Definitions for the quality of the evidence (+OOO, ++OO, +++O, and ++++); the strength of the recommendation (1 or 2), and the difference between a "recommendation" and a "suggestion" are provided at the end of the "Major Recommendations" field.
The Problem with Obesity
The objective of interventions in overweight and obese children and adolescents is the prevention or amelioration of obesity-related co-morbidities (e.g., glucose intolerance and type 2 diabetes mellitus (T2DM), metabolic syndrome, dyslipidemia, and hypertension).
Diagnosis of Overweight and Obesity
The Task Force recommends the use of the Body Mass Index (BMI) (calculated as weight in kilograms divided by height in meters squared), with the Centers for Disease Control and Prevention (CDC) derived normative percentiles, as the preferred method for the diagnosis of the overweight or obese child (1 | ++00).
The Task Force recommends that a child be diagnosed as overweight if the BMI is in at least the 85th percentile but less than the 95th percentile for age and sex, and as obese if the BMI is in at least the 95th percentile for age and sex (1 | +000).
The Task Force recommends against a routine laboratory evaluation for endocrine causes of obesity in obese children or early to mid-pubertal obese adolescents unless the child's height velocity, assessed in relation to stage of puberty and family background, is attenuated (1 | ++00).
The Task Force recommends referral to a geneticist for children whose obesity has a syndromic etiology, especially in the presence of neurodevelopmental abnormalities (1 | +000).
The Task Force suggests that parents of children who have inexorably gained weight from early infancy and have risen above the 97th percentile for weight by 3 years of age be informed of the availability of melanocortin 4 receptor (MC4R) genetic testing. However, the test is positive in only 2–4% of such patients who are above the 97th percentile for weight and currently will not alter treatment (2 | +000).
The Task Force recommends that children with a BMI in at least the 85th percentile be evaluated for associated co-morbidities and complications (1 | +000). See "Table 1: Screening Tests for the More Common Obesity Co-Morbidities" and Figure 1 "Diagnosis and Management Flow Chart" in the original guideline document for more detailed information.
Treatment of Obesity
Lifestyle Recommendations
The Task Force recommends that clinicians prescribe and support intensive lifestyle (dietary, physical activity, and behavioral) modification for the entire family and the patient in an age-appropriate manner and as the prerequisite for all overweight and obesity treatments for children and adolescents (1 | +000).
Dietary Recommendations
The Task Force recommends that clinicians prescribe and support healthy eating habits such as:
- Avoiding the consumption of calorie-dense, nutrient-poor foods (e.g., sweetened beverages, sports drinks, fruit drinks and juices, most "fast food," and calorie-dense snacks) (1 | ++00).
The Task Force suggests that clinicians prescribe and support:
- Controlling caloric intake through portion control in accordance with the Guidelines of the American Academy of Pediatrics [http://pediatrics.aappublications.org/cgi/reprint/117/2/544.pdf] (2 | +000).
- Reducing saturated dietary fat intake for children older than 2 years of age (2 | ++00).
- Increasing the intake of dietary fiber, fruits, and vegetables (2 | +000).
- Eating timely, regular meals, particularly breakfast, and avoiding constant "grazing" during the day, especially after school (2 | +000).
Physical Activity Recommendations
The Task Force recommends that clinicians prescribe and support 60 min of daily moderate to vigorous physical activity (1 | ++00).
The Task Force suggests that clinicians prescribe and support a decrease in time spent in sedentary activities, such as watching television, playing video games, or using computers for recreation. Screen time should be limited to 1–2 hours per day, according to the American Academy of Pediatrics (2 | +000).
Psychosocial Recommendations
The Task Force suggests that clinicians educate parents about the need for healthy rearing patterns related to diet and activity. Examples include parental modeling of healthy habits, avoidance of overly strict dieting, setting limits of acceptable behaviors, and avoidance of using food as a reward or punishment (2 | +000).
The Task Force suggests that clinicians probe for and diagnose unhealthy intrafamily communication patterns and support rearing patterns that seek to enhance the child's self-esteem (2 | +000).
Pharmacotherapy Recommendations
The Task Force suggests that pharmacotherapy (in combination with lifestyle modification) be considered if a formal program of intensive lifestyle modification has failed to limit weight gain or to mollify comorbidities in obese children. Overweight children should not be treated with pharmacotherapeutic agents unless significant, severe co-morbidities persist despite intensive lifestyle modification. In these children, a strong family history of Type 2 Diabetes Mellitus or cardiovascular risk factors strengthens the case for pharmacotherapy (2 | +000).
The Task Force suggests that pharmacotherapy be offered only by clinicians who are experienced in the use of anti-obesity agents and are aware of the potential for adverse reactions (2 | +000).
Bariatric Surgery Recommendations
The Task Force suggests that bariatric surgery be considered only under the following conditions:
- The child has attained Tanner 4 or 5 pubertal development and final or near-final adult height.
- The child has a BMI greater than 50 kg/m2 or has BMI above 40 kg/m2 and significant, severe comorbidities.
- Severe obesity and co-morbidities persist despite a formal program of lifestyle modification, with or without a trial of pharmacotherapy.
- Psychological evaluation confirms the stability and competence of the family unit.
- There is access to an experienced surgeon in a medical center employing a team capable of long term follow-up of the metabolic and psychosocial needs of the patient and family, and the institution is either participating in a study of the outcome of bariatric surgery or sharing data.
- The patient demonstrates the ability to adhere to the principles of healthy dietary and activity habits (2 | ++00).
The Task Force recommends against bariatric surgery for preadolescent children, for pregnant or breastfeeding adolescents, and for those planning to become pregnant within 2 years of surgery; for any patient who has not mastered the principles of healthy dietary and activity habits; for any patient with an unresolved eating disorder, untreated psychiatric disorder, or Prader-Willi syndrome (1 | ++00).
Prevention of Obesity
The Task Force recommends breast-feeding for a minimum of 6 months (1 | ++00).
The Task Force suggests that clinicians promote and participate in efforts to educate children and parents by means of ongoing anticipatory guidance about healthy dietary and activity habits and, further, that clinicians encourage school systems to provide adequate health education courses promoting healthy eating habits (2 | ++00).
The Task Force suggests that clinicians promote and participate in efforts to educate the community about healthy dietary and activity habits (2 | +000).
Societal Barriers to Implementation
The Task Force suggests that clinicians advocate:
- For regulatory policies designed to decrease the exposure of children and adolescents to the promotion of unhealthy food choices in the community (e.g., by media advertisements targeting children and adolescents) (2 | +000).
- That school districts ensure that only nutritionally sound food and drinks are available to children in the school environment, including the school cafeteria and alternative sources of food such as vending machines (2 | +000).
- For parental participation in the design of school-based dietary or physical activity programs and that schools educate parents about the rationale for these programs to ensure their understanding and cooperation (2 | +000).
- That community master planners design, redesign, and organize communities to maximize opportunities for safe walking or cycling to school, recreational activity and athletic events, and neighborhood shopping as a means to encourage greater physical activity (2 | +000).
- That clinicians advocate that policymakers provide incentives to ensure that retailers can offer affordable, high-quality fresh fruits and vegetables to all (2 | +000).
Definitions:
Strength of Recommendations
1 - Indicates a strong recommendation and is associated with the phrase "The Task Force recommends."
2 - Denotes a weak recommendation and is associated with the phrase "The Task Force suggests."
Quality of the Evidence
+OOO Denotes very low quality evidence
++OO Denotes low quality evidence
+++O Denotes moderate quality evidence
++++ Denotes high quality evidence
