EPIDEMIOLOGY AND DEFINITIONS The prevalence of obesity in children has increased dramatically.

Data from 1999-2000 indicate that 15% of American children age 6 to 19 years were considered overweight (body mass index [BMI] 95th percentile). The prevalence of obesity has increased to approximately 10% in children 4 to 5 years old. The largest increases in the prevalence of obesity were seen in the most overweight classifications and in certain ethnic groups, such as African American and Mexican American children, of whom more than 20% are overweight. Many obese children become obese adults. The risk of remaining obese increases with age and the degree of obesity. Eleven-year-old children who are overweight are more than twice as likely to remain overweight at age 15 than are 7-year-old overweight children. The risk of becoming obese as a child and remaining obese as an adult also is influenced by family history. If one parent is obese, the odds ratio for the child to be obese in adulthood is 3, but this increases to 10 if both parents are obese. Obesity runs in families; this could be related to genetic influences or the influence of a common, shared environment. In comparisons of adopted twin pairs, 80% of the variance in weight for height or skin-fold thickness may be explained on the basis of genetics. A strong relationship exists between the BMI of adoptees and that of their biologic parents; a weaker relationship exists between the BMI of adoptees and that of their adoptive parents. These relationships support the influence of genetics. The association between obesity and television watching and dietary intake, the different rates of obesity observed in urban versus rural areas, and changes in obesity with seasons also support the important influence of environment CLINICAL MANIFESTATIONS Complications of obesity in children and adolescents can affect virtually every major organ system. The clinician should direct the history and physical examination toward screening for many potential complications noted among obese patients (Table 29-1) in addition to specific diseases associated with obesity (Table 29-2). Medical

complications usually are related to the degree of obesity and usually decrease in severity or resolve with weight reduction. Table 29-1. Complications of Obesity Complication Effects Psychosocial Peer discrimination, teasing, reduced college acceptance, isolation, reduced job promotion* Growth Advance bone age, increased height, early menarche CNS Pseudotumor cerebri Respiratory Sleep apnea, pickwickian syndrome Cardiovascular Hypertension, cardiac hypertrophy, ischemic heart disease,* sudden death* Orthopedic Slipped capital femoral epiphysis, Blount disease Metabolic Insulin resistance, type 2 diabetes mellitus, hypertriglyceridemia, hypercholesterolemia, gout,* hepatic steatosis, polycystic ovary disease, cholelithiasis *Complications unusual until adulthood. The diagnosis of obesity depends on the measurement of excess body fat. Actual measurement of body composition is not practical in most clinical situations. BMI is a convenient screening tool that correlates fairly strongly with body fatness in children and adults. BMI agespecific and gender-specific percentile curves (for 2- to 20-year-olds) allow an assessment of BMI percentile (available online at http://www.cdc.gov/growthcharts ). Table 29-3 provides BMI interpretation guidelines. For children younger than 2 years old, weight for length greater than 95th percentile may indicate overweight or obesity and warrants further assessment

ASSESSMENT Early recognition of at risk for overweight or overweight children is

essential because family counseling and treatment interventions are more likely to be successful before obesity becomes severe. Routine evaluation at well-child visits should include the following: 1. Anthropometric data, including weight, height, and calculation of BMI. Data should be plotted on age-appropriate and genderappropriate growth charts and assessed for weight gain trends and upward crossing of percentiles. 2. Dietary and physical activity history (Table 29-4). Assess patterns and potential areas for change. 3. Physical examination. Assess blood pressure, adiposity distribution (central versus generalized), markers of comorbidities (acanthosis nigricans, hirsutism, hepatomegaly, orthopedic abnormalities), and physical stigmata of genetic syndrome (PraderWilli syndrome). 4. Laboratory studies. These are generally reserved for children who are overweight (BMI >95th percentile) or who have evidence of comorbidities or both. Useful laboratory tests may include a fasting lipid profile, fasting insulin and glucose levels, liver function tests, and thyroid function tests (if evidence of plateau in linear growth). Other studies should be guided by findings in the history and physical examination. page 140 page 141 Table 29-2. Diseases Associated with Childhood Obesity* Syndrome Manifestations Alstrm syndrome Hypogonadism, retinal degeneration, deafness, diabetes mellitus Carpenter syndrome Polydactyly, syndactyly, cranial synostosis, mental retardation Cushing syndrome Adrenal hyperplasia or pituitary tumor Frhlich syndrome Hypothalamic tumor Hyperinsulinism Nesidioblastosis, pancreatic adenoma,

Laurence-Moon-BardetBiedl syndrome Muscular dystrophy Myelodysplasia Prader-Willi syndrome

Pseudohypoparathyroidism Turner syndrome

hypoglycemia, Mauriac syndrome (poor diabetic control) Retinal degeneration, syndactyly, hypogonadism, mental retardation; autosomal recessive Late onset of obesity Spina bifida Neonatal hypotonia, normal growth immediately after birth, small hands and feet, mental retardation, hypogonadism; some have partial deletion of chromosome 15 Variable hypocalcemia, cutaneous calcifications Ovarian dysgenesis, lymphedema, web neck; XO chromosome

*These diseases represent <5% of cases of childhood obesity

TREATMENT Table 29-3. Body Mass Index (BMI) Interpretation BMI/Age percentile Interpretation <5th Underweight 5-85th Normal 85-95th At risk for overweight >95th Overweight or obese Table 29-4. Key Areas of Assessment for Overweight/Obesity Evaluation Diet Meal and snack pattern: structured versus grazing, skipping meals; where and with whom are meals/snacks eaten; eating in front of TV?

Portion sizes: are portions age-appropriate; portions for child same as adult? Frequency of meals away from home (restaurants, takeout, childcare setting) Frequency and amounts of caloric beverages (soda, juice, milk, energy drinks, specialty coffee and tea drinks) Frequency of eating fruits and vegetables Activity Hours per day spent in sedentary activity: television, computer games/Internet, video games Daily or weekly time spent in vigorous (i.e., generating sweating!) activity: organized sports, physical education, free play Activities of daily living: walking, free unstructured play, chores Activity levels of parents page 141 page 142 The approach to therapy and aggressiveness of treatment should be based on risk factors, including age, severity of obesity and comorbidities, and family history and support. The primary goal for all children with uncomplicated overweight is to achieve healthy eating and activity patterns. For children with a secondary complication, improvement of the complication is an important goal. For children 2 to 7 years old with BMI greater than or equal to 95th percentile and without complications, the goal is maintenance of baseline weight, allowing the child to "grow into" their height, with a gradual normalization of BMI. For children 2 to 7 years old with BMI greater than or equal to 95th percentile and secondary complications, weight loss is indicated. For children older than 7 years with BMI between 85th and 95th percentile, without complications, weight maintenance is an appropriate goal. Weight loss is recommended if secondary complications are present; an appropriate goal is 1 lb weight loss per month until a BMI less than 85th percentile is achieved. Because children and young adolescents are still growing, excessive acute weight loss should be avoided, as this may contribute to linear growth stunting

and nutrient deficiencies. Childhood and adolescent obesity treatment programs can lead to sustained weight loss and decreases in BMI when treatment focuses on behavioral changes and is family centered. Concurrent changes in dietary and physical activity patterns are most likely to provide success. Healthy eating patterns need to be adopted by the whole family, with parents modeling healthy food choices, controlling foods brought into the home, and guiding appropriate portion sizes. Limiting sedentary activity has been found to be more effective than specifically promoting increased physical activity. The AAP recommends no television for children younger than 2 years old and a maximum of 2 hours per day of television and video/computer games for older children. When considering treatment, three options can be considered depending on the severity of the problem, the age of the child, the ability and readiness of the family to make changes, the preferences of the parents and child, and the skills of the healthcare provider: 1. General guidelines: Counseling regarding problem areas identified by dietary and physical activity history should be provided (see Table 29-4); emphasis should be on healthy eating and physical activity patterns. This is especially appropriate for preventing further weight gain and for mildly overweight children. Advice that is appropriate for all children includes encouragement to increase active play, reduce television and other screen time, increase intake of fruits and vegetables, and limit intake of soda and juice drinks. 2. Structured advice: This approach provides more specific dietary guidance, such as meal and menu planning, and an exercise prescription and behavioral change goals. This may be done in the primary care setting or by referral to a more specialized treatment center. 3. Group treatment programs: This type of program generally works best for older children or adolescents, with varying level of parental involvement depending on the age of the child. Several published programs are available. The Weight Information

Network is a service available through the National Institutes of Health, which disseminates information on weight control programs (available at http://www.niddk.nih.gosv//NutritionDocs.html ). There is no single course of treatment that is likely to be effective for all patients. The physician would do best to assess the severity of overweight/obesity with attention to comorbidities, the child's treatment needs in the context of the family's preferences and abilities, and access to resources, such as registered dietitians with expertise in pediatric weight management and behavioralists or family therapists. Pharmacotherapy and bariatric surgery are treatment options for adults and are being studied as treatment options for older children and adolescents, but evidence from controlled trials is insufficient to justify specific recommendations PREVENTION Obesity is challenging to treat and can cause significant medical and psychosocial issues for young children and adolescents. Families need to be counseled on age-appropriate and healthy eating patterns beginning in infancy with the promotion of breastfeeding. For infants, transition to complementary and table foods and the importance of regularly scheduled meals and snacks versus grazing behavior should be emphasized. Age-appropriate portion sizes for meals and snacks should be encouraged. Children should be taught to recognize hunger and satiety cues, guided by reasonable portions and healthy food choices by parents. Children should never be forced to eat when they are not willing, and overemphasis of food as a reward should be avoided. The U.S. Department of Agriculture Food Guide Pyramid provides a good framework for a healthy diet, with an emphasis on whole grains, fruits, and vegetables and with age-appropriate portion sizes. After age 2 years, most children should change from whole or 2% milk to skim milk because other food sources provide adequate fat for growth and development.

The importance of physical activity should be emphasized. For some children, organized sports and school-based activities provide opportunities for vigorous activity and fun, whereas for others a focus on activities of daily living, such as increased walking, using stairs, and more active play may be better received. Time spent in sedentary behavior, such as television viewing and video/computer games, should be limited. Television in children's rooms is associated with more television time and with higher rates of overweight, and the risks of this practice should be discussed with parents. Clinicians may need to help families identify alternatives to sedentary activities, especially for families with deterrents to activity, such as unsafe neighborhoods or lack of supervision after school.