Endocrine Society Releases New Practice Guidelines to Prevent, Treat Childhood Obesity

CINDY SANDERS

Endocrine Society Releases New Practice Guidelines to Prevent, Treat Childhood Obesity | Endocrine Society, Prevention and Treatment of Pediatric Obesity, Journal of Clinical Endocrinology & Metabolism, Gilbert P. August, orlistat, sibutramine, Childhood Obesity, Francine R. Kaufman, Gilbert P. August
The apple doesn't fall far from the tree.

In light of today's lifestyle choices, however, the old adage should probably be rephrased to more accurately depict 21st century America — the deep fried apple pie doesn't fall far from the fast food chain.

Considering the number of overweight and obese adults in this country, it shouldn't be surprising that the nation is raising more and more overweight and obese children. Still, this issue somehow seems to catch many parents and healthcare providers off guard.

Like many chronic conditions impacting public health, the nation's collective weight gain is multifactorial … from highly engaging media options and technology that have greatly increased screen time over the years to an academic push that leaves little time for physical education to busy schedules that make quick meals and processed food very tempting. The net result is that children... like adults... have begun to consume much more energy than they expend.

To address this issue, The Endocrine Society recently released "Prevention and Treatment of Pediatric Obesity: An Endocrine Society Clinical Practice Guideline Based on Expert Opinion." A rapid release version appeared in the December issue of the Journal of Clinical Endocrinology & Metabolism and is also available in the clinical practice section online at www.endo-society.org.

Gilbert P. August, MD, professor emeritus at George Washington School of Medicine, led a team of specialists in turning knowledge gleaned from the current body of research into practical application in a patient setting.

"We worked on the guidelines almost two years," noted the board certified pediatric endocrinologist. He added the impetus for creating the document was the increase in type 2 diabetes in children and adolescents coupled with a growing concern over long-term health outcomes.


Physician Advocates

An Ecological Approach to Childhood Obesity
Physicians can preach about the need for better nutrition and prescribe one of two FDA-approved drug therapies … but the real change must happen outside the clinic walls.

"We're not going to combat this just one kid at a time in our offices," said Francine R. Kaufman, MD, a board certified pediatric endocrinologist practicing at Childrens Hospital Los Angeles and a member of the task force that created The Endocrine Society's new clinical practice guidelines on childhood obesity. "What the clinician can do with the individual child and family is the proper workup to make sure there isn't an underlying etiology." However, she continued, "The real focus needs to be an ecological approach."

For that, Kaufman and task force chair Gilbert P. August, MD, readily agree providers might have to step out of the comfort zone of their traditional clinical roles and become community child advocates.

"One of the things we do recommend is that physicians take a more active role in the community and sit down with the school board and come up with an action plan," August said of the need to get more physical activity into the day. Even though many school districts are under pressure to improve academic outcomes, August said ample research shows taking time out to exercise actually improves concentration and performance.

"I think we ought to get back to the ancient Greek philosophy of sound mind and sound body," he said.

Kaufman noted that she believes our society has reached a "tipping point." The good news, she continued, is that measures can be taken to make a difference. A distinguished professor of pediatrics and communications for the University of Southern California, Kaufman said such changes have happened in her own backyard as large coalitions of healthcare providers, educators, parents and concerned citizens have worked together to look at the food, community and school environments. California has banned trans fats and will soon post nutritional information on chain restaurant menus.

She added there is a tremendous interest in addressing the obesity issue and that policy changes are beginning to be made state-by-state and county-by-county. Although there is a very long way to go, Kaufman did point to the last set of NHANES data, which seems to show a leveling off in obesity rates. The hope is that by attacking on the problem on different fronts, the rates will actually begin to decline.

"The guidelines continue to bring the issue to the forefront and show the multiple roles we need to play in this epidemic," Kaufman concluded.


"When I started (practicing) pediatric endocrinology in 1969, type 2 diabetes was virtually unheard of in children and adolescents," he said, adding the disorder "now makes up about 20 percent of all diabetes seen in children." Furthermore, August noted, "Pediatric obesity is clearly predictive of adult obesity."

Certainly the statistics bear out the concerns. When comparing data from the National Health and Nutrition Examination Survey 1963-1970 (at which time it was NHES) and 1999-2000 (NHANES IV, Part 1), August said you see a four-fold increase in obesity among children between the ages of six and 11 and a three-fold increase in adolescents ages 12-19 in the latter survey.

As with the guidelines for many conditions and diseases, the starting point is an emphasis on early intervention and prevention. August said an easy addition to newborn visits is for physicians to stress to new mothers the benefits of breast-feeding for a minimum of six months. He noted there is fairly strong evidence that this measure lowers the incidence of childhood obesity.

He said, "We really have to invest in preventative care; and unfortunately, it's not well reimbursed. There's sort of a disincentive to provide all the preventative care necessary."

The task force also indicated anticipatory guidance as outlined by the American Academy of Pediatrics should be given at every well child visit. Unfortunately, August pointed to several studies that show less than half of the families actually receive this anticipatory guidance concerning overweight and obesity.

"In some studies of primary care physicians, only 19 percent of them were aware of the American Academy of Pediatrics recommendations on obesity, and only 3 percent complied with all the recommendations if they were aware of them … so I think the medical establishment has to do a much better job."

For children already experiencing weight issues, intensive lifestyle modification is the next step.

"When you see the BMI go into the overweight range, I think that's when the healthcare provider takes an active role to intervene," he said. "For those who are currently obese or even just overweight, we did stress lifestyle modification," he said of the guidelines.

"What seems to work much better is to sit down with the doctor, dietician … and in some cases, a social worker … to find out how to make changes in what is going on with the family," August explained. "This means sitting down with healthcare workers and the family at least once a month for three-to-four months because you often need mid-course correction." He added it is more effective to actively involve school-aged children in the sessions.

While the healthcare setting is ideal for learning about proper nutrition and healthy eating, the exercise part of the equation needs to involve the community.

"What we've recommended is that the schools get back to providing physical education in all grades, every day," he said, adding there should be at least 45-60 minutes of physical activity in the school day.

After six-12 months of lifestyle modification or with the onset of co-morbid conditions and/or strong family history for such conditions, physicians might elect to move to the next step of adding drug therapy.

"Lifestyle intervention must always precede drug therapy and must be maintained during drug therapy," August stressed, adding pharmacotherapy is not a panacea.

The two drugs approved by the FDA for the treatment of childhood obesity are orlistat, which interferes with the absorption of fat and is available in lower doses over the counter, and sibutramine. The first is not recommended for children under age 12, and the second is not approved for children under 16. Neither, August said, should be considered unless the BMI is at or above the 95th percentile.

Although once inconceivable, the guidelines allow that bariatric surgery might be appropriate for some adolescents as a last resort. However, August emphasized, this should only be considered in children who are well into puberty and have reached … or very nearly reached … their adult height.

He added a potential candidate should have a BMI of 50 or greater or a BMI over 40 if there are also "significant and severe" co-morbidities; have failed a program of lifestyle modification; and have undergone a psychological evaluation to confirm that the child is emotionally stable and that the family unit is stable. Another important element is to have access to an experienced surgeon with a team capable of long-term follow up.

"Because there isn't much long-term data, we'd like to have that institution participate in a national study or be willing to share data," August added of bariatric centers.

While the guidelines cover a broad spectrum of options and ages, August and his team of co-authors recognize it's difficult to create a "one size fits all" course of action when it comes to weight loss in children.

"There are always exceptions to this," he noted. "Guidelines are not written in stone so we have to look at the individual child."