ARTICLE

Obesity in Children
Nikita Nagpal, MD, MS,*† Mary Jo Messito, MD,*† Michelle Katzow, MD, MS,‡ Rachel S. Gross, MD, MS*†
*New York University Grossman School of Medicine, New York, NY
†
Bellevue Hospital Center, New York, NY
‡
Zucker School of Medicine at Hofstra/Northwell, New Hyde Park, NY

EDUCATION GAP AND PRACTICE GAPS

The prevalence of childhood obesity and its associated comorbidities is

worsening, but specialized care for patients has limited availability. Primary
care clinicians should be aware of current guidelines for performing the
screening, evaluation, and treatment of children and adolescents with
obesity. Primary care clinicians should be familiar with the nuances in care
and be comfortable with deciding when patients need referrals.

OBJECTIVES After completing this article, readers should be able to:

1. Provide definitions and describe the epidemiologic landscape of childhood

obesity.
2. Describe and identify multifactorial causes of obesity.
3. Describe new knowledge on neuroendocrine and genetic causes of obesity.
4. Describe evaluation and treatment in the primary care and specialty
care settings.
AUTHOR DISCLOSURE Drs Nagpal,
5. Describe initiatives focusing on childhood obesity prevention. Messito, Katzow, and Gross have
disclosed no financial relationships
relevant to this article. This review does
ABSTRACT not contain a discussion of an
investigative use of a commercial
Child obesity is widely prevalent, and general pediatricians play an important product/device. This review does contain
role in identifying and caring for patients with obesity. Appropriate evaluation a discussion of off-label medication use.
and treatment require an understanding of the complex etiology of child
obesity, its intergenerational transmission, and its epidemiologic trends, ABBREVIATIONS
including racial/ethnic and socioeconomic disparities. The American Academy AAP American Academy of Pediatrics
of Pediatrics has published screening, evaluation, and treatment guidelines ALT alanine transaminase
based on the best available evidence. However, gaps in evidence remain, and AST aspartate aminotransferase
BP blood pressure
implementation of evidence-based recommendations can be challenging. It is CDC Centers for Disease Control and
important to review optimal care in both the primary care and multidisciplinary Prevention
weight management settings. This allows for timely evaluation and appropriate FDA Food and Drug Administration
HbA1c hemoglobin A1c
referrals, with the pediatrician playing a key role in advocating for patients at LAGB laparoscopic adjustable gastric
higher risk. There is also a role for larger-scale prevention and policy measures band
that would not only aid pediatricians in managing obesity but greatly benefit NAFLDnonalcoholic fatty liver disease
PCOS polycystic ovary syndrome
child health on a population scale.
RYGB Roux-en-Y gastric bypass
VSG vertical sleeve gastrectomy

Vol. 43 No. 11 N O V E M B E R 2 0 2 2 601

Downloaded from [Link]

by HINARI 2 user
 INTRODUCTION for infants) should be measured at health supervision vis-
Child obesity is a public health crisis, given the dramatic its from birth through adolescence. Unlike in adults, the
increases in the past 3 decades. (1)(2)(3)(4) For many chil- definition of obesity in children depends on weight, height,
dren, the onset of obesity occurs in early childhood. (2)(5) age, and sex (Table 1). The 2000 Centers for Disease Con-
Infant rapid growth and overweight status are especially trol and Prevention (CDC) growth charts are recommended
consequential because they strongly predict later obesity for children aged 2 to 19 years, (26) with weight status de-
(6)(7)(8)(9)(10)(11)(12) and comorbidities (eg, diabetes, car- fined using either BMI (calculated as weight in kilograms
diovascular disease). (13)(14)(15)(16) Obesity during adoles- divided by height in meters squared), percentiles, (27)(28) or
cence is associated with greater likelihood of comorbidities BMI cutoff values. (29) Severe obesity, which is associated
and adult obesity. (17) Significant disparities in obesity rates with greater cardiometabolic risk, (30) can be defined as a
exist in the United States, with higher prevalence in children proportion of the 95th percentile (Table 1). The extended
from lower-income and racial/ethnic minority families. (1)(18) BMI growth curves to classify and monitor children with se-
(19)(20)(21)(22) These disparities, often with onset during in- vere obesity are available in electronic medical records or can
fancy, (23) have implications for long-term obesity and cardio- be charted manually. (31) Adaptation of clinical tools to use z
vascular and metabolic health. (18)(24)(25) scores in addition to percentiles may be beneficial.
Given the high prevalence, disparities, and long-term From birth through 23 months, the CDC and the Ameri-
consequences of child obesity, it is critical for pediatricians can Academy of Pediatrics (AAP) recommend using weight,
to be knowledgeable about 1) obesity definitions, 2) multi- recumbent length, and sex to determine weight-for-length
factorial causes, 3) associated comorbidities and screening percentile based on the World Health Organization growth
recommendations, and 4) prevention and treatment. charts (Table 1). Overweight is defined as weight-for-length
of at least the 97.7th percentile, which is at or above 2 SD
DEFINITIONS AND CLASSIFICATIONS above the median for sex. Rapid infant weight gain, defined
Assessment of healthy growth is a key component of pedi- as an upward change in weight-for-length or weight-for-age
atric primary care. Weight and height (recumbent length z score greater than 0.67 (equivalent to crossing 2 percentile

Table 1. Definitions and Classifications of Weight Status

AGE AND WEIGHT CATEGORY WEIGHT STATUS DEFINITION AND CLASSIFICATION
Adults
Weight category BMI
Underweight <18
Healthy weight 18 to <25
Overweight 25 to <30
Obesity $30
Class I 30 to <35
Severe class II 35 to <40
Severe class III $40
Children 2–19 years old (based on CDC 2000 growth charts)
Weight category BMI percentile
Underweight <5th percentile
Healthy weight 5th to <85th percentile
Overweight 85th to <95th percentile or BMI $25a
Obesity $95th percentile or BMI $30a
Class I $95th to 120th percentile of the 95th percentile
Severe class II $120th to 140th percentile of the 95th percentile or BMI 35 to <40a
Severe class III $140th percentile of the 95th percentile or BMI $40a
Children <2 years old (based on WHO growth charts)
Weight category WFL percentile
Underweight <2.3rd percentileb
Healthy weight >2.3rd to <97.7th percentile
Overweight $97.7th percentile

CDC5Centers for Disease Control and Prevention, WFL5weight-for-length, WHO5World Health Organization.
a
Overweight and obese status categories for children are defined using either BMI percentiles or BMI cutoff values depending on which
value is lower.
b
Using WHO Anthro Survey Analyser Quick Guide.

602 Pediatrics in Review

Downloaded from [Link]

by HINARI 2 user
 lines) over a 6-month period, is highly predictive of later families earning at least 400% of the federal poverty
obesity. (6)(13) level. (36)

ETIOLOGY
EPIDEMIOLOGY
Pediatric obesity is a complex, multifactorial disease
Based on 2017–2018 National Survey of Children’s Health
caused by interaction between genetics and environmen-
(National Health and Nutrition Examination Survey) data,
tal exposures. (37)(38)(49)(40) Ultimately, excess energy
obesity affects 13.7% of preschool-age (2–5 years), 19.3% of
intake relative to expenditure leads to excess weight gain
school-age (6–11 years), and 20.9% of adolescent (12–18 years)
and adiposity (41)(42)(43)(44) and represents the final
children in the United States. Overweight status affects
pathway to obesity. (45)(46) Contextual factors before
9.2% of children younger than 2 years. Although the preva-
conception, and continuing through pregnancy, infancy,
lence of obesity has stabilized for young children, it has in-
childhood, and adolescence, (47)(48)(49) create an inter-
creased from rates in 1999 that were 15.8% and 16.0%, generational cycle of obesity risk (Fig). Adverse social de-
respectively, among school-age children and adolescents. terminants of health, defined as economic and social
(32) Racial and ethnic disparities can begin in infancy, espe- conditions that affect health, contribute to disparities and
cially if living below the poverty line, as seen with higher this intergenerational transmission.
rates for Black, Latino, and American Indian/Alaskan native Before conception, parental obesity and comorbidities
children; (32)(33) prevalence was 28.7% among 10- to are risk factors for the next generation. (50)(51)(52) Pre-
17-year-old American Indian/Alaskan natives. (34) Although conception is also a time when adults establish their
obesity prevalence among Asian youth is lower (8.7%) than own attitudes, beliefs, and lifestyle behaviors (eg, smok-
that of other racial/ethnic groups, cardiometabolic complica- ing, diet, exercise) that affect their energy balance and
tions tend to occur at a lower BMI and younger age among will shape the attitudes, beliefs, and lifestyle behaviors
South Asian children. (35) of their children. During pregnancy, women with over-
Disparities based on income are similarly large, with weight/obesity at conception are more likely to have excess
a 21.5% prevalence of obesity among youth in house- gestational weight gain, to develop gestational diabetes melli-
holds earning less than the federal poverty level com- tus and hypertensive disorders of pregnancy, to have an oper-
pared with 8.8% prevalence of obesity among youth in ative delivery, and to deliver an infant with large- or small-for-

Figure. A life course perspective of child obesity etiology.

Vol. 43 No. 11 N O V E M B E R 2 0 2 2 603

Downloaded from [Link]

by HINARI 2 user
 gestational-age birthweight. All of these factors predispose the EVALUATION OF CHILD OVERWEIGHT AND
child to excess weight gain and obesity, (45)(46) whereas OBESITY IN THE PRIMARY CARE SETTING
modification of lifestyle behaviors during pregnancy can re- Multiple expert panels recommend a careful history and phys-
duce this risk. (19)(53)(54)(55) During infancy and early child- ical examination and a thorough evaluation for comorbidities
hood, a variety of parent feeding practices are associated with and secondary conditions for children with overweight and
the risk of child obesity, including formula feeding (56)(57) obesity at every health supervision visit. (37)(103)(104)(105)
and combination feeding versus exclusive breastfeeding, Recommended laboratory screening includes fasting analyses
(58)(59)(60)(61)(62)(63) consumption of sugar-sweetened bev- for glucose, lipids, and liver function tests (alanine transami-
erages (64)(65)(66) and high–energy-dense foods, (67)(68) nase [ALT], aspartate aminotransferase [AST]), although many
early introduction of solids, (69)(70)(71)(72)(73) and con- providers perform nonfasting laboratory tests for convenience.
sumption of limited fruits and vegetables. (74) In addition, Children with overweight status should have these screening
maternal obesity is associated with reduced initiation, estab- laboratory tests obtained if they have an elevated risk of co-
lishment, and maintenance of breastfeeding. (75)(76) Less re- morbidities. Evaluation for endocrine, neurologic, or genetic
sponsive parent-child feeding styles, which include pressuring syndromes is indicated only if signs and symptoms are found.
or restricting feeding, not following infant cues, indulgent Additional laboratory screening for diabetes suggested by the
feeding without appropriate limit setting, or uninvolved/inat- Pediatric Endocrine Society and the American Diabetes Asso-
tentive feeding, (77)(78) are also associated with child obesity ciation includes an oral glucose tolerance test and hemoglobin
(79)(80)(81)(82)(83)(84)(85)(86) and can potentially disrupt in- A1c (HbA1c) (Table 3). Some weight management clinics
fant self-regulatory capacity around eating and energy intake. obtain vitamin D levels because the prevalence of vitamin D
(45)(77)(78)(87)(88)(89)(90)(91)(92)(93) In addition, infant and deficiency is higher among children with overweight and obe-
child appetite traits develop during this time, influencing sity. (106) Routine screening for other micronutrient deficien-
parent feeding styles and practices, as well as child cies is not recommended. The timing of testing depends on
weight gain and obesity risk. (94)(95)(96)(97)(98)(99) the level of risk, based on history, physical examination, previ-
During later childhood and adolescence, a child’s own at- ous laboratory tests, and clinical judgment, and testing may
titudes, beliefs, and lifestyle behaviors affecting energy begin as early as age 2 years. If results of nonfasting studies
balance develop. Lifestyle patterns of low physical activ- are abnormal, fasting studies should be obtained. There are
ity, high screen time, and inadequate sleep are also asso- limited recommendations for how often to repeat normal lab-
ciated with obesity across the life cycle. Decreased sleep oratory tests. In our practice, this is determined by level of
has been linked to obesity, abnormal glucose regulation, risk from history, physical examination, weight status, signs,
and increased hunger/appetite. (100) and symptoms. Generally, laboratory tests are repeated annu-
Most cases of child obesity are due to interrelated indi- ally for children with a BMI that remains greater than or
vidual and environmental factors, and affected children equal to the 95th percentile.
commonly have typical cognitive and pubertal develop-
ment, normal or tall stature, and a lack of dysmorphic SCREENING FOR COMMON COMORBIDITIES
features. However, in rare circumstances, obesity is sec- Weight-related comorbidities can affect every organ sys-
ondary to identifiable conditions, such as endocrine, ge- tem. It is helpful to consider a systems-based approach for
netic, or central nervous system disorders. Genome-wide screening and diagnosis (Table 3).
association studies have identified mutations in genes as-
sociated with neuroendocrine feedback loops (eg, leptin Cardiovascular
and ghrelin pathways) that regulate energy intake and ap- Dyslipidemia. Disordered lipid metabolism is an early
petite, as well as energy expenditure, although to a lesser marker of cardiovascular risk and is found in approximately
degree (Table 2). (101) A secondary cause should be con- 40% of children with obesity. (107) Combined dyslipidemia,
sidered for an infant, child, or adolescent with obesity with elevated triglyceride levels, low high-density lipoprotein
and developmental delay, short stature, delayed puberty, cholesterol levels, and normal or moderately elevated total
early-onset obesity, or hyperphagia, warranting referrals cholesterol levels, is the most common pattern and is related
for endocrine, developmental, and genetic evaluations. to insulin resistance. (108)(109) Children with dyslipidemia
Genetic analysis from saliva can be used for DNA collec- should have fasting tests repeated within 1 to 3 months and if
tion and epigenetic analysis to help identify underlying still abnormal should receive targeted nutritional counseling
causes of obesity. (102) and weight management. Guidance should focus on reducing

604 Pediatrics in Review

Downloaded from [Link]

by HINARI 2 user
 Table 2. Syndromic and Monogenic Obesity
OBESITY CLINICAL
CAUSEa LOCUS GENE ONSET (TYPE) FEATURES

Syndromic
Albright hereditary 20q13.2 GNAS1 Early (generalized) Short stature, short metacarpals and
osteodystrophy metatarsals, round facies, delayed
(pseudohypoparathyroidism dentition, hypocalcemia, subcutaneous
type 1a) calcium or bone deposition, precocious
puberty, mild cognitive deficit
Alstr€
om 2p13 ALMS1 Age 2–5 y (central) Blindness, deafness, acanthosis nigricans,
chronic nephropathy, T2DM, cirrhosis,
hypogonadism in males, normal cognition
Bardet-Biedl 11q13 BBS1, multiple others Age 1–2 y (central) Intellectual disability, hypotonia, retinitis
pigmentosa, polydactyly, hypogonadism,
1/– glucose intolerance, deafness, renal
disease
Beckwith-Wiedemann 11p15.5 Multiple Infancy Hyperinsulinemia, hypoglycemia,
hemihypertrophy, intolerance of fasting
Carpenter 6p11 RAB23 Mid-childhood Intellectual disability, short stature,
(central) brachycephaly, polydactyly, syndactyly of
feet, cryptorchidism, umbilical hernia, high-
arched palate, hypogonadism
Cohen 8q22 COH1 Mid-childhood Intellectual disability, microcephaly, small
(central) hands and feet, cryptorchidism, hypotonia,
failure to thrive in infancy, prominent
central incisors, long and thin fingers and
toes
Prader-Willi 15q NDN, SNRPN Age 1–3 y Intellectual disability, microcephaly, short
(generalized) stature, hypotonia, almond-shaped eyes,
high-arched palate, small hands and feet,
late puberty, early failure to thrive then
later hyperphagia
Monogenic obesitya
Leptin deficiency 7q32.1 LEP Infancy–3 y Extreme hyperphagia, frequent infections,
hypogonadotropic hypogonadism, mild
hypothyroidism
Leptin receptor deficiency 1p31.3 LEPR Infancy Extreme hyperphagia, frequent infections,
hypogonadotropic hypogonadism, mild
hypothyroidism
POMC deficiency 2p23.3 POMC Infancy Hyperphagia, cholestatic jaundice or adrenal
crisis due to ACTH deficiency, pale skin,
and red hair (depending on racial/ethnic
background)
PCSK1 deficiency 5q15 PCSK1 Data unknown Small bowel enteropathy, hypoglycemia,
(varies) hypothyroidism, ACTH deficiency, diabetes
insipidus
MC4R deficiency 18q21.32 MC4R Infancy–3 y Rapid weight gain, food-seeking behavior, tall
stature/increased growth velocity

ACTH5adrenocorticotropic hormone, ALMS15Alstr€ om syndrome protein 1, BBS15Bardet-Biedl syndrome 1, COH15VPS13B gene, GNAS15guanine
nucleotide binding protein alpha stimulating activating polypeptide, LEP5leptin, LEPR5leptin receptor, MC4R5melanocortin 4 receptor, NDN5necdin,
PCSK15proprotein convertase subtilisin/kexin type 1, POMC5proopiomelanocortin, RAB235ras-associated binding protein 23, SNRPN5small nuclear
ribonucleoprotein polypeptide N, T2DM5type 2 diabetes mellitus.
a
This list is not comprehensive. There are additional causes of syndromic and monogenic obesity.

intake of refined carbohydrates and saturated fats and increas- Hypertension. Nearly 10% of children with obesity have
ing exercise and intake of vegetables, fruits, and healthy fats. hypertension. Stage 1 hypertension is an average systolic or
One should consider familial hypercholesterolemia and refer- diastolic blood pressure (BP) greater than or equal to the
ral to a lipid specialist for low-density lipoprotein cholesterol 95th percentile or greater than or equal to 130/80 mm Hg
levels greater than 190 mg/dL (>4.92 mmol/L) and triglycer- measured on at least 3 separate occasions confirmed by man-
ide levels greater than 600 mg/dL (>6.78 mmol/L). ual BP measurement using an appropriately sized cuff and

Vol. 43 No. 11 N O V E M B E R 2 0 2 2 605

Downloaded from [Link]

by HINARI 2 user
 606

by HINARI 2 user
Table 3. Recommended Laboratory Screening for Children with Overweight and Obesity
NEXT STEPS FOR
LABORATORY
a
GUIDELINES BMI $95% NORMAL/DIAGNOSTIC VALUES ABNORMALITIESb
AAP Institute for Healthy Glucose Glucose (fasting) Glucose

Pediatrics in Review
Child Weight (obtain Lipid panel Normal, <100 mg/dL (<5.55 mmol/L) Prediabetes: repeat in
fasting laboratory ALT, AST Prediabetes, 100–125 mg/dL (5.55–6.94 mmol/L) 1–2 mo, consider
tests)c Diabetes, $126 mg/dL ($6.99 mmol/L) HbA1c, 2-h OGTT
Nonfasting glucose $200 mg/dL ($11.10 mmol/L) is diagnostic for diabetes Diabetes: refer to
Lipid panel (fasting) endocrine
LDL-C <110 mg/dL (<2.85 mmol/L) Lipids
Triglycerides <75–90 mg/dL (<0.85–1.02 mmol/L) LDL-C >190 mg/dL
ALT <22 U/L (<0.37 lkat/L) (girls) (>4.92 mmol/L)
ALT <26 U/L (<0.43 lkat/L) (boys) Triglycerides >
600 mg/dL (>6.78
mmol/L)
Consider familial
hypercholesterolemia
Refer to a lipid
specialist
ALT >22–26 U/L
(>0.37–0.43 lkat/L):
repeat in 1–3 mo
ALT 60–100 U/L
(1–1.67 lkat/L): refer
to gastroenterology
ADA, PES Prediabetes Diabetes

Downloaded from [Link]

HbA1cd 5.7%–6.4% $6.5%
2-hour OGTTd 140–199 mg/dL (7.77–11.04 mmol/L) 200 mg/dL (11.10 mmol/L)

AAP5American Academy of Pediatrics, ADA5American Diabetes Association, ALT5alanine transaminase, AST5aspartate aminotransferase, HbA1c5hemoglobin A1c, LDL-C5low-density lipopro-
tein cholesterol, OGTT5oral glucose tolerance test, PES5Pediatric Endocrine Society.
a
Laboratory tests should also be performed for the 85th percentile or greater if risk factors are present.
b
Normal laboratory tests can be repeated yearly for patients with persistent/worsening obesity.
c
Can be performed nonfasting for patient convenience.
d
Can additionally be considered depending on patient risk of diabetes.
 proper placement. Stage 2 hypertension is an average systolic biochemical signs of hyperandrogenism, and 3) polycystic
or diastolic BP greater than or equal to the 95th percentile 1 12 ovaries. (115) This evaluation may be performed in primary
mm Hg or greater than or equal to 140/90 mm Hg. Many elec- care settings or in adolescent, endocrine, or comprehensive
tronic medical record systems calculate BP percentiles. Clini- weight management clinics. Laboratory tests include first-
cians without access to these systems may use standardized morning 17-OH-progesterone, dehydroepiandrosterone sulfate,
tables (110) or smartphone applications. Additional evaluation androstenedione, total and free testosterone, sex hormone
for children with hypertension includes serum electrolyte binding globulin, b-human chorionic gonadotropin, luteiniz-
levels, blood urea nitrogen/creatinine level, urinalysis, and ing hormone, follicle-stimulating hormone, estradiol, prolac-
urine microalbumin to creatinine ratio. Treatment includes tin, thyroxine, thyroid-stimulating hormone, and insulin.
weight management and salt reduction. One should consider Patients with normal laboratory test results and persistent
referral to nephrology or cardiology for children with persistent menstrual irregularity should undergo pelvic sonography to
stage 1 hypertension for more than 6 months, stage 2 hyper- assess for polycystic ovaries. Similar to all obesity-related co-
tension, or risk factors (renal anomalies, prematurity, cardiac morbidities, first-line treatment is weight loss. Initial pharma-
or rheumatologic disease) for evaluation of secondary causes, cologic treatment should include oral contraceptive pills, and
end organ damage, and the need for pharmacotherapy. for patients with significant insulin resistance or continued
symptoms despite weight loss, metformin can be added. Met-
Endocrine formin can be used as monotherapy if there are other contra-
Prediabetes and Type 2 Diabetes Mellitus. Up to 15% of indications to hormonal treatment.
adolescents with obesity have prediabetes or type 2 diabe-
tes mellitus. (111) The 2015 Institute for Healthy Child Gastrointestinal
Weight guidelines recommend obtaining fasting glucose Up to 29% to 38% of children with obesity have nonalcoholic
levels for children with overweight/obesity. Guidelines fatty liver disease (NAFLD), with an increased prevalence
from the American Diabetes Association and the Pediatric among Hispanic adolescents. NAFLD can progressively range
Endocrine Society recommend obtaining HbA1c levels, from fibrosis to end-stage liver disease. (116) NAFLD is typically
although they acknowledge its poor predictive value. asymptomatic. (107) Although hepatic magnetic resonance im-
(112)(113)(114) A 2-hour oral glucose tolerance test should aging or biopsy can detect NAFLD even when liver function
be considered in children with abnormal screening labo- test results are normal, screening with ALT is recommended
ratory tests, a strong family history, or other risks, such as for all patients with overweight/obesity. Patients with elevated
acanthosis nigricans. Children with diabetes should be ALT levels should have repeated laboratory tests in 1 to
referred to endocrinology. Children with prediabetes should be 3 months. One should consider referral to gastroenterology
referred to endocrinology or a comprehensive weight manage- and/or a weight management clinic for patients with ALT lev-
ment clinic, obtain targeted nutritional counseling to reduce els twice the upper limit of normal (60 U/L [1.0 mkat/L]) or
refined carbohydrate intake, and potentially receive medication persistently elevated for 3 months to evaluate for other causes
management. HbA1c in the prediabetic range should be (eg, infectious, metabolic, inflammatory, genetic) using he-
repeated in 1 to 3 months, and a 2-hour oral glucose tolerance patic ultrasonography and additional laboratory analyses. Life-
test should be considered if the HbA1c concentration worsens style modifications to improve diet and physical activity are the
or shows no improvement. first-line treatment for NAFLD, with emphasis on avoidance of
Menstrual Irregularities and Polycystic Ovary Syndrome. sugar-sweetened beverages. (107)
Up to 5% to 10% of women of childbearing age have poly-
cystic ovary syndrome (PCOS). Insulin resistance associ- Pulmonary
ated with obesity is one of the most common etiologies. Obesity is related to an increased risk of obstructive sleep ap-
Although oligomenorrhea and anovulatory cycles are com- nea, (117) occurring in 13% to 59% of children with severe
mon during the first 2 years after menarche, evaluation obesity. (117)(118) Screening should assess snoring, respira-
for PCOS should be considered in adolescents with BMI tory pauses, and daytime sleepiness. There is limited evi-
greater than or equal to the 85th percentile and irregular dence for validated screening tools, but some use the
menses and/or signs of hyperandrogenism (eg, hirsutism, Pediatric Sleep Questionnaire. (117)(119)(120) Examination
acne). The Endocrine Society recommends using the Rot- should evaluate degree of tonsillar hypertrophy and nasal ob-
terdam criteria: PCOS is diagnosed when 2 of 3 criteria struction due to allergies or other causes. Treatment for aller-
are present: 1) anovulation/oligomenorrhea, 2) clinical/ gic rhinitis with nasal corticosteroids and/or antihistamines

Vol. 43 No. 11 N O V E M B E R 2 0 2 2 607

Downloaded from [Link]

by HINARI 2 user
 may relieve symptoms. One should also consider referrals to health issues. Baseline screening for disordered eating, de-
otolaryngology and/or pulmonology for polysomnography, pression, and anxiety should be completed for all patients,
initiation of continuous positive airway pressure treatment, and if identified, patients should be referred to adolescent
and tonsillectomy and adenoidectomy. medicine, psychology, or psychiatry for therapy and/or phar-
macologic management.
Musculoskeletal Due to the heterogeneity of comorbidity risk within
Children with obesity should be screened for extremity and BMI categories, there are other approaches for categoriz-
gait abnormalities. Obesity increases the risk of Blount dis- ing obesity. The Edmonton Obesity Staging System for Pe-
ease, which presents as genu varum or bowed legs and has ju- diatrics defines 4 stages for children 2 years and older
venile- and adolescent-onset peaks (4–10 years or >10 years). based on severity and functioning within 4 domains: met-
(121) School-age and adolescent children with severe obesity abolic, mechanical, mental health, and psychosocial. (127)
have a lifetime risk of 1:450 for slipped capital femoral epiphy- Using this framework may help prioritize referrals to
sis, (122) which should be considered for a child with obesity weight management programs with limited availability,
and hip or knee pain and an abnormal gait/limp. Blount dis- create individualized care plans, and decrease stigma.
ease and slipped capital femoral epiphysis require urgent re-
ferral to orthopedic surgery. Flat feet (pes planus) can be TREATMENT
referred to physical therapy, podiatric medicine, and/or ortho-
Overall Approach
pedic surgery if associated with pain.
Behavioral interventions, composed of lifestyle modifica-
tion counseling (eg, changes in diet, physical and seden-
Neurologic
tary activities, and sleep habits), remain the core treatment
The prevalence of pseudotumor cerebri (idiopathic intra-
for obesity at all ages and degrees of severity, with phar-
cranial hypertension) in children with obesity and severe
macotherapy and bariatric surgery as additional options
obesity is approximately 26 and 65 per 100,000, respec-
tively. (123) Patients with signs of increased intracranial for select patients. The AAP recommends a staged ap-
pressure, eg, headache or papilledema, should be referred proach (Table 4) that increases in frequency and intensity.
for emergency evaluation. Stage 1: prevention plus includes lifestyle modification
counseling that benefits most patients in the primary care set-
Psychosocial ting. Stage 2: structured weight management includes more
The most common comorbidities of obesity are mental health structured lifestyle modification counseling in the primary
issues, including depression, anxiety, low self-esteem, and care setting with additional support from a dietitian, social
poor body image. Recent systematic reviews estimate that worker, health educator, or physical therapist. For children
rates of depression and anxiety are approximately 1.5- to 2-fold with class II and III obesity who are not achieving weight loss
higher in children with obesity than in those with weight in goals and for those with weight-related comorbidities, referral
the healthy range. (124) Disordered eating also occurs, includ- to a comprehensive multidisciplinary treatment program
ing binge eating, bulimia nervosa, anorexia nervosa, and night should be considered. Stage 3: comprehensive multidisciplin-
eating syndrome, which occurs with insomnia and eating dur- ary intervention occurs in a pediatric weight management spe-
ing the night. Weight stigmatization, such as teasing, bully- cialty clinic and includes increased intensity in lifestyle
ing, and social exclusion, (125)(126) contributes to mental modification counseling, including input from a dietitian,

Table 4. AAP Management and Treatment Stages for Patients with Overweight or Obesity
STAGE SETTING COMPONENTS
1: Prevention plus Primary care Positive behavior change; “5-2-1-0”
messaging
2: Structured weight management Primary care with appropriate training 1 Positive behavior change with goal of
nutrition weight maintenance or decrease in BMI
velocity; self-monitoring; medical
screening
3: Comprehensive multidisciplinary Pediatric weight management clinic Increased intensity of behavior change;
intervention increase visit frequency
4: Tertiary care intervention Pediatric weight management clinic Intensive diet and activity counseling; meal
replacements; medications; surgery

AAP5American Academy of Pediatrics.

608 Pediatrics in Review

Downloaded from [Link]

by HINARI 2 user
 psychologist, or social worker, and management of mental Lifestyle Modification Counseling Techniques. Lifestyle
health concerns and weight-related comorbidities. Participa- modification counseling is the foundation and initial treatment
tion in a behavioral treatment program, if available, should be for all children with obesity in all stages of treatment. The most
considered. Behavioral treatment programs are a component effective method is motivational interviewing, which is a patient-
of many comprehensive weight management clinics and are centered communication style involving reflective listen-
also offered in multiple settings, including school and commu- ing, support of autonomy, shared decision-making, and eliciting
nity centers and many larger group and university-affiliated pe- change-talk. (134) The stages of change used in motivational in-
diatric practices. Behavioral treatment programs are family- terviewing include precontemplation, contemplation, prepara-
centered, multicomponent programs that offer intensive, mul- tion, action, maintenance, and relapse (Table 5). Keeping these
tiphasic, lifestyle modification counseling and generally in- stages in mind supports “meeting the patient where they are.”
clude weekly visits in the treatment phase and monthly Lifestyle modification counseling aims to increase goal
maintenance visits. Stage 4: tertiary care intervention occurs in setting, self-monitoring, problem-solving, contingent re-
a pediatric weight management specialty clinic setting and ward systems, and stimulus control to support behavior
adds intensive dietary management, pharmacologic therapy, change. Goal setting can promote behavior change in chil-
and bariatric surgery to the stage 3 interventions. dren (135) and is a key component of the contemplation,
In accordance with evidence that at least 26 contact hours preparation, and action phases. SMART goals are defined
of behavioral treatment over 2 to 12 months is necessary to as Specific, Measurable, Achievable, Realistic, and Time-
achieve desired outcomes, (128) the AAP recommends follow- based. Allowing the patient to select the frequency and
up visits every month in stage 1, every 2 to 4 weeks in stages 2 timeframe of the goal fosters autonomy. (135) Once goals
and 3, and tailored frequency depending on patient motivation are set, follow-up should review progress, provide support,
and medical status in stage 4. Interventions with at least 52 and troubleshoot barriers.
contact hours had greater improvements, regardless of the var- Self-monitoring of diet, exercise, and weight is associ-
iations in content of the interventions. (128) Because this fre- ated with weight loss (136) and should be used to track pro-
quency of visits is not achievable or feasible for many families gress and increase awareness of behaviors. Phone apps can
or practices, (129) we recommend targeted visits at least every 3 help monitor diet and physical activity. Contingent reward
months, including telemedicine to minimize travel and school systems provide rewards for meeting goals. For stimulus
absences. Behavioral treatment programs with weekly visits, control, patients/families focus on changing environmental
including telehealth sessions, can also help meet US Preven- factors that affect nutrition (eg, decreasing available snacks)
tive Services Task Force recommendations. Evidence from and physical activity (eg, having clothing for varied weather,
multiple systematic reviews has shown that behavioral treat- removing screens from bedrooms).
ment programs can lead to modest short-term reductions in Although the pediatric primary care office is a key setting
BMI, in the range of BMI z score reductions of –0.06 units for for providing lifestyle modification counseling, numerous
6- to 11-year-old children and –0.3 units for 0- to 6-year-old barriers exist, including time for providers and patients, re-
children, with minimal risk of adverse events. (128)(130)(131) imbursement, provider training, and limited availability of
(132)(133) specialty weight management clinics and behavioral

Table 5. Stages of Change

STAGE OF CHANGE DEFINITION PATIENT STATEMENT PLAN
Precontemplation Patient/family does not see “I don’t want to talk about my Acknowledge wishes and
weight as a problem weight today.” revisit at next appointment
Contemplation Patient/family interested in “I would like to decrease my risk Discuss SMART goals
behavior change of diabetes.”
Preparation Patient/family planning to “I think I could drink less soda.” Eliminate soda and drink more
address the problem water
Action Patient/family actively carrying “I bought a water bottle and Congratulate patient on
out behavior change stopped buying soda.” positive behavior change
Maintenance Patient/family sustaining “I always drink water now.” Focus on new SMART goal
behavior change by
establishing habits and
modifying the environment
Relapse Return to earlier stages/ “I was stressed with school and Normalize relapse and work on
behaviors started craving soda.” “resetting”

SMART5Specific, Measurable, Achievable, Realistic, and Time-based.

Vol. 43 No. 11 N O V E M B E R 2 0 2 2 609

Downloaded from [Link]

by HINARI 2 user
 treatment programs for children. Potential strategies to ad- fasting (time-restricted feeding), which has shown bene-
dress barriers include 1) telehealth visits for primary and spe- fits on overall health, disease, and aging in adults (144)
cialty care; 2) inclusion of nurses, dietitians, and health and can lead to weight loss in selected patients; it is less
educators to participate in lifestyle modification; 3) increased effective if the 6-hour eating period occurs at the end of
reimbursement for treatment with chronic disease care mod- the day and is followed by sleep or sedentary time (145);
els; and 4) more providers receiving training in obesity treat- 2) ketogenic diets are very-low-carbohydrate, high-fat,
ment and prevention strategies. Advocacy is needed for and high-protein diets, with evidence of efficacy and
policy changes to increase availability and reimbursement safety (146); and 3) low- and very-low-calorie diets,
for these important services. 1,000 to 1,500 and 800 cal per day, respectively, which
Lifestyle Modification Counseling Content. Counseling can be facilitated by meal replacement plans. All inten-
should promote healthy changes in diet, physical activity, sive nutrition and diet plans should be performed only
screen time, and sleep, depending on patient needs. The AAP with the guidance of a physician and registered
“5-2-1-0” message recommends 5 or more servings of fruits
dietitian.
and vegetables, less than 2 hours of screen time, 1 hour or
more of physical activity, and 0 sugary drinks. (137) Physical Activity
Although increasing physical activity without altering dietary
Diet
intake is generally not sufficient to attain healthy weight loss,
Common obesogenic dietary patterns are identified to guide
the quantity of daily activity for most children falls well be-
practical goals, including decreasing portion sizes; increasing
low current guidelines. Physical activity recommendations
fruit, vegetable, and whole grain intake; decreasing processed
vary by age. For infants (birth–12 months), interactive floor-
sugar and carbohydrate consumption; and increasing water
based play and at least 30 minutes of tummy time spread
intake. (132) Some popular ways to conceptualize diet include
throughout the day while awake is recommended. For tod-
1) MyPlate, which focuses on a balanced plate with half fruits
dlers (12–36 months) and young children (3–5 years), at
and vegetables, one-quarter whole grains, and one-quarter
least 180 minutes daily, of which at least 60 minutes are
lean protein ([Link] (138) and 2) the Traf-
moderate to vigorous intensity, is recommended. For 6- to
fic Light Diet, (139)(140) which organizes food into catego-
12-year-old children, 60 minutes of moderate to vigorous
ries using the colors of a traffic light, with green for anytime
foods, yellow for sometimes foods, and red for foods to eat activity is recommended. (104)(147)(148) For adolescents,
rarely. 60 to 90 minutes of physical activity is recommended. To
Plant-based and vegetarian diets have become more improve compliance and sustainability, one should select
common, as evidence in adults shows that such diets may activities that the child enjoys. Older children with poor
lower cardiovascular risk through lowering BMI, total cho- exercise tolerance can start with walking goals, aiming for a
lesterol level, blood pressure, fasting plasma glucose levels, particular number of steps or minutes per day, and use
and HbA1c concentration. (141) Carefully planned vegetar- phone apps for self-monitoring.
ian diets can provide adequate nutrition during childhood
and adolescence with appropriate knowledge, counseling, Screen Time
and surveillance. (142) Depending on the content of the The AAP recommends zero screen time for children
diet, special attention should be given to the amounts of younger than 2 years, less than 1 hour daily for 2- to 4-
protein, essential fatty acids, vitamin B12, calcium, vitamin year-olds, (149) and less than 2 hours daily for school-age
D, iron, and zinc consumed. (143) children and adolescents. (150) Screen time for family
Many patients and their families find information communication or education is not included in these
about intensive nutrition and diet plans using the Inter- totals.
net, social media, and word of mouth. Many of these
diets have no benefit, and some may be harmful. Some Sleep
intensive nutrition plans may have benefit for carefully The American Academy of Sleep Medicine and the AAP
evaluated adolescent patients. Intensive nutrition plans recommend optimal sleep duration of 12 to 16 hours for
should be offered only in weight management clinic set- infants, 11 to 14 hours for 1- to 2-year-olds, 10 to 13 hours
tings with close physician and registered dietitian moni- for 3- to 5-year-olds (including naps), 9 to 12 hours for
toring. Examples of intensive nutrition and diet plans 6- to 12-year-olds, and 8 to 10 hours for adolescents.
that may benefit some patients include 1) intermittent (151)(152)

610 Pediatrics in Review

Downloaded from [Link]

by HINARI 2 user
 Pharmacologic Management comorbidities in adolescents compared with behavioral
Pharmacotherapy can be used as an adjunct to lifestyle and pharmacologic interventions. (157) Meta-analysis of
changes in a multidisciplinary weight management program weight loss outcomes after bariatric surgery report mean
for class I obesity with a comorbidity or class II or III obe- BMI reductions at 6 and 36 months, respectively, of 5.4%
sity; all medications require close follow-up and dose titra- and 10.3% for LAGB, 11.5% and 18% for VSG, and 13%
tion (Table 6). (153) There are currently 3 US Food and Drug and 15% for RYGB. (156) The Teen Longitudinal Assess-
Administration (FDA)–approved medications for weight loss ment of Bariatric Surgery cohort, the largest multicenter
in children and adolescents. Additional medications with case series, reported major perioperative (within 30 days
other primary indications that have weight loss as a side ef- of surgery) complications in 8% of patients, (118) minor
fect are used off-label in the pediatric weight management complications (eg, nausea and dehydration) in 15%, and
setting. Generally, medications are considered effective if no deaths. Micronutrient deficiencies are the most com-
there is at least 5% BMI reduction or slowed weight gain mon long-term complications. Due to increased postopera-
within 12 weeks of reaching optimal dose, and they are gen- tive fertility, an increased risk of unintended pregnancy in
erally discontinued if no improvement occurs. The average adolescents has been well documented. (160) We recom-
range of weight loss for each medication is listed in Table 6. mend discussing this risk and providing contraception. Ul-
Weight regain is common when medications are stopped. In timately, the choice to have surgery should be guided by the
general, the cost of these medications for children, other patient’s age, sex, severity of obesity, comorbidities, psychoso-
than metformin and phentermine, is not covered by insur- cial factors, pubertal status, and patient/family preferences
ance, especially if used off-label. Some plans may cover within a comprehensive pediatric weight management clinic.
liraglutide. Both private and public medical insurance plans cover the
cost of bariatric surgery for adolescents who meet the crite-
Bariatric Surgery ria. Most patients who receive bariatric surgery are
The AAP recommends bariatric surgery as a treatment to 16 years and older and complete VSG after 6 months of inten-
consider for youth with class III obesity or class II obesity sive lifestyle counseling and evaluation by the pediatric weight
with severe comorbidities when the response to behavioral management, surgery, nutrition, and psychology teams.
and/or medical interventions is limited. (154)(155) The 3
most common types of bariatric surgery procedures, all Prevention
performed laparoscopically, are 1) Roux-en-Y gastric by- The mainstay of prevention is promoting healthy behaviors
pass (RYGB), which creates a small stomach pouch and at- throughout childhood, regardless of weight status. Despite
taches a section of the small intestine directly to the standard counseling in primary care, the progression of
pouch, allowing “bypass” of the upper portion of the intes- obesity is common, highlighting the need for additional
tines; 2) vertical sleeve gastrectomy (VSG), which removes preventive strategies. Several evidence-based obesity preven-
a large portion of the stomach, creating a small, tube- tion programs exist for preschool- and school-age children,
shaped stomach; and 3) laparoscopic adjustable gastric based in child care and school settings. The Nutrition and
band (LAGB), which places an inflatable, adjustable sili- Physical Activity Self-Assessment for Child Care Program
cone band around the top portion of the stomach, creating uses public health professionals to focus on physical activ-
a small pouch that slows the passage of food to the lower ity, nutrition, policy, and physical environments in child
portion. These procedures restrict food intake, reduce ap- care facilities. (161) Planet Health is a school-based program
petite, and increase satiety through similar mechanisms focused on decreasing television viewing and fast food in-
(including impacting the ghrelin and leptin pathways). take and increasing fruit/vegetable intake and physical activ-
RYGB also has a malabsorption component from the by- ity. (162) Team Kid Power is an academic-community
passed small intestine. Currently, VSG is the most com- partnership with face-to-face contact between health men-
monly performed procedure. Complications, both surgical tors and elementary school students to improve nutrition
(staple-line leak, stricture formation, and bleeding) and and activity. (163)
nutritional (eg, iron and vitamin B12 deficiency), are less Recent clinical trials of obesity prevention interventions
common after VSG than after RYGB. LAGB is now less during pregnancy and/or infancy have demonstrated prom-
often used due to higher complication rates. (156) Bariatric ising effects on obesity-related feeding practices and child
surgery produces greater sustained weight loss, improved weight during the first 2 years after birth. The Starting
quality of life, (157)(156)(158)(159) and resolution of Early Program, (164) is a strengths-based intervention in

Vol. 43 No. 11 N O V E M B E R 2 0 2 2 611

Downloaded from [Link]

by HINARI 2 user
 612

by HINARI 2 user
Table 6. Pharmacologic Treatment Options for Weight Loss
COST PER
MEDICATION MECHANISM OF CONTRAINDICATIONS/ MEAN WEIGHT MONTH,
(ROUTE) ACTION CONSIDER USE CAUTION RISKS/SIDE EFFECTS LOSS AGE, y mo
FDA-Approved Use
Orlistat (oral) Inhibits dietary fat Healthy patient who Renal impairment, liver Gastrointestinal 2.6 kga $12 800
absorption by 30% wants option of OTC impairment. use of symptoms (oily stool,

Pediatrics in Review
or not systemically levothyroxine, gas, rectal discharge),
absorbed cyclosporine, seizure hepatic dysfunction,
medications. chronic nephrolithiasis
malabsorption, nephropathy,
cholestasis cholelithiasis
Liraglutide (daily Appetite suppressant, Medication-induced Family or personal history Nausea, reflux, changes in BMI reduction $12 1,100
injection) increases satiety, weight gain, PCOS, of medullary thyroid bowel movements, –4.29%c
regulates insulin and insulin resistance, cancer or MEN type pancreatitis
blood glucose levels diabetes 2,b history of
pancreatitis, fear of
needles
Phentermined (oral) Appetite suppressant, Healthy patient without Hypertension, Increased heart rate, BMI reduction $16 35
stimulates metabolism cardiac issues palpitations, increased blood 4.1%a
arrythmias,b heart pressure, palpitations,
disease,b anxiety anxiety, insomnia
Off-Label Use
Metformin (oral) Increases insulin Atypical antipsychotics,e Impaired renal function, Nausea, looser stool BMI reduction $10 4–100
sensitivity PCOS, insulin liver disease (temporary) 0.86a
resistance, diabetes
Lisdexamfetamine (oral) Decreases thoughts Binge-eating disorder or Hypertension, Palpitations, increased Reduction 1.1 $6 380
around food and behavior palpitations, heart rate, increased to 2 kga
compulsive eating arrythmias,b heart blood pressure,

Downloaded from [Link]

disease,b anxiety anxiety, jitters,
constipation, insomnia,
dry mouth
Topiramate (oral) Increased satiety Migraines, seizures Glaucoma,b metabolic Impaired cognition, BMI reduction $16 50
acidosis, academic difficulty –4.9%a
difficulties, suicidal concentrating,
ideation, teratogenicb paresthesia
Phentermine/topiramate Appetite suppressant, Healthy patient without Hypertension, Increased heart rate, % weight $16 230
(oral) stimulates metabolism, cardiac issues, palpitations, increased blood change: low
increased satiety migraines arrythmias,b heart pressure, palpitations, dose: –4.78%;
disease, anxiety, anxiety, cognitive high dose:
glaucomab slowing, decreased –6.02%f
efficacy of birth
control
Semaglutide (weekly Appetite suppressant, Medication-induced Family or personal history Nausea, reflux, changes in Weight $12 1,400
injection or oral) increases satiety, weight gain, PCOS, of medullary thyroid bowel movement, reduction
regulates insulin and insulin resistance, cancer or MEN type pancreatitis –14.9%g
blood glucose levels diabetes 2,b history of
pancreatitis
Continued
 which registered dietitians support responsive parenting

FDA-approved for use in individuals 16 years and older for BMI $27 and at least 1 comorbidity. Phentermine is a class IV controlled substance. Phentermine is generally recommended for short-

Per Hsia DS, Gosselin NH, Williams J, et al. A randomized, double-blind, placebo-controlled, pharmacokinetic and pharmacodynamic study of a fixed-dose combination of phentermine/topiramate
FDA5Food and Drug Administration, LEPR5leptin receptor, MEN5multiple endocrine neoplasia, OTC5over the counter, PCOS5polycystic ovary syndrome, PCSK15proprotein convertase subtili-

Per Clement K, van den Akker E, Argente J, et al. Efficacy and safety of setmelanotide, an MC4R agonist, in individuals with severe obesity due to LEPR or POMC deficiency: single-arm, open-label,
COST PER
MONTH,

20,000 and active practicing of skills using prenatal and postpar-

tum nutrition counseling and parenting support groups co-
mo

ordinated with health supervision visits. (165) Greenlight

Per Srivastava G, Fox CK, Kelly AS, et al. Clinical considerations regarding the use of obesity pharmacotherapy in adolescents with obesity. Obesity (Silver Spring). 2019;27(2):190–204.
(166) is a health literacy–informed intervention with train-
AGE, y

ing in communication strategies, plain-language booklets,

$6

and tangible tools to reinforce healthy behaviors, delivered

by providers at health supervision visits. (167)(168) The In-
MEAN WEIGHT

tervention Nurses Start Infants Growing on Healthy Trajec-

Per Kelly AS, Auerbach P, Barrientos-Perez M, et al. A randomized, controlled trial of liraglutide for adolescents with obesity. N Engl J Med. 2020;382(22):2117–2128.
Mean weight

Per adult data from Wilding JPH, Batterham RL, Calanna S, et al. Once-weekly semaglutide in adults with overweight or obesity. N Engl J Med. 2021;384(11):989.
baseline

tories (169) intervention uses a home visiting model, with

change

–25%i

nurses providing counseling on positive parenting in feed-

LOSS

term treatment (12 weeks). In some states, it is considered a controlled substance and has strict guidelines for the prescriber to review before initiation.

ing, sleep, and emotional regulation. (170) Participation in

these interventions is associated with a 0.2 reduction in
pigmentation, nausea,

BMI z score compared with children in standard care con-

headache, depression
RISKS/SIDE EFFECTS

trol groups.
A recent systematic review found that obesity preven-
Increased skin

tive interventions targeting diet and physical activity for

children from infancy through adolescence can lead to re-
ductions in mean BMI z score from 0.07 to 0.05 and do
not have adverse effects. (171) Despite the small effect
size, the multifactorial environmental influences leading
CONTRAINDICATIONS/

to child obesity support the need for prevention across

Severe depression

the lifespan.
CAUTION

Weight Stigma
Weight bias or stigma is defined as negative attitudes, be-
liefs, judgments, stereotypes, or discriminatory acts toward
Table 6. Pharmacologic Treatment Options for Weight Loss (Continued)

individuals because of their weight. (172) Data show that

POMC deficiency, PCSK1

peers, family, health-care professionals, teachers, and me-

dia contribute to cultural norms that fail to acknowledge
deficiency, LEPR
CONSIDER USE

Metformin can be initiated concurrently with atypical antipsychotic agents.

obesity as a complex, multifactorial chronic disease. (125)

multicentre, phase 3 trials. Lancet Diabetes Endocrinol. 2020;8(12):960–970.
deficiency

Bias occurs as early as preschool, with young children plac-

in adolescents with obesity. Diabetes Obes Metab. 2020;22:480–491.

ing negative stereotypes onto peers with larger body sizes.

Bias causes adverse physical and psychological outcomes
and promotes social norms that marginalize people.
hunger, satiety, energy
receptor (regulation of
Works on melanocortin-4

These effects can be minimized with people-first lan-

guage, careful word choices to describe weight, and a wel-
Studies completed for children 6 years and older.
MECHANISM OF

sin/kexin type 1, POMC5proopiomelanocortin.

coming setting. People-first language can enhance weight-

expenditure)

related communication between parents, providers, and

children to focus on building healthy habits rather than
ACTION

on weight. (173) Discussing “a child with obesity” rather

than “an obese child” recognizes that the child has the
Absolute contraindications.

medical problem, rather than equating the child with the

Setmelanotideh (daily

problem. People-first language has not been adopted con-

sistently for obesity. (174)
MEDICATION

Using appropriate language and word choice for describ-

injection)
(ROUTE)

ing obesity decreases stigmatization. (126) Some terms that

clinicians use enhance stigma, including “fat,” “obese,” and
“extremely” or “morbidly obese,” whereas terms such as
b

g
h
e
a

Vol. 43 No. 11 N O V E M B E R 2 0 2 2 613

Downloaded from [Link]

by HINARI 2 user
 “high weight” and “unhealthy weight” are considered moti- syndemic) of epidemic obesity, undernutrition, and cli-
vating. Stigmatizing language could cause families to switch mate change will be required, and that reducing obesity
doctors or avoid medical appointments. (126) Finally, hav- disparities will require improving underlying societal
ing appropriately sized chairs, BP cuffs, scales, and exami- structures that lead to all health disparities.
nation gowns readily available can help increase patient
comfort in the clinical setting. Summary
• According to Level D evidence, BMI percentiles
Policy
and extended BMI charts can help better classify
Policy strategies are needed to address changes at a popu-
obesity severity. (26)(27)(28)(29)(30)(31)
lation level and have focused on 1) supporting evidence-
based interventions and implementing effective programs • According to Level D evidence, contextual factors
at wider community levels, (171)(175) 2) revising existing affect child obesity risk beginning before conception
nutrition support programs, 3) taxing sugar-sweetened and through pregnancy, infancy, childhood, and
adolescence, creating an intergenerational cycle of
beverages, and 4) adding calorie labels and nutrient warn-
obesity risk. (37)(38)(39)(40)(41)(42)(43)(44)(45)(46)
ings to menus and food products.
(47)(48)(49)
Revisions to the Special Supplemental Nutrition Program
for Women, Infants, and Children package reduced juice and • According to Level D evidence, children with
increased fruit, vegetable, and whole grain allowances and led developmental delay, short stature, delayed
to changes in consumption of the targeted items and a rever- puberty, early-onset obesity, or hyperphagia
sal of the increasing obesity prevalence among program par- warrant referrals for endocrine, developmental,
ticipants. (176)(177)(178) In addition, the Healthy, Hunger- and genetic evaluations to rule out secondary
Free Kids Act of 2010, which strengthened nutrition stand- causes.
ards for meals and beverages provided through the National • According to Level D evidence, for children with
School Lunch, School Breakfast, and Smart Snacks in obesity, recommended screening includes fasting
School programs, found a significant decline in obesity for laboratory analyses for glucose, lipids, and liver
children in poverty after its implementation. (179) function testing (alanine transaminase and
Several systematic reviews of taxation on sugar-sweet- aspartate transaminase). (37)(103)(104)(105)(106)
ened beverages show that taxes can decrease their pur- • According to Level A evidence, the American
chase and consumption. (180) Calorie labeling, which Academy of Pediatrics (AAP) recommends a
requires restaurants with multiple locations to post the ca- staged approach that begins with behavioral
loric content of regular menu items, did not change the interventions in primary care (stage 1), increases
level of calories purchased in fast food restaurants, (181) in frequency and intensity if the patient does not
although some reduction in other settings was found. respond favorably (stage 2), progresses to
(182) Studies of health warning labels, a type of food label behavioral management in a comprehensive,
that requires products with excessive levels of unhealthy multidisciplinary program (stage 3), and is finally
nutrients to display front-of-package warning labels (eg, complemented by the addition of pharmacologic
“WARNING: High in added sugar”), demonstrate decreased and surgical treatment options available in a
purchase of labeled products. (183)(184)(185) tertiary referral center (stage 4).
Expert panels from the Institute of Medicine and the • According to Level B evidence, motivational
World Health Organization have emphasized that obesity interviewing is a patient-centered communication
on a population scale is fostered and sustained by socioen- style that involves reflective listening, support of
vironmental contextual factors that include overconsump- autonomy, shared decision-making, and eliciting
tion of palatable, high-calorie processed foods, sedentary change-talk. (134)
work, learning and leisure environments, and financial in- • According to Level D evidence, the AAP
centives that perpetuate these circumstances in both the recommends taking the patient’s physical,
general and highest-risk populations. (186)(187) These psychological, developmental, psychosocial, and
panels have suggested that in addition to implementing mental health into account when deciding when
policies such as those listed previously herein, systems- to initiate medications. (153)
level transformation considering the synergy (or

614 Pediatrics in Review

Downloaded from [Link]

by HINARI 2 user
 • According to Level C evidence, the AAP recommends • According to Level D evidence, use of people-
bariatric surgery as a treatment to consider for youth first language can enhance weight-related
with class II obesity with comorbidities or youth with communication between parents, providers,
class III obesity. (154)(155) and children to focus on building healthy habits
rather than on weight. (173)(174)
• According to Level A evidence, bariatric surgery
demonstrates both short-and long-term weight loss,
a greater amount of weight loss compared with
behavioral and pharmacologic interventions, and References and teaching slides for this article can be found at
[Link]
resolution of comorbidities. (156)(157)(158)(159)

Vol. 43 No. 11 N O V E M B E R 2 0 2 2 615

Downloaded from [Link]

by HINARI 2 user
 PIR QUIZ

1. A 10-year-old boy with obesity is brought to the clinic by his parents for an
initial visit. Both parents and his 6-year-old sister have obesity. In the
discussion of causes of obesity by the clinician, the most likely cause in their
child includes which of the following?
A. A single autosomal dominant gene.
B. Can only be determined with 100% certainty with obesity genetic testing
panel.
C. Interaction between genetic factors and the environment in most cases.
D. Maternal factors.
E. Prader-Willi syndrome. REQUIREMENTS: Learners can
take Pediatrics in Review quizzes
2. An 8-year-old boy with obesity has a blood pressure (BP) of 135/85 mm Hg and claim credit online only at:
on 2 separate pediatric visits taken with an appropriately sized BP cuff. [Link]
Which of the following would be the most appropriate next step in
To successfully complete 2022
management?
Pediatrics in Review articles for
A. Obtain serum electrolytes. AMA PRA Category 1 Credit™,
B. Obtain urine analysis. learners must demonstrate a
minimum performance level of
C. Perform renal ultrasonography to assess for a renal malformation.
60% or higher on this
D. Refer to pediatric nephrology. assessment. If you score less
E. Repeat BP measurement at the next clinic visit. than 60% on the assessment,
you will be given additional
3. An 11-year-old girl with obesity is found to have a normal fasting blood opportunities to answer
glucose level and a hemoglobin A1c (HbA1C) level in the prediabetic range. questions until an overall 60%
A repeat HbA1C 2 months later is unchanged. Which of the following is the or greater score is achieved.
most appropriate next step in management of this patient?
This journal-based CME activity
A. Consider ordering an oral glucose tolerance test (OGTT). is available through Dec. 31,
B. Medication management only. 2024, however, credit will be
C. Repeat hemoglobin A1C in 2 months. recorded in the year in which
the learner completes the quiz.
D. Refer to a pediatric endocrinology clinic, provide nutritional counseling,
and consider medical management.
E. Repeat laboratory studies in 1 year and refer to endocrinology and
nutrition if her repeated laboratory values are in the diabetic range.
4. A 15-year-old girl with class III obesity has been followed by her primary care
provider for the past year using a combination of prevention and lifestyle 2022 Pediatrics in Review is
modification strategies. She has acanthosis nigricans and an elevated approved for a total of 30
Maintenance of Certification
hemoglobin A1c level. Which of the following is the most appropriate next
(MOC) Part 2 credits by the
step in management? American Board of Pediatrics
A. A more intense regimen of increased physical activity. (ABP) through the AAP MOC
Portfolio Program. Pediatrics in
B. Bariatric surgery.
Review subscribers can claim up
C. In-office implementation of SMART (Specific, Measurable, Achievable, to 30 ABP MOC Part 2 points
Realistic, and Time-based) goals using motivational interviewing to help upon passing 30 quizzes (and
obtain behavior change. claiming full credit for each
D. Pharmacologic treatment. quiz) per year. Subscribers can
start claiming MOC credits as
E. Referral to a comprehensive multidisciplinary weight management program.
early as October 2022. To learn
how to claim MOC points, go
to: [Link]
journals/pages/moc-credit.

616 Pediatrics in Review

Downloaded from [Link]

by HINARI 2 user
 5. The family of a 16-year-old girl with obesity is interested in pursuing bariatric
surgical options after a suboptimal response to behavioral and
pharmacologic interventions. The patient meets the criteria and her
insurance covers the procedure. The family asks about the various
procedures available and the safety and complication rates of each of them.
Which of the following is the most appropriate bariatric procedure to
perform in this patient?
A. The laparoscopic adjustable gastric band (LAGB) because of lowest nutritional
complications.
B. The LAGB because of highest mean BMI reductions.
C. The Roux–en-Y gastric bypass because of lowest risk of unintended
pregnancy due to increased fertility.
D. The vertical sleeve gastrectomy because of lowest risk of unintended
pregnancy due to increased fertility.
E. The vertical sleeve gastrectomy because of lowest surgical complications.

Vol. 43 No. 11 N O V E M B E R 2 0 2 2 617

Downloaded from [Link]

by HINARI 2 user