric intake and weight, praise, and stimulus control significantly reduced the percentage of subjects who remained overweight compared with those given nutrition education alone.³ These behavior-based programs can be found in special overweight camps and residential schools that also can control access to food and promote physical activity.

Pharmacotherapy can be considered if weight loss programs fail. However, there are limited studies of the use of pharmacotherapy with children. Sibutramine (Meridia, Abbott) plus comprehensive behavioral treatment has been shown to be more efficacious than the behavior program alone.⁴ However, the drug dosage was reduced or discontinued because of adverse events for many in the sibutramine group. Orlistat (Xenical, Roche) is approved for use in adolescence, and again the results have shown limited short-term benefit.⁵ Gastrointestinal side effects are frequent.

Finally, surgical intervention can be considered for older adolescents with a BMI ≥40 associated with severe comorbidities or BMI ≥50 if all else fails.⁶ Although data is limited, it appears weight-loss goals and reduction in morbidity can be achieved with bariatric surgery when performed by an experienced multidisciplinary team and reserved for youth who have completed linear growth.

Regardless of what approach is taken, to improve the chances that this child will succeed and to prevent more children from becoming obese in the first place, we must change the environment in which children live. ▪