Obesity in children increased three- to sixfold from 1950 to 2000 with 12% to 18% of those ages 2 to 19 years defined as obese according to the 2000 CDC growth charts.1 In the past 10 years, obesity seems to have hit a plateau except in male children ages 6 to 19 years.2 Data through 2008 show that in children ages 2 to 19 years, 17% are obese and 32% are overweight (ages 2 to 5: 10.4%, 6 to 11: 19.6%, 12 to 19: 18.1%).3
Obese children can become obese adults and suffer increased health burdens. Numerous health issues seen in obese adults are now being seen in obese children. Increased risk and incidence of type 2 diabetes mellitus, fatty liver, hypertension, increased lipid profiles, asthma, and increased risk of anesthesia complications have been reported in obese children. Obese children have also been shown to suffer from increased incidence of depression and low self-esteem.
As a result of childhood obesity, life expectancy is actually expected to decline for the first time since 1900 when the government began predicting and keeping records.4 In 2005, an obesity researcher from Children's Hospital Boston stated that life expectancy was reduced by 4 to 9 months in obese children but expected the reduction to increase to 2 to 5 years over the next decades.2 The results of a study that followed Pima Indian children for a median of 23.9 years showed that obesity, glucose intolerance, and hypertension during childhood were strong risk factors for premature death.5
The need for screening
In February 2010, the United States Preventive Services Task Force (USPSTF) released an updated guideline for obesity screening in children and adolescents.1,6 The major recommendation is that providers should screen children age 6 years and up for obesity and refer those found to be obese to intensive counseling and behavior interventions for weight management. (Grade B recommendation-high certainty that the net benefit is moderate or moderate certainty that the net benefit is moderate to substantial.)6,7 Body mass index (BMI) is the screening tool recommended and is calculated from the patient's height and weight. Overweight is defined as the 85th to 94th percentile and obesity as the 95th percentile or greater for age and sex.1 (See Obesity in children and adolescents.)
The evidence did not support screening children younger than 6 and the current guideline does not recommend it.1,6 However, if overweight and obesity is a problem within the family, it would be prudent to consider dietary and behavioral counseling for the family.
Behavior and counseling
Behavior and other counseling interventions, including diet and exercise, have demonstrated positive results, such as a decrease in BMI, maintained for at least 1 year after treatment.6 Incorporating the parents of younger children into the treatment plan may help improve results by changing the behavior of those who provide the food and set the example for diet and exercise. Programs with the best results are defined as moderate-to-high intensity due to the number of hours of contact with the patient, which exceeds 25 hours over a 6-month period. Moderate is defined as 26 to 75 hours and high as more than 75 hours. Lesser hours of contact did not yield significant behavioral or weight loss changes.1,6
In clinical trials, when behavioral interventions were combined with pharmacotherapy using either sibutramine (Meridia) or orlistat(Xenical), modest weight loss and decreased BMI were seen at 1 year in children at least 12 years of age.6 Sibutramine's adverse reactions include hypertension, tachycardia, and gastrointestinal effects. Because of the increased risk of myocardial infarction or stroke in patients with cardiovascular disease who were taking sibutramine, the FDA convened a federal advisory panel to review the drug's postmarket clinical trial data.8 The FDA announced on October 8, that Abbott Laboratories has agreed to voluntarily withdraw Meridia from the U.S. drug market because of the increased risk of myocardial infarction and stroke.9
Orlistat is a lipase inhibitor approved for children ages 12 and up. The main adverse reactions associated with orlistat include gastrointestinal effects of cramping, foul-smelling diarrhea or loose stools, and fecal incontinence. Orlistat did not interfere with fat-soluble vitamin levels. In general, adverse reactions occurred in 3% or less of children taking either medication. Data regarding extended use of over 1 year or the effect on weight after discontinuing the medication is not currently available in children.6
The USPSTF identifies that research needs to be done on children less than 6 years of age, as well as further research on interventions related to overweight as well as obesity. In the meantime, primary care providers need to screen patients for obesity and, when identified, refer to a multidisciplinary program to concentrate on healthy eating, physical activity, and behavioral aspects of food.
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