Chapter Summary: AAP Says What!?! : Treatment of Obesity Part 1

Obesity is one of the most common chronic conditions we care for in pediatric patients. Until recently, there have not been standardized guidelines for the use of medication or surgery in the treatment of obesity in children. Sit down with Parul and Alaina Vidmar, assistant professor of clinical pediatrics, Diplomate of the American Board of Obesity Medicine and the Medical Director of the Healthy Weight Clinic in the Division of Endocrinology at Children's Hospital of Los Angeles, as they discuss AAP's recently published Clinical Practice Guideline for the Evaluation and Treatment of Children and Adolescents with Obesity.

Pearls:

• Obesity is one of the most common pediatric chronic diseases with increasing prevalence and needs to be treated like all other chronic diseases.
• Guidelines include youth two years and older, living with overweight and obesity.
• Early intervention is encouraged and watchful waiting is no longer the first line.
  • New guidelines are intervention focused and not prevention focused
• Pathophysiology of childhood obesity:
  • Complex interactions between genetic, physiologic, socioeconomic, and environmental factors
  • Pathophysiology drives behaviors resulting in excessive weight gain, not a patient’s individual behaviors
• Pediatric obesity risk factors:
  • When children live with inequities, it increases their obesity risks that are embedded into the socio-ecological and environmental fabric of these children's lives
    • This can lead to a danger of stigmatizing children with obesity based on race/ethnicity
• Definition of overweight and obesity:
• Overweight: BMI in the 85th to the 95th percentile
• Obese:  BMI in excess of the 95th percentile
  • Guidelines divide up obesity into three classes that mirror risk stratification with regards to co-morbidities.

• • • Class 1 obesity: BMI 95-120% of the 95^th percentile
    • Class 2 obesity: BMI 120-140% of the 95^th percentile
    • Class 3 obesity: BMI greater than or equal to 140% of the 95^th percentile

• History and physical
• There should not be a conflict with obesity management and the positive body movement
• Learn as much as you can about the home eating situation and physical activity to tailor recommendations to the patient
  • Do caretakers cook? Do they eat at school?
  • Is it not safe for them to leave the house to get exercise?  What are their hobbies?
• On exam (to name a few findings), evaluate for acanthosis, striae, localized adiposity, hirsutism and muscular/orthopedic conditions

• Laboratory screening:
• Ref: AAP Clinical Decision Support Toolkit
• Screening for obstructive sleep apnea, hypertension  and polycystic ovarian syndrome, and depression:

• Obstructive sleep apnea: ask about snoring, apnea, daytime sleepiness, nocturnal enuresis.  Check polysomnogram if symptomatic.
• Hypertension: check blood pressures  at each office visit over time starting at age 3 years.
• Polycystic ovarian syndrome (PCOS): screen for irregular menses, signs of hyperandrogenism.  Work-up if present.
  • Editor’s note: Laboratory testing for PCOS may include: 17-hydroxyprogesterone, total testosterone, free testosterone, sex hormone-binding globulin, dehydroepiandrosterone sulfate, androstenedione, luteinizing hormone, follicle-stimulating hormone, estradiol, prolactin, free thyroxine, thyroid stimulating hormone, and insulin.
• Depression: universal screening for age 12 years and older
• Treatment of Obesity:
  • Prompt treatment needed. No more watchful waiting.
    • Behavioral interventions alone have an efficacy (on average) of 2-3% of weight loss goals, over 6-12 month time period
      • Ref: AAP Clinical Decision Support Toolkit

1. Behavioral and Lifestyle treatment:

• Eating behaviors 
• Nutrition
• Focus on avoiding sugar sweetened beverages
• Portion control 
• Psychological health addressed
• Physical activity
• The more face to face hours spent with a family doing behavioral intervention, the more successful these treatments are:
• Guidelines goal: 26 contact hours over 2-12 month period

2.   Medications: 

• Should offer medications to kids >12 years with obesity
• May offer medications to children 8-11 years with obesity (off-label)
• Glucagon like peptide-1 (GLP1) agonists: 

• Expensive, hard to find 
• FDA approved for ages 12 and over:

• Liraglutide (Victoza, Saxenda)- daily injection
• Semaglutide (Ozempic)- weekly injection

• Side effects: nausea, diarrhea
• Medications have an efficacy on average of 5-15% weight loss goals 

• Phenteramine: 
• Accessible, fairly cheap
• Stimulant, suppresses appetite
• Side effect: insomnia
• FDA approved 16 years and older
• 3 month course at a time
• Often used in combination with Topiramate
• Topiramate: 
• Cheap, readily available
• Side effect: brain fog and tiredness, given at night (often will counteract Phentermine side effects)
• Combination pill of Phenterimine/Topiramate available (Qsymia), but can prescribe them separately
• Metformin:
• Not great for weight loss alone but can help with antipsychotic induced weight gain
• Used to decrease insulin resistance
• Melanocortin 4 receptor (MC4R) agonists (Setmelanotide):
• For patients 6 years and older with proopiomelanocortin (POMC) deficiency, proprotein subtilisin or kexin type 1 deficiency, and leptin receptor deficiency confirmed by genetic testing
• Naltrexone/Bupropion (Contrave)
• Controls depression and is weight loss promoting
• Lisdexamfetamine (Vyvanse) 
• Used in ADHD and can also have a weight loss effect

3.   Bariatric surgery: 

• Outcomes very good,  postoperative complications are low
• Indications:
• Age >13 years
• Class 2 obesity (BMI >35) with clinically significant obesity related disease including:
• DM2
• Idiopathic intracranial hypertension
• NAFLD
• Blount disease (proximal tibia deformity leading to bowed legs)
• Slipped Capital Femoral Epiphysis (SCFE)
• Gastroesophageal reflux disease (GERD)
• Obstructive sleep apnea (Apnea hypopnea index >5)
• Cardiovascular disease risks (HTN, hyperlipidemia, insulin resistance)
• Depressed health-related quality of life
• OR Class 3 obesity (BMI >40) on its own

References:

1. Barlow SE; Expert Committee. Expert committee recommendations regarding the prevention, assessment, and treatment of child and adolescent overweight and obesity: summary report. Pediatrics. 2007;120 Suppl 4:S164-S192. PMID: 18055651
2. Centers for Disease Control and Prevention. About social determinants of health (SDOH). Accessed October 5, 2022.Link
3. Hampl SE, et al. Clinical practice guideline for the evaluation and treatment of children and adolescents with obesity. Pediatrics. 2023;151(2):e2022060640. PMID: 36622115
4. Inge TH, et al. Comparison of surgical and medical therapy for type 2 diabetes in severely obese adolescents. JAMA Pediatr. 2018;172(5):452-460. PMID: 29532078
5. Jastreboff AM, et al. Obesity as a disease: The Obesity Society 2018 Position Statement. Obesity (Silver Spring). 2019;27(1):7-9. PMID: 30569641
6. Spear BA, et al. Recommendations for treatment of child and adolescent overweight and obesity. Pediatrics. 2007;120 Suppl 4:S254-S288. PMID: 18055654
7. Trent M, et al. The impact of racism on child and adolescent health. Pediatrics. 2019;144(2):e20191765. PMID: 31358665

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