Full Guideline: Pediatric Obesity— Assessment, Treatment, and Prevention
JCEM | January 2017
Dennis M. Styne (chair), Silva A. Arslanian, Ellen L. Connor, Ismaa Sadaf Farooqi, M. Hassan Murad, Janet H. Silverstein, and Jack A. Yanovski
The Endocrine Society's 2017 guideline is an update of the previous version from 2008. This guideline addresses:
- Preventing and treating childhood obesity with lifestyle changes
- Evaluating affected children for medical or psychological complications
- Deciding when to evaluate children for rare genetic causes of obesity
- Determining when medication or surgery is appropriate for severely affected adolescents
Pediatric Obesity - Assessment, Treatment, and Prevention: An Endocrine Society Clinical Practice Guideline | ENDO 2016
Essential Points
- Children or teens with a BMI greater than or equal to the 85th percentile should be evaluated for related conditions such as metabolic syndrome and diabetes.
- Youth being evaluated for obesity do not need to have their fasting insulin values measured, because it has no diagnostic value.
- Children or teens affected by obesity do not need routine laboratory evaluations for endocrine disorders that can cause obesity unless their height or growth rate is less than expected based on age and pubertal stage.
- Specific genetic testing should be considered when there is early onset obesity (before 5 years old), an increased drive to consume food (extreme hyperphagia), other clinical findings of genetic obesity syndromes, or a family history of extreme obesity.
Summary of Changes Since 2008 Guideline
- Updated references and epidemiology
- Increased emphasis on the limitations of applying BMI calculations to all ethnic groups.
- Endocrine evaluations and insulin values may not be necessary for most children. Evaluation section discusses appropriate laboratory testing and how to avoid unnecessary tests.
- The genetics section has been extensively revised and includes a flow chart for evaluation children with early onset obesity, family history of extreme obesity, and hyperphagia for genetic factors.
- Previous lifestyle recommendations for prevention and treatment continue to be supported, but breast-feeding as prevention has been downgraded from a recommendation to a suggestion based on recent data.
- The psychological factors affecting childhood obesity are discussed, as well as the toll it takes on children.
- Information on the risks, contraindications, and recommendations for medication and surgery for severely affected adolescents has been added, including a discussion on bariatric surgery.
- Goals for future research has been updated.
Summary of Recommendations
+ 1.0 Diagnosing overweight and obesity
- 1.1 We recommend using body mass index (BMI) and the Centers for Disease Control and Prevention (CDC) normative BMI percentiles to diagnose overweight or obesity in children and adolescents ≥2 years of age. (1|⊕⊕⊕⚪)
- 1.2 We recommend diagnosing a child or adolescent >2 years of age as overweight if the BMI is ≥85th percentile but <95th percentile for age and sex, as obese if the BMI is ≥95th percentile, and as extremely obese if the BMI is ≥120% of the 95th percentile or ≥35 kg/m2 (1|⊕⊕⚪⚪). We suggest that clinicians take into account that variations in BMI correlate differently to comorbidities according to race/ethnicity and that increased muscle mass increases BMI. (2|⊕⚪⚪⚪)
- 1.3 We suggest calculating, plotting, and reviewing a child’s or adolescent’s BMI percentile at least annually during well-child and/or sick-child visits. (Ungraded Good Practice Statement)
- 1.4 We suggest that a child <2 years of age be diagnosed as obese if the sex-specific weight for recumbent length is ≥97.7th percentile on the World Health Organization (WHO) charts, as US and international pediatric groups accept this method as valid. (2|⊕⚪⚪⚪)
- 1.5 We recommend against routine laboratory evaluations for endocrine etiologies of pediatric obesity unless the patient’s stature and/or height velocity are attenuated (assessed in relationship to genetic/familial potential and pubertal stage). (1|⊕⊕⊕⚪)
- 1.6 We recommend that children or adolescents with a BMI of ≥85th percentile be evaluated for potential comorbidities (see Table 2 and Fig. 1). (1|⊕⊕⊕⚪)
+ 2.0 Genetic obesity syndromes
- 2.1 We suggest genetic testing in patients with extreme early onset obesity (before 5 years of age) and that have clinical features of genetic obesity syndromes (in particular extreme hyperphagia) and/or a family history of extreme obesity. (2|⊕⊕⚪⚪)
+ 3.0 Prevention of obesity
- 3.1 We suggest that clinicians promote and participate in the ongoing healthy dietary and activity education of children and adolescents, parents, and communities, and encourage schools to provide adequate education about healthy eating (Daniels SR, Hassink SG; Committee on Nutrition. The role of the pediatrician in primary prevention of obesity. Pediatrics. 2015;136:e275–e292.). (2|⊕⚪⚪⚪)
- 3.2 We recommend that clinicians prescribe and support healthy eating habits such as:
- avoiding the consumption of calorie-dense, nutrient-poor foods (e.g., sugar-sweetened beverages, sports drinks, fruit drinks, most “fast foods” or those with added table sugar, high-fructose corn syrup, high-fat or high-sodium processed foods, and calorie-dense snacks)
- encouraging the consumption of whole fruits rather than fruit juices. (1|⊕⊕⚪⚪)
- 3.3 We recommend that children and adolescents engage in at least 20 minutes, optimally 60 minutes, of vigorous physical activity at least 5 days per week to improve metabolic health and reduce the likelihood of developing obesity. (1|⊕⊕⚪⚪)
- 3.4 We suggest fostering healthy sleep patterns in children and adolescents to decrease the likelihood of developing obesity due to changes in caloric intake and metabolism related to disordered sleep. (2|⊕⊕⚪⚪)
- 3.5 We recommend balancing unavoidable technology-related screen time in children and adolescents with increased opportunities for physical activity. (1|⊕⊕⚪⚪)
- 3.6 We suggest that a clinician’s obesity prevention efforts enlist the entire family rather than only the individual patient. (2|⊕⚪⚪⚪)
- 3.7 We suggest that clinicians assess family function and make appropriate referrals to address family stressors to decrease the development of obesity. (2|⊕⊕⚪⚪)
- 3.8 We suggest using school-based programs and community engagement in pediatric obesity prevention. (2|⊕⊕⚪⚪)
- 3.9 We recommend using comprehensive behavior-changing interventions to prevent obesity. Such programs would be integrated with school- or community-based programs to reach the widest audience. (1|⊕⊕⚪⚪)
- 3.10 We recommend breast-feeding in infants based on numerous health benefits. However, we can only suggest breast-feeding for the prevention of obesity, as evidence supporting the association between breast-feeding and subsequent obesity is inconsistent. (2|⊕⚪⚪⚪)
+ 4.0 Treating obesity
- 4.1 We recommend that clinicians prescribe and support intensive, age-appropriate, culturally sensitive, family-centered lifestyle modifications (dietary, physical activity, behavioral) to promote a decrease in BMI. (1|⊕⊕⊕⚪)
- 4.2 We recommend that clinicians prescribe and support healthy eating habits in accordance with the following guidelines of the American Academy of Pediatrics and the US Department of Agriculture:
- decreased consumption of fast foods
- decreased consumption of added table sugar and elimination of sugar-sweetened beverages
- decreased consumption of high-fructose corn syrup and improved labeling of foods containing high-fructose corn syrup
- decreased consumption of high-fat, high-sodium, or processed foods
- consumption of whole fruit rather than fruit juices
- portion control education
- reduced saturated dietary fat intake for children and adolescents >2 years of age
- US Department of Agriculture recommended intake of dietary fiber, fruits, and vegetables
- timely, regular meals, and avoiding constant “grazing” during the day, especially after school and after supper
- recognizing eating cues in the child’s or adolescent’s environment, such as boredom, stress, loneliness, or screen time
- encouraging single portion packaging and improved food labeling for easier use by consumers. (Ungraded Good Practice Statement)
- 4.3 We recommend that clinicians prescribe and support the reduction of inactivity and also a minimum of 20 minutes of moderate to vigorous physical activity daily, with a goal of 60 minutes, all in the context of a calorie-controlled diet. (1|⊕⊕⚪⚪)
- 4.4 We suggest that clinicians encourage and support patients to limit nonacademic screen time to 1 to 2 hours per day and decrease other sedentary behaviors, such as digital activities. (2|⊕⚪⚪⚪)
- 4.5 We suggest that the health care team identify maladaptive rearing patterns related to diet and activity and educate families about healthy food and exercise habits. (2|⊕⚪⚪⚪)
- 4.6 We suggest that the health care team probe for and diagnose unhealthy intrafamily communication patterns and support rearing patterns that seek to enhance the child’s or adolescent’s self-esteem. (2|⊕⚪⚪⚪)
- 4.7 We suggest that the health care team evaluate for psychosocial comorbidities and prescribe assessment and counseling when psychosocial problems are suspected. (2|⊕⚪⚪⚪)
- 4.8 We suggest pharmacotherapy for children or adolescents with obesity only after a formal program of intensive lifestyle modification has failed to limit weight gain or to ameliorate comorbidities (2|⊕⚪⚪⚪). We recommend against using obesity medications in children and adolescents <16 years of age who are overweight but not obese, except in the context of clinical trials. (1|⊕⚪⚪⚪)
- 4.9 We suggest that Food and Drug Administration (FDA)–approved pharmacotherapy for obesity be administered only with a concomitant lifestyle modification program of the highest intensity available and only by clinicians who are experienced in the use of anti-obesity agents and are aware of the potential for adverse reactions. (2|⊕⚪⚪⚪)
- 4.10 We suggest that clinicians should discontinue medication and reevaluate the patient if the patient does not have a >4% BMI/BMI z score reduction after taking antiobesity medication for 12 weeks at the medication’s full dosage. (2|⊕⚪⚪⚪)
- 4.11 We suggest bariatric surgery only under the following conditions:
- the patient has attained Tanner 4 or 5 pubertal development and final or near-final adult height, the patient has a BMI of >40 kg/m2 or has a BMI of >35 kg/m2 and significant, extreme comorbidities
- extreme obesity and comorbidities persist despite compliance with a formal program of lifestyle modification, with or without pharmacotherapy
- psychological evaluation confirms the stability and competence of the family unit [psychological distress due to impaired quality of live (QOL) from obesity may be present, but the patient does not have an underlying untreated psychiatric illness]
- the patient demonstrates the ability to adhere to the principles of healthy dietary and activity habits
- there is access to an experienced surgeon in a pediatric bariatric surgery center of excellence that provides the necessary infrastructure for patient care, including a team capable of long-term follow-up of the metabolic and psychosocial needs of the patient and family. (2|⊕⊕⚪⚪)
- 4.12 We suggest against bariatric surgery in preadolescent children, pregnant or breast-feeding adolescents (and those planning to become pregnant within 2 years of surgery), and in any patient who has not mastered the principles of healthy dietary and activity habits and/or has an unresolved substance abuse, eating disorder, or untreated psychiatric disorder. (2|⊕⚪⚪⚪)
