Continuing Medical Education

Childhood Obesity: TIPS for Pediatricians

childhood_obesity_today_a_webinar_for_pediatricians_and_families

Rates of obesity, the most common chronic illness of childhood and adolescence in the US, were rising steadily before the COVID-19 pandemic, and have accelerated since early 2020. A 2021 CDC study estimated that 22 percent of children nationawide now meet the criteria for obesity, an increase from 19 percent just one year earlier. Obesity causes metabolic changes that are likely to persist throughout a child’s life. Pediatricians can play a central role in helping families prevent obesity and navigate lifestyle changes and other treatment strategies for overweight and obese children. For more information, you can watch the video of our recent discussion (linked to above). 

The Demographics of Obesity

  • Prevalence has tripled since the 1970s
  • Twenty percent of children and teenagers between 2-19 years of age are obese
  • Approximately 55 percent of obese children go on to be obese in adolescence and 80 percent of obese adolescents will still be obese in adulthood
  • Children and adolescents have a threefold risk of obesity if one parent is overweight, and a tenfold risk of obesity if both parents are overweight
  • If a woman has gestational diabetes during pregnancy, the presence of dysglycemia imposes an additional stress on the fetus’s beta cells,  often leading to obesity in the child.

COVID-19 and Childhood Obesity

During the COVID-19 pandemic weight gain among healthy-weight children increased by 50 percent. Among children who were already overweight, weight gain almost doubled from about 8.8 to 14.6 pounds per year. The pandemic has fueled childhood obesity due to:

  • School closures
  • Increased “screen time”
  • Decreased physical activity
  • Poor food choices

During the pandemic the incidence of type 2 diabetes in children, a significant disease with the potential for more severe complications than in adults, increased dramatically in parallel with the increase in obesity among children and adolescents.

  • The relationship between obesity and type 2 diabetes is profound
  • Consequences are accelerated in children, not delayed
  • Whether SARS-COV-2 directly attacks pancreatic beta cells or whether viral infection causes the metabolic consequences leading to insulin resistance and increased weight is not clear

The Genetics of Obesity

Genes contribute strongly to the risk of becoming obese, but act in the context of the environment.

  • Based on studies of identical and non-identical twin pairs, the genetic underpinnings of body weight or obesity are in the 40-50 percent range.
  • The pandemic was a perfect storm for children with a genetic predisposition to obesity by creating an environment that restricted physical activity and promoted poor food choices.
  • Body weight and adiposity are regulated physiological variables in the same way that height, blood pressure, and blood glucose are regulated. Obesity causes lifelong changes and will resist clinical efforts to change reduce weight.

Managing Obesity

Involving a child’s family is paramount when working with overweight children and adolescents. Parents and caregivers manage the food environment and lifestyle modifications for the entire family and can serve as healthy role models. Whether children are treated through adjuvant therapy or medication, they are likely to have to continue these throughout their lives to maintain their weight loss. But even modest weight loss will reverse many metabolic complications of obesity including diabetes, hypertension, and dyslipidemia.

A multidisciplinary step-wise management paradigm employs the following:

  • Individualized dietary counseling for the child and family
  • Behavioral interventions
  • Nutrition education for parents
  • Exercise classes for children and adolescents
  • Pharmacotherapy (details below)
  • Bariatric surgery (details below)

Pharmacotherapy

Medications should be prescribed in conjunction with the other diet and lifestyle modifications and under the care of a multidisciplinary team that includes a nutritionist and behavioral specialist

Orlistat, a lipase inhibitor, prevents the breakdown and absorption of fat.

  • Because of side effects including abdominal distress, and fatty, oily stools this medication is of limited clinical use.

Phentermine, approved for obesity in patients older than 16 years of age works on the central nervous system to control appetite.

Metformin, an insulin sensitizer approved for children and adolescents over the age of 10 with type 2 diabetes. 

  • Enhances glucose dependent insulin secretion
  • Delays gastric emptying
  • Reduces postprandial glucagon 
  • Reduces food intake in order to maximize nutrient absorption and limit weight gain
  • Multiple trials have shown a small amount of weight loss with its use, particularly in the first few months of initiation
  • The goal is to prevent the progression to type two diabetes
  • Side effects include diarrhea and nausea.

Liraglutide, a GLP-1 agonist

  • FDA approved in 2019 for type 2 diabetes in children 10 or older
  • FDA approved in 2020 to treat obesity in 12- to 17-year-olds
  • Affects glucose control through several mechanisms that together maximize nutrient absorption and limit weight gain
  • Enhances glucose dependent insulin secretion
  • Slows or delays gastric emptying
  • Reduces postprandial glucagon and food intake
  • Significant abdominal side effects, particularly abdominal pain and nausea, as well as pancreatitis.

Setmelanotide, a melanocortin agonist

  • FDA approved in November 2020 for patients six or older who have obesity due to three rare genetic mutations:
    • Palm C deficiency
    • PCSK 1 deficiency
    • LEP-R deficiency
  • Currently undergoing clinical trials for additional rare genetic disorders

Bariatric surgery        

Bariatric surgery serves as an adjunct for weight control and management of obesity for a select group of adolescent patients.

Until position papers by American Society for Metabolic and Bariatric Surgery (2012, 2019) and the American Academy of Pediatrics (2018) endorsing the procedure and providing guidelines for appropriate candidates, surgery was rarely considered for children with severe obesity

Teen Lab Study report five-year outcomes with a

  • 96 percent compliance and adherence rate
  • Mean percent weight loss of 26 percent
  • Mean reduction in the complications and comorbidities of obesity
  • 68 percent normalized their blood pressure
  • 81 percent normalized their triglycerides
  • 86 percent of patients with type 2 diabetes remained in remission

Bariatric surgery is a safe, effective long-term alternative, however, enduring weight loss after surgery requires a positive change in eating behavior and increased exercise

Contributors
Marisa Censani, MD, Director, Pediatric Obesity Program; Associate Professor of Clinical Pediatrics, Weill Cornell Medicine
Jane Chang, MD, Adolescent Medicine Specialist; Associate Professor of Clinical Pediatrics Weill Cornell Medicine.
Rudolph Leibel, MD, Chief, Division of Pediatric Molecular Genetics; Professor of Pediatrics Columbia
John Rausch, MD, MPH, Associate Clinical Director, Pediatric Obesity Initiative; Associate Professor of Pediatrics Columbia
Jeffrey Zitsman, MD, Director, Center for Adolescent Bariatric Surgery; Professor of Surgery, Columbia