Introduction of Obesity Medicine Association’s Pediatric Obesity Algorithm
by Wendy Scinta, MD, MS
Bariatric Times. 2016;13(11): 26–29.
The Scope of the Problem
In the United States, more than one-third (36.5%) of adults have obesity (CDC). Further, childhood obesity has more than doubled in children and quadrupled in adolescents in the past 30 years, reaching 18 and 21 percent, respectively. Not only are the rates of obesity rapidly rising, the degree of obesity is increasing over time, with more children having severe obesity than ever before.[1] This upward trend is occurring in the wake of campaigns and government-sponsored programs purportedly focusing on reducing the problem.
The statistics are startling and we must act to stem the tide of this dangerous epidemic. The probability of childhood obesity persisting into adulthood is estimated to be 20 percent at age 4 and 80 percent by adolescence.[2] If current obesity trends continue, 1 in 3 children born after 2000 will have diabetes in their lifetime.[3] Childhood overweight and obesity is related to cardiovascular risk; more significant levels of obesity are strongly associated with the number and severity of cardiometabolic risk factors.[4] In addition, childhood obesity more than doubles the risk of dying before age 55.[5] If we do not close the gap between prevention and treatment, we are resigning the next generation to a wave of obesity related health issues and a significantly shorter life expectancy than their parents.
A Noticeable Treatment Gap
The rate and severity of childhood obesity has understandably taken the pediatric medical community by surprise. Previous to the epidemic, outpatient pediatrics was focused mainly on prevention: well-child visits, immunizations, and treatment of chronic diseases specific to the pediatric population. With the obesity epidemic, adult diseases have started to affect our children at alarming rates, forcing family practitioners and pediatricians to develop new skill sets as they treat metabolic syndrome, sleep apnea, hypertension, dyslipidemia, fatty liver disease, and diabetes in a growing, developing child.
A New, Evidence-Based Clinical Resource
Treating childhood obesity and its associated conditions effectively is a science that involves a multidisciplinary approach, including nutrition, activity, behavioral modification, and medication management. These are skills a physician does not learn in standard medical training, underscoring the need for effective treatment guidelines and protocols. Three years ago, The Obesity Medicine Association (OMA) acknowledged this treatment gap, and began to accumulate historical evidence and proven best-practice techniques that culminated in The Pediatric Obesity Algorithm, which was released during the OMA Overcoming Obesity conference on September 23, 2016 in Chicago, Illinois.
The purpose of the algorithm is to guide the treatment of infant, child, and adolescent obesity based upon scientific evidence, supported by the medical literature, and derived from the clinical experiences of members of the OMA.
In comparison to other guidelines that have been released, this algorithm provides an updated, comprehensive clinical and educational resource for physicians and other healthcare providers to aid in the management of children with obesity. It is unique in that it has been been created by front-line physicians who specialize in childhood obesity for ease of use in daily practice depicted with simple, elegant visuals. It starts from preconception with epigenetics, describes diagnosis and evaluation, and ends with treatment of the infant, child, and adolescent with overweight and obesity. The treatment approach is multidisciplinary, combining evidence-based medicine with best-practice techniques for nutrition, physical activity, behavioral modification, and medication management. The recommendations are broken up by age, as treatment varies with stages of development.
Algorithm Highlights
The algorithm can be reviewed in its entirety on the OMA website, and is available for free to anyone interested in downloading it for teaching purposes or patient care (see end of article for instructions). Specific areas of interest are as follows:
1. Epigenetics. As the potential for childhood obesity begins prior to conception, the algorithm starts with epigenetics: abnormalities in gene expression that occur without altering the genetic code itself. In pregnancy, these modifications can be transmitted to the offspring, affecting the birth weight and the future weight of that child. Such changes can be caused by toxins, diet and physical activity of the mother, infections, exogenous hormones and medications. After delivery, breastfeeding can also play a role.
2. Assessment. The assessment of a child with obesity is dependent upon the age. In infancy, standard weight for length (CDC/WHO) assessment is used. Once a child reaches 2 years of age, BMI percentile is used (CDC) in all cases except severe obesity until age 20 (Figure 1). For children with severe obesity, BMI is used, which is measured on a separate graph from the routine CDC charts. All are discussed in the algorithm.
Figure 2 is an example of the charts used to graph BMI percentile for 2- to 20-year-olds with overweight and obesity (but not severe obesity). Separate CDC charts exist for boys and girls.
3. Obesity as a Disease. Similar to OMA’s adult Obesity Algorithm, obesity as a disease is discussed, separating obesity into the endocrine and immune response (termed adiposopathy), the physical or mechanical response (fat mass disease), and the psychological response (quality of life), which is unique to children due to bullying and potential developmental delays (Figure 3).
4. Differential Diagnosis. In children, obesity can be associated with abnormalities in growth and development, and it is important to rule out genetic syndromes, such as Prader Willi or Cohen Syndrome. Additionally, the rate of linear growth can be decreased (e.g., congenital hypothyroidism) or accelerated (from the obesity itself). History, physical exam and sometimes bone age and blood work can help determine the etiology.
5. Review of Systems. The review of systems (ROS) is extremely important in children, and quite different from the adult ROS. Something as simple as a headache can help differentiate obesity that is related to pseudotumor cerebri, and hip and knee pain can reveal an undiagnosed slipped capital femoral epiphysis (SCFE). Skin tags, hyperpigmentation, and excessive hunger can provide clues about insulin resistance even before the testing is initiated (Figure 4).
6. Diagnostic Work-up. In a child with a weight issue, the diagnostic work up begins with a careful history of nutrition, exercise/activity, sleep, and eating behavior of the family and the individual child. Labs and studies performed should be specific to the individual child; however, previous guidelines are pooled with recommendations based upon age.
7. Normal Weight Recommendations. Unique to the Pediatric Obesity Algorithm is the inclusion of normal-weight guidelines for nutrition, sleep, and activity. Each of the guidelines are broken down by age groups, as recommendations are based on phases of development. The goal is to provide a resource for clinicians who focus on obesity prevention in normal-weight children. These slides can be used as handouts for parents with healthy-weight children and as a basis for assessing the intake, activity, and sleep duration of children and adolescents with obesity.
8. Nutrition, Activity, and Behavioral Recommendations for Overweight and Obese Infants, Children and Adolescents. Although not as rigorously studied as adult nutrition plans, data on childhood nutrition plans for weight loss does exist, and is summarized in the OMA algorithm as shown in Figure 5. Future versions will be taking deeper dives into each modality.
Recommendations depicted in tabular form are also summarized in the wheel shown in Figure 6. Intake includes nutritional recommendations summarized from previously published evidence -based guidelines. Activity includes age specific, evidence-based recommendations. Behavior is generally focused on the family in younger children. By adolescence, an individual, can start to purchase his or her own food and is more independent in the behavioral decision making process. For children over 10, a section on pharmacology summarizes studies that focus specifically on pharmacological interventions for children and adolescents.
9. Obesity Related Co-morbidities. Obesity-related comorbidities are treated much more conservatively in children than adults, with the most effective treatment always consisting of weight loss and exercise. Recommendations for polycystic ovary syndrome, pre-diabetes, dyslipidemia, vitamin D deficiency, sleep apnea, hypertension and obesity-related orthopedic conditions are all summarized and provide specific guidelines for diagnosis, evaluation, and treatment.
10. Medications. Medications are summarized in the treatment section in conjunction with nutritional, behavioral, and activity recommendations using the wheels as depicted in Figure 6. Because this is such an important aspect of effectively treating childhood obesity, they are also outlined in more detail at the end of the algorithm. Pharmacological intervention for obesity is an important component of effectively losing and maintaining lost weight in the pediatric population. Although many of the recently released medications used to treat obesity have not been studied in children, there are a handful of drugs worth mentioning that can help support a comprehensive weight loss plan for pediatric patients. Some of these medications are summarized in Figure 7.
It is not unusual to see medications used to treat obesity-related conditions in children further exacerbate the weight issue, and many clinicians do not take this into account when prescribing medications for the pediatric population. For this reason, the algorithm includes a section on potential weight gain associated with the most common medications used to treat pediatric patients.
11. Bariatric Surgery. Bariatric surgery is addressed at the end of the algorithm as shown in Figure 8. How to Access the Pediatric Obesity Algorithm The Pediatric Obesity Algorithm is available free of charge on the Obesity Medicine Association website at www.PediatricObesityAlgorithm.org. The adult Obesity Algorithm, which is updated every year and is now on its third version, is available at www.ObesityAlgorithm.org.
Conclusion
The Pediatric Obesity Algorithm is a new tool that arms clinicians on the front lines of care with a multidisciplinary treatment approach that includes includes evidence-based medicine and best practice techniques for nutrition, physical activity, behavior modification, and medication management. Many of the slides can be used as handouts to equip patients with guidelines on recommendations for nutrition, activity, and sleep, as well as simple behavioral changes every family can make at home. By providing guidance to healthcare providers, the Obesity Medicine Association can help ensure that families with children affected by obesity will leave the doctor’s office with solid recommendations on how to prevent and treat obesity, thus reversing the potential chronic disease processes associated with excess weight.
FUNDING: No funding was provided for this article.
FINANCIAL DISCLOSURES: Dr. Scinta reports no conflicts of interest relevant to the content of this article.
Category: Medical Methods in Obesity Treatment, Past Articles
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