medwireNews: The Endocrine Society has released updated clinical guidelines for the diagnostic assessment, prevention and management of obesity in children.
The society considered this update a priority; it notes in the report that around 17% of US children and adolescents are obese, and that if these 12.7 million children become obese adults, their individual associated costs would exceed US$ 92,000 (€ 86,707) and the combined societal costs could exceed $ 1.1 trillion (€ 1.04 trillion).
The guidelines, published in The Journal of Clinical Endocrinology & Metabolism, are based on two systematic reviews commissioned for the purpose, and are spilt into sections on diagnosis, prevention and management. It contains a management flowchart, focused largely on diagnosis.
The guidelines committee recommends testing for endocrine, genetic or neurological causes of obesity only if the patient’s medical history and/or physical examination are abnormal. In particular, reduced growth velocity should prompt an endocrine examination and evidence of severe neurodevelopmental abnormalities or hyperphagia should prompt a genetic analysis.
The guidelines advise using body mass index (BMI) to diagnose obesity, and set out the thresholds for diagnosis, but caution that “it is not an infallible indicator of overweight or obesity”, highlighting, for example, the need to account for racial and ethnic differences.
“Clinicians should consult endocrinologists when questions arise”, say Dennis Styne (University of California Davis, Sacramento, USA) and fellow guideline writers.
The diagnosis section also places heavy emphasis on screening for obesity-related complications and comorbidities, specifically:
- Non-alcoholic fatty liver disease
- Polycystic ovary syndrome
- Obstructive sleep apnoea
- Mental health disorders
Recommendations for the prevention of obesity encompass healthy eating, physical activity, healthy sleeping patterns and “comprehensive behaviour-changing interventions”, ideally integrated with school- or community-based programmes. And much of the treatment section is focused on the prescription and support of these healthy lifestyle behaviours, with additional focus on identifying and tackling family and psychosocial barriers to weight loss.
Pharmacotherapy is recommended only if intensive lifestyle modification fails, and only in the company of continued lifestyle intervention. The guideline authors stress that no anti-obesity medications have been approved by the US Food and Drug Administration for patients younger than 16 years, and off-label treatment of younger patients should be attempted only by physicians with extensive experience of anti-obesity drugs and their side effects. They stipulate that patients should be reviewed and medication potentially discontinued if at least a 4% BMI reduction is not achieved within 12 weeks after starting treatment at the maximum dose.
Bariatric surgery is advised only in adolescents at Tanner stage 4 or 5 who have achieved, or nearly achieved, their final adult height, with BMI greater than 40 kg/m2 or greater than 35 kg/m2 if they have severe comorbidity. And only then if other options have failed and there is access to the appropriate clinical expertise. The authors note that this recommendation “places a high value on amelioration of life-threatening complications and lower value on surgical cost and perioperative complications.”
By Eleanor McDermid
J Clin Endocrinol Metab 2017; Advance online publication
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