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A direct comparison of the American Heart Association (AHA), Massachusetts Department of Public Health (MDPH), and The Endocrine Society (TES) recommendations for management of overweight and obesity in children and adolescents is provided in the tables below.
Following the content and recommendation comparison tables, the areas of agreement and areas of differences among the guidelines are identified.
Abbreviations used in the text and table
TABLE 3: COMPARISON OF RECOMMENDATIONS | |
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General Recommendations | |
AHA (2005) |
The principal strategies for the treatment of overweight in children are similar to those for adults (dietary modification and increased physical activity), with treatment goals based on age, severity of obesity, and the results of risk factor assessment. Guiding Principles Five guiding principles are important for the treatment of overweight. These guiding principles can be summarized as follows:
Treatment of overweight should rarely be instituted before 2 years of age because of the rapid growth and development that occurs during these early years and lower correlation with overweight in later years. Family involvement is critical in the treatment of childhood overweight. If treatment is initiated when a family is not ready to support the program, then success is unlikely. The treatment planned should also take into consideration long-term management with the continued assessment of the child for adequate growth and development because overweight is a long-term problem. |
MDPH (2007) |
No recommendations offered |
TES (2008) |
Lifestyle: General Considerations The Task Force recommends that clinicians prescribe and support intensive lifestyle (dietary, physical activity, and behavioral) modification to the entire family and to the patient, in an age-appropriate manner, and as the prerequisite for all overweight and obesity treatments for children and adolescents (1 | +000). Evidence Although good-quality pediatric and adolescent data are scarce, there is sufficient evidence that intensive lifestyle modification programs, as in adults, can be an effective tool for pediatric weight control. Furthermore, implementation of a formal maintenance program after the treatment phase is completed can be of added importance in maintaining achieved weight loss. This fits into a concept of obesity as a chronic disease. 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) Remarks It is important to remember that clinician interactions with the family and all educational materials should be culturally sensitive and in the language best understood by the family. |
Dietary Interventions | |
AHA (2005) |
Dietary Management
|
MDPH (2007) |
No recommendations offered |
TES (2008) |
Dietary Recommendations The Task Force recommends that clinicians prescribe and support healthy eating habits such as:
The Task Force suggests that clinicians prescribe and support:
Remarks Many different diets have been proposed for weight loss. Currently there is debate about whether a low-fat (usually 30% of calories as fat) or a low-carbohydrate diet is more efficacious. At the present time, there is insufficient pediatric evidence to warrant recommending any one hypocaloric diet over another. But caution should be exercised when using unbalanced hypocaloric diets that may be deficient in essential vitamins and minerals. |
Physical Activity | |
AHA (2005) |
Physical Activity
|
MDPH (2007) |
No recommendations offered |
TES (2008) |
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 h per day, according to the American Academy of Pediatrics (2 | +000) Evidence In the absence of caloric restriction, moderate exercise does not generally cause weight loss. However, in combination with decreased caloric intake, exercise can achieve significant weight loss. The beneficial effects of both aerobic exercise and resistance training can be short-lived, and exercise must be sustained. Time spent in daily vigorous exercise in excess of 60 minutes per day provides additional reduction in cardiovascular risk factors. |
Pharmacological Treatment | |
AHA (2005) |
Pharmacological Treatment
|
MDPH (2007) |
No recommendations offered |
TES (2008) |
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 co-morbidities 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 T2DM 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 antiobesity agents and are aware of the potential for adverse reactions (2 | +000) Evidence The utility of pharmacotherapy in adolescents has been reviewed, and the use of medication to treat severe obesity can be an additional treatment modality. Several limitations preclude physicians from early implementation of drug therapies. These include: 1) the lack of U.S. FDA approval for use in preadolescents and younger adolescents; 2) reduced efficacy over time, with a plateau after 6 months of treatment due to reduced energy expenditure offsetting the decrease in energy intake—an effect also noted with hypocaloric diets; 3) the existence of a limited number of well-controlled studies of the safety and efficacy of pharmacological intervention in obese children; and 4) the need to weigh the relative risk of severe adverse events in children against the long-term potential for obesity-related morbidity and mortality. Despite these concerns, the negative health impact of childhood obesity may justify long-term medication, but only in combination with lifestyle modification. Three pharmacotherapeutic agents—sibutramine, orlistat, and metformin (metformin is not FDA approved for the treatment of obesity)—are most commonly used at present. Although metformin reduces hepatic glucose production and plasma insulin, inhibits lipogenesis, increases peripheral insulin sensitivity, and may reduce appetite by increasing levels of glucagon-like peptide, its mechanism of action on weight is unresolved. Only sibutramine (for children > 16 yr of age) and orlistat (for children 12 yr of age) are FDA approved for the treatment of obesity in adolescents (see Table 2 in the original guideline document). Table 2 in the original guideline document summarizes the dosage, efficacy, adverse effects, contraindications, and monitoring needs of some of the medications used for the treatment of obesity, including:
Remarks The assessment of drug efficacy presented in the original guideline document founded only on the ability of medications to reduce BMI or BMI z-score. It must be emphasized that "antiobesity" drugs may have differential effects on BMI and obesity-associated co-morbidities. For example, certain medications (e.g., sibutramine, orlistat) may be more effective for weight loss than for treatment of impaired glucose tolerance, whereas other medications (e.g., metformin) have more potent effects on insulin production and glucose tolerance than on body weight per se. Drug selection should be tailored to the individual patient, with strong attention paid to the family history. The primary objective is to prevent co-morbidities in the obese (BMI > 95th percentile) patient. Most importantly, the benefits of any drug used to treat childhood obesity should clearly outweigh its risks. In general, children with a BMI below the 95th percentile should not be treated with antiobesity drugs. Pharmacotherapy for overweight children (BMI > 85th but < 95th percentile) should be reserved for those with significant, severe comorbidities who have not responded to lifestyle modification. Although data suggest that adult Asians (and Native-Americans) develop obesity-associated comorbidities at a lower BMI than do Europeans, similar data are not available for children and adolescents, and so we cannot recommend the use of pharmacotherapy at a BMI range differing from the above recommendations. The use of pharmacotherapeutic agents not yet approved for the treatment of pediatric obesity should be restricted to participation in large, well-controlled clinical trials. |
Surgical Interventions | |
AHA (2005) |
Surgical Treatment
|
MDPH (2007) |
Pediatric/Adolescent
|
TES (2008) |
Bariatric Surgery Recommendations The Task Force suggests that bariatric surgery be considered only under the following conditions:
(2 | ++00) The Task Force recommends against bariatric surgery for preadolescent children, for pregnant or breast-feeding adolescents, and for those planning to become pregnant within 2 yr 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) Evidence Although the LAGB procedure is considered safer than RYGB, the FDA has not yet approved LAGB for use in adolescents. The Task Force agrees with the expert panels that suggest bariatric surgery for adolescents with obesity related comorbid conditions that threaten the adolescent's health-a BMI above 40 kg/m2 and a severe comorbidity or a BMI above 50 kg/m2 and less severe comorbidity. These cut-points are the ones generally accepted for adolescents. Others have suggested that we should consider using a BMI in at least the 99th percentile-equivalent to an adult BMI of 35-40 kg/m2-with severe co-morbidities as a cutpoint. There are insufficient data concerning the complication rates using the current cut-points to warrant suggesting any changes. Remarks Requirements for patients. It must be clear to the patient and the family that bariatric surgery is an adjunct to a sincere commitment to alteration of lifestyle and behavior rather than a cure. All obese children must first demonstrate their ability to adhere to a family-based dietary and lifestyle modification program. Requirements for preoperative care. Bariatric surgery in adolescents should be performed in regional pediatric academic centers with programs equipped to handle the data acquisition, long-term follow-up, and multidisciplinary issues of these difficult patients. A multidisciplinary team with medical (including endocrine, gastrointestinal, cardiovascular, pulmonary, and otolaryngological expertise), surgical, nutritional, and psychological expertise should carefully select adolescents who are well informed and motivated as potential candidates for bariatric surgery and should provide preoperative care and counseling. Patients and families must be well informed as to the risks and complications of bariatric surgery. Requirements for postoperative care. Postoperative attention to the principles of growth, development, and compliance is essential to avoid adverse physical, cognitive, and psychosocial outcomes after bariatric surgery. Adolescents undergoing bariatric surgery require lifelong medical and nutritional surveillance postoperatively, especially to ensure adequate vitamin and mineral intake, as well as extensive counseling. Patients lacking such help tend to regain their weight over time. |
TABLE 4: BENEFITS AND HARMS | |
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Benefits | |
AHA (2005) |
The short- and long-term association of obesity with morbid outcomes raises the level of importance for understanding overweight as a major public health concern for children and adolescents. Prevention and treatment of overweight and obesity in children and adolescents may help prevent these adverse outcomes. |
MDPH (2007) |
|
TES (2008) |
Appropriate prevention and treatment of pediatric obesity |
Harms | |
AHA (2005) |
|
MDPH (2007) |
The complications of commonly performed WLS procedures are well defined. They include: LRYGB Common causes of death include pulmonary embolism and anastomotic leaks. Nonfatal perioperative complications include venous thromboembolism, wound infections, small bowel obstruction, and bleeding. Postoperative gastrointestinal complications include nausea and vomiting, micronutrient deficiencies, and possible weight regain. LAGB Data link LAGB with intermediate and long-term complications (e.g., band erosion or slippage, failure to achieve or maintain weight loss) that require reoperation in up to 20% of patients. LAGB has been linked to intermediate and long-term complications. BPD BPD is capable of producing substantial and sustained weight loss, perhaps associated with markedly suppressed ghrelin levels. However, increased incidence of stomal ulceration, severe protein-energy malnutrition, diarrhea, and dumping has limited its broad acceptance. Subgroups Most Likely to Experience Harms
|
TES (2008) |
Obesity Medications
Bariatric Procedures
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TABLE 5: EVIDENCE RATING SCHEMES AND REFERENCES | |
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MDPH (2007) |
Grading System for Evidence-Based Recommendations* Category A: Evidence obtained from at least one well-conducted randomized clinical trial (RCT) or a systematic review of all relevant RCTs Category B: Evidence from well-conducted prospective cohort studies, registry or meta-analysis of cohort studies, or population-based case-control studies Category C: Evidence obtained from uncontrolled or poorly controlled clinical trials, or retrospective case-control analyses, cross-sectional studies, case series, or case reports Category D: Evidence consisting of opinion from expert panels or the clinical experience of acknowledged authorities *Adapted from the criteria used by the U.S. Preventive Services Task Force (USPSTF) and the American Diabetes Association. |
TES (2008) |
The Task Force used the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) method. 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 |
AHA and TES agree that, as in adults, dietary, physical activity, and behavioral modification are the primary strategies for the treatment of obesity and overweight in children. The groups further agree that family involvement is critical to the success of the treatment plan. According to AHA, success is unlikely if treatment is initiated when a family is not ready to support the program. TES recommends that clinicians probe for and diagnose unhealthy intrafamily communication patterns and support rearing patterns that seek to enhance the child's self-esteem. The guidelines further agree that long-term management is necessary. According to TES, implementation of a formal maintenance program after the treatment phase is completed can be of added importance in maintaining achieved weight loss. AHA states that long-term management should include continued assessment of the child for adequate growth and development.
The two groups that provide physical activity recommendations, AHA and TES, recommend vigorous daily activity. AHA states that the current recommendation is 30 to 60 minutes; TES recommends 60 minutes. The groups also agree that a complementary approach to physical activity is to limit sedentary activities (e.g., watching television, playing video games, or using computers for recreation) to less than two hours per day.
The two groups that address dietary interventions, AHA and TES, agree that incorporation of healthy eating habits is the cornerstone of dietary management. AHA states that the major goals in dietary management are to provide appropriate caloric intake, provide optimum nutrition for the maintenance of health and normal growth, and to help the child develop and sustain healthful eating habits. They recommend that all caregivers be involved in helping the child to adhere to recommended consumption patterns and healthier food choices. TES recommends: reduction of saturated fat intake for children older than two; avoidance of calorie-dense, nutrient-poor foods; increase of fiber, fruit and vegetable intake; planning of timely, regular meals; and avoidance of "grazing" during the day. TES also suggests control of caloric intake through portion control in accordance with the guidelines of the American Academy of Pediatrics.
The two groups that address pharmacological treatment, AHA and TES, discuss sibutramine, orlistat, metformin, leptin, and octreotide. TES also addresses topiramate and growth hormone. Only sibutramine (for adolescents > 16 yr of age) and orlistat (for adolescents > than 12 years of age) are FDA approved for the treatment of obesity in adolescents. TES states that sibutramine, orlistat and metformin are most commonly used at present. The groups agree that, among other adverse effects, sibutramine is associated with cardiac side effects and orlistat with gastrointestinal side effects. There is also agreement that while not approved by the FDA for the treatment of obesity, leptin and octreotide are useful for leptin deficiency and hypothalamic obesity, respectively. AHA and TES agree that while metformin (approved for children > 10 years of age for type 2 diabetes mellitus) has been used in insulin-resistant children and adolescents who are overweight, its mechanism of action on weight is unclear.
AHA provides no specific pharmacotherapy recommendations, stating that data supporting the use of pharmacological therapy for pediatric overweight are limited and inconclusive. TES provides explicit recommendations, suggesting that pharmacotherapy (in combination with lifestyle modification) be considered for obese children if a formal program of intensive lifestyle modification has failed to limit weight gain or to mollify co-morbidities. With regard to non-obese children, TES states that, in general, children with a BMI below the 95th percentile should not be treated with antiobesity drugs. They add that pharmacotherapy for overweight children (BMI > 85th but < 95th percentile) should be reserved for those with significant, severe comorbidities who have not responded to lifestyle modification.
According to MDPH, RYGB is considered a safe and effective option for extremely obese adolescents as long as appropriate long-term follow-up is provided. TES notes that although LAGB is considered safer than RYGB, the FDA has not yet approved LAGB for use in adolescents. MDPH similarly notes that AGB use in adolescents should be considered investigational for this reason. MDPH adds that BPD and DS procedures, as well as sleeve gastrectomy, cannot currently be recommended for use in adolescents.
All three groups emphasize that adolescents undergoing bariatric surgery should be physically mature. The groups define this in slightly different ways, with AHA stating that surgery should be reserved for "full-grown adolescents" with the severest obesity-related morbidity. According to MDPH, physical maturity is defined as "completion of 95% of adult stature based on radiographic study". Lastly, TES states that adolescents being considered should have attained "Tanner 4 or 5 pubertal development and final or near-final adult height".
There is also overall agreement that adolescents being considered for surgery should be assessed for psychological maturity and stability, as demonstrated by understanding of the surgery, mature motivations for the operation, compliance with preoperative therapy, and the ability to adhere to the principles of healthy dietary and activity habits. The guidelines emphasize the importance of the role of the family both pre- and post-operatively.
All three guidelines agree that surgery should only be managed by an experienced multidisciplinary team with medical, surgical, nutritional, mental health, and pediatric expertise. MDPH and TES agree that in an effort to improve the evidence base for evaluating the risks and benefits of surgery in this age group, the institution where the surgery is performed should either be participating in a study of the outcomes of bariatric surgery or sharing data.
Refer to Areas of Differences for recommendations regarding BMI cutpoints.
AHA and TES agree that adolescents being considered for bariatric surgery should generally have a BMI > 40 kg/m2 and severe co-morbidities, or a BMI > 50 kg/m2 with less severe comorbidities. MDPH, in contrast to AHA and TES, states that BMI cutpoints in children and adolescents who meet other criteria should be >35 kg/m2 with major comorbidities and >40 kg/m2 with less severe comorbidities.
TES addresses the issue of discrepancies in BMI cutpoint recommendations between groups, noting that the cutpoints they recommend are the ones generally accepted for adolescents. They add that while other groups have suggested using a BMI in at least the 99th percentile—equivalent to an adult BMI of 35-40 kg/m2—with severe co-morbidities as a cutpoint, they conclude that there are insufficient data concerning the complication rates using the current cut-points to warrant suggesting any changes to their current recommendation.
AHA and MDPH agree that comorbidities typically classified as severe include type 2 diabetes mellitus, moderate to severe OSA, and pseudotumor cerebri. Comorbidities considered less severe include conditions such as hypertension, dyslipidemia, interference with activities of daily living, and mild sleep apnea.
This synthesis was prepared by ECRI on March 2, 2005. The information was verified by SIGN on April 12, 2005. It was updated to include RNAO on June 21, 2005, and to include AHA and USPSTF on July 22, 2005. The information was verified by AHA on August 23, 2005 and by USPSTF on September 19, 2005. This Synthesis was revised in October 2008 to remove AAP and SIGN recommendations. This synthesis was revised most recently in March 2009 to remove SMOH, USPSTF and RNAO recommendations and to add MDPH and TES. The information was verified by TES on April 7, 2009 and by MDPH on April 17, 2009.
Internet citation: National Guideline Clearinghouse (NGC). Guideline synthesis: Management of overweight and obesity in children and adolescents. In: National Guideline Clearinghouse (NGC) [website]. Rockville (MD): 2005 Apr 29 (updated 2009 May). [cited YYYY Mon DD]. Available: http://www.guideline.gov.