Childhood Obesity: Evidence-Based Guidelines for Clinical Practice-Part One

Behavioral Counseling for Weight Management by Pediatric Nurse Practitioners: A Quantitative Cross-Sectional Study

INTRODUCTION

This study assessed counseling by pediatric nurse practitioners (PNPs) for management of overweight and obesity.

METHOD

Using a cross-sectional design, 1,058 PNPs completed a one-time survey regarding counseling for healthy body weight, physical activity, and consumption of protein, fruits and vegetables.

RESULTS

Study findings suggest PNPs are using behavioral counseling for weight management in pediatric patients. Counseling was more frequent for healthy body weight, fruit and vegetable intake, and physical activity than for protein consumption and muscle strengthening. Furthermore, when PNPs counseled for healthy body weight they were also more likely to counsel for physical activity (OR = 25.99 [95% CI: 19.25, 35.11]), fruit and vegetable intake (OR = 22.35 [95% CI: 16.71, 29.88]), protein intake (OR = 9.82 [95% CI: 7.60, 12.69]), and muscle strengthening (OR = 6.41 [95% CI: 4.98, 8.24]).

DISCUSSION

PNPs are counseling for healthy body weight and necessary behavioral tools, but increased emphasis on muscle strengthening may benefit overweight and obese youth.

Interventions for High Body Mass Index in Children and Adolescents: US Preventive Services Task Force Recommendation Statement

Importance

Approximately 19.7% of children and adolescents aged 2 to 19 years in the US have a body mass index (BMI) at or above the 95th percentile for age and sex, based on Centers for Disease Control and Prevention growth charts from 2000. The prevalence of high BMI increases with age and is higher among Hispanic/Latino, Native American/Alaska Native, and non-Hispanic Black children and adolescents and children from lower-income families.

Objective

The US Preventive Services Task Force (USPSTF) commissioned a systematic review to evaluate the evidence on interventions (behavioral counseling and pharmacotherapy) for weight loss or weight management in children and adolescents that can be provided in or referred from a primary care setting.

Population

Children and adolescents 6 years or older.

Evidence Assessment

The USPSTF concludes with moderate certainty that providing or referring children and adolescents 6 years or older with a high BMI to comprehensive, intensive behavioral interventions has a moderate net benefit.

Recommendation

The USPSTF recommends that clinicians provide or refer children and adolescents 6 years or older with a high BMI (≥95th percentile for age and sex) to comprehensive, intensive behavioral interventions. (B recommendation).

Screening for obstructive sleep apnea (OSA) in children and adolescents with obesity: A scoping review of national and international pediatric obesity and pediatric OSA management guidelines

Obstructive sleep apnea (OSA) is a prevalent complication that affects up to 60% of children and adolescents with obesity. It is associated with poorer cardiometabolic outcomes and neurocognitive deficits. Appropriate screening and intervention for OSA are crucial in the management of children with obesity. We performed a scoping review of international and national pediatric obesity (n = 30) and pediatric OSA (n = 10) management guidelines to evaluate the recommendations on OSA screening in pediatric obesity. Sixteen (53%) of the pediatric obesity guidelines had incorporated OSA screening to varying extents, with no consistent recommendations on when and how to screen for OSA, and subsequent management of OSA in children with obesity. We provide our recommendations that are based on the strength and certainty of evidence presented. These include a clinical-based screening for OSA in all children with body mass index (BMI) ≥ 85th percentile or those with rapid BMI gain (upward crossing of 2 BMI percentiles) and the use of overnight polysomnography to confirm the diagnosis of OSA in those with high clinical suspicion. We discuss further management of OSA unique to children with obesity. An appropriate screening strategy for OSA would facilitate timely intervention that has been shown to improve cardiometabolic and neurocognitive outcomes.

Effect modification of time spent outdoors on the association between early childhood overweight and myopia: a one-year follow-up study

BACKGROUND

This study examined the moderating role of outdoor time on the relationship between overweight and myopia.

METHODS

The data for this study was obtained from a prospective study in Shanghai, where non-myopic children wore wristwear and were followed up for 1 year. Eye examinations were performed at each visit. The modification effect was assessed on the additive scale using multivariable logistic regression, and relative excess risk due to interaction was used to calculate the modification effect.

RESULTS

A total of 4683 non-myopic children were included with 32.20% being overweight at baseline. Following a 1-year period, 17.42% of children had myopia. When compared to those who spent <90 minutes outdoors, children who spent >120 had a relative risk of myopia onset that was reduced to 0.61. As time spent outdoors decreased, more risks of myopia onset were identified among overweight children than among normal children, the modification effect on the additive scale was -0.007, with ~70% of this effect attributed to the modifying influence of outdoor time.

CONCLUSIONS

Increasing outdoor time can reduce myopia more among overweight children than normal. Future interventions should focus on outdoor activities among overweight children to reduce myopia risks.

Incorporation of patient and family values and preferences for health-related outcomes in paediatric obesity management: A systematic review

OBJECTIVE

A systematic review of value and preference studies conducted in children and their caregivers related to the estimated benefits and harms of interventions for managing paediatric obesity.

METHODS

We searched Ovid Medline (1946-2022), Ovid Embase (1974-2022), EBSCO CINAHL (inception to 2022), Elsevier Scopus (inception to 2022), and ProQuest Dissertations & Theses (inception to 2022). Reports were eligible if they included: behavioural and psychological, pharmacological, or surgical interventions; participants between (or had a mean age within) 0-18 years old with overweight or obesity; systematic reviews, primary quantitative, qualitative, or mixed/multiple methods studies; and values and preferences as main study outcomes. At least two team members independently screened studies, abstracted data, and appraised study quality.

RESULTS

Our search yielded 11 010 reports; eight met the inclusion criteria. One study directly assessed values and preferences based on hypothetical pharmacological treatment for hyperphagia in individuals with Prader-Willi Syndrome. Although not having reported on values and preferences using our a priori definitions, the remaining seven qualitative studies (n = 6 surgical; n = 1 pharmacological) explored general beliefs, attitudes, and perceptions about surgical and pharmacological interventions. No studies pertained to behavioural and psychological interventions.

CONCLUSION

Future research is needed to elicit the values and preferences of children and caregivers using the best available estimates of the benefits and harms for pharmacological, surgical, and behavioural and psychological interventions.

Risk Factors, Clinical Consequences, Prevention, and Treatment of Childhood Obesity

Obesity might adversely affect the health and well-being of children and their families. Childhood obesity has crucial implications for health, both during childhood and as they age. It is highly associated with many acute problems and is commonly present during childhood, making visits and hospital admissions polarized in this group of children. The problems that may affect these children can be medical, such as asthma, chronic inflammation, orthopedic abnormalities, liver disease, diabetes mellitus or dyslipidemia. Long-term consequences of cardiovascular risk factors, the persistence of obesity and premature mortality are common among adults who had obesity during their early lives. Additionally, they could also suffer from psychological issues, such as low self-esteem, which puts them at risk of a much more serious psychosocial problem that may lead to depression, as well as a disruption in educational achievements and social relationships. A healthy diet, physical activity, adequate sleep, and limited screen time are all preventive measures that should be implemented at the family and community levels, preferably through well-structured programs. Furthermore, pharmacological management of childhood obesity is limited and only used after non-pharmacological interventions have failed or in the late stages of obesity. However, recent guidelines advocate the early use of medical interventions. Approved pharmacotherapeutic options include orlistat, phentermine/topiramate combination and liraglutide. There are several other options approved primarily for other specific forms of obesity or for other indications, including setmelanotide, metformin, lisdexamfetamine, zonisamide and fluoxetine. Bariatric surgery is a safe and effective option in cases with extreme obesity and comorbidities considering the need for long-term monitoring and support for cases and their families post-surgery. This review aims to discuss and highlight the recent evidence regarding risk factors, clinical consequences, prevention, and treatment of childhood obesity.

Screening for metabolic complications of childhood and adolescent obesity: A scoping review of national and international guidelines

The rise in prevalence of childhood obesity is paralleled by an increase in obesity-related metabolic complications, which add significantly to the population burden of cardiovascular morbidity in the long term. Early detection of obesity-related metabolic complications through appropriate screening strategies forms a crucial aspect of obesity management. We performed a scoping review of international and national guidelines on the management of pediatric obesity to evaluate the recommendations on screening for metabolic complications, namely, hypertension, diabetes, dyslipidemia, and non-alcoholic fatty liver disease. Thirty guidelines were included, 23 (76.7%) of which had some guidance on screening for metabolic complications. However, there were significant variations in the extent and details of recommendations for screening for these metabolic complications. There has been no consensus on the body mass index (BMI) thresholds, age of onset, frequency, and screening tests recommended for detecting hypertension, diabetes, dyslipidemia, and non-alcoholic fatty liver disease between guidelines. These variations did not appear to be polarized based on geographical location or population ethnicity. We provide our recommendations on metabolic screening based on the strength of evidence in the guidelines, also incorporating recommendations from key childhood hypertension, diabetes, and lipid guidelines. Appropriate implementation of screening strategies is crucial to improve detection of metabolic complications, to allow for earlier or more intensified interventions for affected children with obesity.

Clinical practice guidelines for the prevention of childhood obesity: A systematic review of quality and content

Obesity in childhood is a significant global issue, and prevention is key to reducing prevalence. Healthcare providers can play an important role in the prevention of obesity. The aim of this systematic review was to identify and evaluate clinical practice guidelines (CPGs) for preventing childhood obesity with a focus on the role of medical doctors. Peer-reviewed literature and gray literature sources were searched for CPGs published from 2010 to 2021. Eleven CPGs were identified. Quality was evaluated using the Appraisal of Guidelines for Research and Evaluation Collaboration (AGREE II) instrument; seven CPGs were higher quality and four lower quality. Recommendations within the CPGs covered three main areas: growth monitoring, maintaining a healthy weight, and managing overweight. The importance of involving the whole family and healthy lifestyle behaviors was emphasized. The majority of the CPGs rated poorly in guideline applicability highlighting the need for practical implementation tools. Although our review identified a number of CPGs relevant to the prevention of obesity for doctors working with children and their families, more research is needed to produce high-quality meaningful and applicable CPGs to maximize uptake, implementation, and ultimately, benefit to children and their families.

Increased Incidence of Obesity in Children and Adolescents Post-COVID-19 Pandemic: A Review Article

The recent coronavirus 2019 (COVID-19) pandemic has immensely impacted all classes of society, but the effects on children and adolescents are much more pronounced than on others. While obesity and its comorbidities in children and adolescents have always been a concern, the COVID-19 pandemic has proven to be one of the leading causes of health problems in children and adolescents worldwide, leading to various complications. Hence, understanding its long-term sequelae is of utmost importance. The role of physicians in family counseling, nutrition counseling, and diet education is vital in maintaining a healthy lifestyle. The BMI (body mass index) measurements and retrospective cohort studies of various individuals are useful for the pertinent research. During the pandemic, social isolation, staying at home, increased screen time due to online classes, reduced outdoor activities, and more snacking are some of the contributing factors that have increased the prevalence of obesity and further morbidities associated with it. Multiple studies and guidelines are available for combating these issues; still, an increasing number of such cases have been encountered in routine outpatient department (OPD) practice. As opposed to specific infectious illnesses, obesity and its comorbidities are non-infectious, and a slow-growing silent risk; hence parents approach the pediatrician quite late in the disease process. With the emergence of the COVID-19 pandemic, every aspect of our life has entered a more virtual domain and is no longer confined to a mere physical sphere. This sudden shift to virtual online classes has significantly impacted children and adolescents by decreasing their physical activities and social interactions in schools. This has even led to increased use of social media and mobile phone games by children and adolescents, a grave concern for parents, pediatricians, and epidemiologists. A more detailed assessment and multidisciplinary approach might benefit in dealing with the management of this emerging issue. Gaining enhanced clarity by establishing more guidelines can help physicians as well as parents in the management of this critical issue.