Severely obese preschoolers in a tertiary care obesity program: characteristics and management

Special considerations for the child with obesity: An Obesity Medicine Association (OMA) clinical practice statement (CPS) 2024

Background

This Obesity Medicine Association (OMA) Clinical Practice Statement (CPS) details assessment and management of the child with overweight or obesity. The term "child" is defined as the child between 2 and 12 years of age. Because children are in a continual state of development during this age range, we will specify when our discussion applies to subsets within this age range. For the purposes of this CPS, we will use the following definitions: overweight in the child is a body mass index (BMI) ≥ 85th and <95th percentile, obesity in the child is a BMI ≥95th percentile, and severe obesity is a BMI ≥120% of the 95th percentile.

Methods

The information and clinical guidance in this OMA Clinical Practice Statement are based on scientific evidence, supported by medical literature, and derived from the clinical perspectives of the authors.

Results

This OMA Clinical Practice Statement provides an overview of prevalence of disease in this population, reviews precocious puberty in the child with obesity, discusses the current and evolving landscape of the use of anti-obesity medications in children in this age range, discusses the child with obesity and special health care needs, and reviews hypothalamic obesity in the child.

Conclusions

This OMA Clinical Practice Statement on the child with obesity is an evidence based review of the literature and an overview of current recommendations. This CPS is intended to provide a roadmap to the improvement of the health of children with obesity, especially those with metabolic, physiological, psychological complications and/or special healthcare needs. This CPS addresses treatment recommendations and is designed to help the clinician with clinical decision making.

A Longitudinal Comparison of Alternatives to Body Mass Index Z-Scores for Children with Very High Body Mass Indexes

OBJECTIVE

The current Centers for Disease Control and Prevention (CDC) body mass index (BMI) z-scores are inaccurate for BMIs of ≥97th percentile. We, therefore, considered 5 alternatives that can be used across the entire BMI distribution: modified BMI-for-age z-score (BMIz), BMI expressed as a percentage of the 95th percentile (%CDC95th percentile), extended BMIz, BMI expressed as a percentage of the median (%median), and %median adjusted for the dispersion of BMIs.

STUDY DESIGN

We illustrate the behavior of the metrics among children of different ages and BMIs. We then compared the longitudinal tracking of the BMI metrics in electronic health record data from 1.17 million children in PEDSnet using the intraclass correlation coefficient to determine if 1 metric was superior.

RESULTS

Our examples show that using CDC BMIz for high BMIs can result in nonsensical results. All alternative metrics showed higher tracking than CDC BMIz among children with obesity. Of the alternatives, modified BMIz performed poorly among children with severe obesity, and %median performed poorly among children who did not have obesity at their first visit. The highest intraclass correlation coefficients were generally seen for extended BMIz, adjusted %median, and %CDC95th percentile.

CONCLUSIONS

Based on the examples of differences in the BMI metrics, the longitudinal tracking results and current familiarity BMI z-scores and percentiles. Both extended BMIz and extended BMI percentiles may be suitable replacements for the current z-scores and percentiles. These metrics are identical to those in the CDC growth charts for BMIs of <95th percentile and are superior for very high BMIs. Researchers' familiarity with the current CDC z-scores and clinicians with the CDC percentiles may ease the transition to the extended BMI scale.

Modifiable Early Childhood Risk Factors for Obesity at Age Four Years

Background: Childhood obesity is associated with an increased risk of adult obesity and related chronic disease. Our aim was to identify modifiable exposures that are independently associated with obesity in the preschool age group. Methods: A prospective cohort study of 5734 children in New Zealand with anthropometric measurements was completed at age 4.5 years. The modifiable exposures of interest, measured at age 9 months and 2 years, were: food security during infancy; and, at age 2 years, screen time; sleep duration; and takeaway food and soft drink intake. The risk of obesity independently associated with each exposure was determined using Binomial and Poisson regression and described using adjusted risk ratios (RRs) and 95% confidence intervals (CIs), after controlling for confounding variables including gender, ethnicity, birth weight, and mother's age. The probability of obesity given cumulative exposures to the four risk factors and the population attributable fraction (PAF) were estimated. Results: Lower food security during infancy (<mean study sample score; RR = 1.32; 95% CI : 1.06-1.64) and, at age 2 years, more screen time (>1 hour/day; RR = 1.22; 95% CI : 1.01-1.48), shorter sleep duration (≤11.5 hours/day; RR = 1.30; 95% CI : 1.05-1.61), and weekly to daily consumption of takeaway/soft drink (RR = 1.25, 95% CI : 1.00-1.57) were independently associated with an increased risk of obesity at age 4.5 years. The cumulative PAF for childhood obesity was 42.9%, under an ideal scenario where all risk factors were eliminated. Conclusion: Exposure to modifiable factors by age 2 years is associated with obesity at age 4.5 years. Interventions to prevent childhood obesity need to be effective during infancy.

Clinical Assessment and Treatment of Early-Onset Severe Obesity

PURPOSE OF REVIEW

This review describes clinical management of early-onset severe obesity, defined here as severe obesity in children ≤ 5 years old. It summarizes current information regarding (1) assessment, specifically growth, genetics, cardiometabolic risk, health behaviors, developmental considerations, and psychosocial factors, and (2) treatment, focusing on lifestyle modification including parent training and a brief summary of pharmacotherapy.

RECENT FINDINGS

Prevalence of severe obesity in young children has remained stable yet most of these children will become adults with obesity. Interventions that address multiple health domains, such as eating habits, physical activity, and parenting skills, are necessary for addressing early-onset severe obesity. Research into pharmacotherapy remains limited but may provide future strategies for management. Early-onset severe obesity significantly influences children's long-term health and management should focus on intervention to promote BMI reduction. Further research into effective strategies is necessary to address the needs of this high-risk population.

Severe paediatric obesity and sleep: A mutual interactive relationship!

Childhood severe obesity is a serious, urgent and complex global health problem with long-term co-morbidities. Obstructive sleep-disordered breathing is more common in obese children and adolescents. Increased body mass index is associated with an increase in apnea-hypopnea index. Obstructive sleep apnea leads to a decrease in rapid eye movement sleep, and obese children have been noted to have a decrease in rapid eye movement sleep, leading to weight gain. Short sleep duration and poor sleep quality are associated with childhood obesity and cardiometabolic risks. Public health strategies for obesity prevention should focus more on sleep. Targeting childhood obesity is important in the prevention and management of obstructive sleep-disordered breathing.

Distance and percentage distance from median BMI as alternatives to BMI z score

BMI z (BMIz) score based on the Centers for Disease Control and Prevention growth charts is widely used, but it is inaccurate above the 97th percentile. We explored the performance of alternative metrics based on the absolute distance or % distance of a child's BMI from the median BMI for sex and age. We used longitudinal data from 5628 children who were first examined <12 years to compare the tracking of three BMI metrics: distance from median, % distance from median and % distance from median on a log scale. We also explored the effects of adjusting these metrics for age differences in the distribution of BMI. The intraclass correlation coefficient (ICC) was used to compare tracking of the metrics. Metrics based on % distance (whether on the original or log scale) yielded higher ICCs compared with distance from median. The ICCs of the age-adjusted metrics were higher than that of the unadjusted metrics, particularly among children who were (1) overweight or had obesity, (2) younger and (3) followed for >3 years. The ICCs of the age-adjusted metrics were also higher compared with that of BMIz among children who were overweight or obese. Unlike BMIz, these alternative metrics do not have an upper limit and can be used for assessing BMI in all children, even those with very high BMIs. The age-adjusted % from median (on a log or linear scale) works well for all ages, while unadjusted % from median is better limited to older children or short follow-up periods.

Family members' experiences with adult participation in weight management programs: Triadic perspectives from patients, partners and children

OBJECTIVE

Spouses are known to influence the outcomes of an individual's attempt at weight loss, but little is known about the broader influence of, and on, the family. The objectives were to explore: (a) the effects of an adult weight management program on the family and (b) family factors that help or hinder patient weight loss.

METHODS

A qualitative design was employed to explore triadic family members' experiences of patient participation in a weight management program. Semi-structured interviews were conducted with patients, partners and children (ages 7-18). Questions included support for patient participation and weight loss, dietary choices, meal preparation, physical activity routines, the home-food environment, communication about health and family dynamics. Thematic analysis was used, where codes and categories of codes were then grouped together to create themes and subthemes.

RESULTS

Nineteen triadic interviews were conducted (57 total). Seven themes emerged, including four related to Outcomes (objective 1): (a) shift in family dynamics, (b) family behaviour change, (c) child observations of family change, (d) indirect benefit to partner; and three related to Process (objective 2): (e) level of accountability, (f) patient perception of support and (g) support is essential and flexible.

CONCLUSIONS

Future research and clinical applications from these themes should seek to determine the positive behaviour change that was evident in the families that were interviewed, where the culmination of family interactions, expectations and concurrent partner weight loss indicates the potential longevity of weight management programs beyond patients' own participation.

Effects of an antenatal dietary intervention in women with obesity or overweight on child outcomes at 3-5 years of age: LIMIT randomised trial follow-up

While the effects of an antenatal dietary intervention for women with obesity or overweight on pregnancy and newborn health have been extensively studied, the longer-term effects into childhood are unknown. We followed children born to women who participated in the LIMIT randomised trial, where pregnant women were randomised to an antenatal dietary and lifestyle intervention or standard antenatal care. Our aim was to assess the effect of the intervention, on child outcomes at 3-5 years of age on children whose mothers provided consent. We assessed 1418 (Lifestyle Advice n = 727; Standard Care n = 691) (66.9%) of the 2121 eligible children. There were no statistically significant differences in the incidence of child BMI z-score >85th centile for children born to women in the Lifestyle Advice Group, compared with the Standard Care group (Lifestyle Advice 444 (41.73%) versus Standard Care 417 (39.51%); adjusted relative risk (aRR) 1.05; 95% confidence intervals 0.93-1.19; p = 0.42). There were no significant effects on measures of child growth, adiposity, neurodevelopment, or dietary intake. There is no evidence that an antenatal dietary intervention altered child growth and adiposity at age 3-5 years. This cohort of children remains at high risk of obesity, and warrants ongoing follow-up.

A Review of Modifiable Risk Factors for Severe Obesity in Children Ages 5 and Under

Early-onset severe obesity in childhood presents a significant clinical challenge signaling an urgent need for effective and sustainable interventions. A large body of literature examines overweight and obesity, but little focuses specifically on the risk factors for severe obesity in children ages 5 and younger. This narrative review identified modifiable risk factors associated with severe obesity in children ages 5 and younger: nutrition (consuming sugar sweetened beverages and fast food), activity (low frequency of outdoor play and excessive screen time), behaviors (lower satiety responsiveness, sleeping with a bottle, lack of bedtime rules, and short sleep duration), and socio-environmental risk factors (informal child care setting, history of obesity in the mother, and gestational diabetes). The lack of literature on this topic highlights the need for additional research on potentially modifiable risk factors for early-onset severe obesity.

A Narrative Review of Medical and Genetic Risk Factors among Children Age 5 and Younger with Severe Obesity

Severe obesity defined as an age- and gender-specific body mass index ≥120% of the 95th percentile in children younger than 5 years is well recognized as a significant challenge for prevention and treatment. This article provides an overview of the prevalence, classification of obesity severity, patterns of weight gain trajectory, medical and genetic risk factors, and comorbid disorders among young children with an emphasis on severe obesity. Studies suggest rapid weight gain trajectory in infancy, maternal smoking, maternal gestational diabetes, and genetic conditions are associated with an increased risk for severe obesity in early childhood. Among populations of young children with severe obesity seeking care, co-morbid conditions such as dyslipidemia and fatty liver disease are present and families report behavioral concerns and developmental delays. Children with severe obesity by age 5 represent a vulnerable population of children at high medical risk and need to be identified early and appropriately managed.

Adopción de comportamientos saludables en la niñez: análisis del concepto

La adopción de comportamientos saludables es un fenómeno multidimensional que está determinado tanto por las características individuales del niño, como por las relaciones sociales y con el entorno que se establecen. La niñez es una etapa de grandes cambios a nivel neurofisiológico y social, que determinan el establecimiento de comportamientos asociados a la salud que pueden mantenerse de por vida y por tanto tener un efecto positivo o negativo en el bienestar y calidad de vida del futuro adulto. Este artículo tiene como objetivo analizar el concepto de adopción de comportamientos saludables en la niñez, a través de la metodología propuesta por Walker y Avant (2005), que permite examinar las características definitorias y atributos del concepto. La clarificación de este concepto amplia el conocimiento acerca de este fenómeno, lo que permitirá consolidar y plantear estrategias de promoción, prevención e intervención, así como guiar la investigación y la práctica de cuidado de enfermería en la niñez.

Longitudinal changes in BMI z-scores among 45 414 2-4-year olds with severe obesity

BACKGROUND

BMI z-scores (BMIz) based on the Centers for Disease Control and Prevention (CDC) growth charts among children do not accurately characterise BMI levels among children with very high BMIs. These limitations may be particularly relevant in longitudinal and intervention studies, as the large changes in the L (normality) and S (dispersion) parameters with age can influence BMIz.

AIM

To compare longitudinal changes in BMIz with BMI expressed as a percentage of the 95th percentile (%BMIp95) and a modified z-score calculated as log(BMI/M)/S.

SUBJECTS AND METHODS

A total of 45 414 2-4-year-olds with severe obesity (%BMIp95 ≥ 120).

RESULTS

Changes in very high BMIz levels differed from the other metrics. Among severely obese 2-year-old girls, for example, the mean BMIz decreased by 0.6 SD between examinations, but there were only small changes in BMIp95 and modified BMIz. Some 2-year-old girls had BMIz decreases of >1 SD, even though they had large increases in BMI, %BMIp95 and modified BMIz.

CONCLUSIONS

Among children with severe obesity, BMIz changes may be due to differences in the transformations used to estimate levels of BMIz rather than to changes in body size. The BMIs of these children could be expressed relative to the 95th percentile or as modified z-scores.

Characteristics of Very Young Hispanic Children Referred for Obesity Management

Information on risks associated with obesity during infancy specific to Hispanic children is scarce. This retrospective medical record review describes characteristics and parenting practices of Hispanic children age <2 years referred for obesity care at a tertiary hospital over a 6-year period. Data on 29 Hispanic children collected from parent-completed assessment forms and clinician documentation were analyzed. Children were of mean age 16.2 ± 4.9 months; body mass index z scores ranged from 1.5 to 9.4 (mean 4.5 ± 1.7); 45% were male; 97% received public insurance; 38% were breastfed ≥6 months; and 93% had a parent who was overweight or obese. Parenting practices included bottle feeding in bed (50%), regularly drinking sweetened beverages (33%), ≥2 hours of screen time (60%), and having a TV in child’s bedroom (55%). Better understanding of factors that contribute to the development of rapid weight gain of Hispanic children can inform future clinical and public health interventions.

The Limitations of Transforming Very High Body Mass Indexes into z-Scores among 8.7 Million 2- to 4-Year-Old Children

OBJECTIVE

To examine the associations among several body mass index (BMI) metrics (z-scores, percent of the 95th percentile (%BMIp95) and BMI minus 95th percentile (ΔBMIp95) as calculated in the growth charts from the Centers for Disease Control and Prevention (CDC). It is known that the widely used BMI z-scores (BMIz) and percentiles calculated from the growth charts can differ substantially from those that directly observed in the data for BMIs above the 97th percentile (z = 1.88).

STUDY DESIGN

Cross-sectional analyses of 8.7 million 2- to 4-year-old children who were examined from 2008 through 2011 in the CDC's Pediatric Nutrition Surveillance System.

RESULTS

Because of the transformation used to calculate z-scores, the theoretical maximum BMIz varied by >3-fold across ages. This results in the conversion of very high BMIs into a narrow range of z-scores that varied by sex and age. Among children with severe obesity, levels of BMIz were only moderately correlated (r ~ 0.5) with %BMIp95 and ΔBMIp95. Among these children with severe obesity, BMIz levels could differ by more than 1 SD among children who had very similar levels of BMI, %BMIp95 and ΔBMIp95 due to differences in age or sex.

CONCLUSIONS

The effective upper limit of BMIz values calculated from the CDC growth charts, which varies by sex and age, strongly influences the calculation of z-scores for children with severe obesity. Expressing these very high BMIs relative to the CDC 95th percentile, either as a difference or percentage, would be preferable to using BMI-for-age, particularly when assessing the effectiveness of interventions.

Tracking of BMI z Scores for Severe Obesity

BACKGROUND

Although the Centers for Disease Control (CDC) growth charts are widely used in studies of childhood obesity, BMI z scores are known to be inaccurate at values greater than the 97th percentile.

METHODS

We used longitudinal data from 6994 children in the Bogalusa Heart Study who were examined multiple times to compare tracking of 3 BMI metrics: BMI-for-sex/age z score (BMIz), BMI expressed as a percentage of the 95th percentile (%BMIp95), and levels of BMI z score that adjust for the compression of very high z scores (adjusted z score [BMIaz]). The later 2 metrics, unlike BMIz, do not have an upper limit. The mean interval between examinations was 2.8 years. We were particularly interested in these metrics among children with obesity or severe obesity (%BMIp95 ≥120%).

RESULTS

Although there was little difference in the tracking of the 3 metrics in the overall sample, among 247 children with severe obesity, the correlation of BMIz levels between examinations (r = 0.46) was substantially weaker than those for BMIaz and %BMIp95 (r = 0.65 and 0.61). Age-stratified analyses indicated that the weak tracking of BMIz was particularly evident before the age of 10 years (r = 0.36 vs 0.57 and 0.60). Several children with severe obesity showed BMIz decreases between examinations despite having BMI increases of over 5.

CONCLUSIONS

Among children with severe obesity, the tracking of BMIz is weak. This is because of the constraints in converting very high BMIs into z scores based on the CDC growth charts. Rather than using BMIz, it would be preferable to express very high BMIs relative to the CDC 95th percentile or to use BMIaz.

BMI z-Scores are a poor indicator of adiposity among 2- to 19-year-olds with very high BMIs, NHANES 1999-2000 to 2013-2014

OBJECTIVE

Although the Centers for Disease Control and Prevention (CDC) growth charts are widely used, BMI-for-age z-Scores (BMIz) are known to be uninformative above the 97th percentile. This study compared the relations of BMIz and other BMI metrics (%BMI_p95 , percent of 95th percentile, and ΔBMI_p95 , BMI minus 95th percentile) to circumferences, skinfolds, and fat mass. We were particularly interested in the differences among children with severe obesity (%BMI_p95  ≥ 120).

METHODS

Data was used from 30,003 2- to 19-year-olds who were examined from 1999-2000 through 2013-2014 in the National Health and Nutrition Examination Survey (NHANES).

RESULTS

The theoretical maximum BMIz based on the growth charts varied by more than threefold across ages. The BMI metrics were strongly intercorrelated, but BMIz was less strongly related to the adiposity measures than were ΔBMI_p95 and %BMI_p95 . Among children with severe obesity, circumferences and triceps skinfold showed almost no association with BMIz (r ≤ 0.10), whereas associations with %BMI_p95 and ΔBMI_p95 ranged from r = 0.32 to 0.79. Corresponding associations with fat mass ÷ height² ranged from r = 0.40 (BMIz) to r =0.82 (%BMI_p95 ) among 8- to 19-year-olds.

CONCLUSIONS

Among children with severe obesity, BMIz is only weakly associated with other measures of body fatness. Very high BMIs should be expressed relative to the CDC 95th percentile, particularly in studies that evaluate obesity interventions.

Obesity, Oxidative Stress, and Their Effect on Serum Heme Oxygenase-1 Concentrations and Insulin in Children Aged 3 to 5 Years in a Pediatric Hospital of the Ministry of Health CDMX

BACKGROUND

Obesity during early stages of life may condition states of oxidative stress. Heme oxygenase-1 (HO-1) is an enzyme involved in oxidative metabolism; it has antioxidant and anti-inflammatory functions and is related in sensitivity to insulin. However, a high concentration of this enzyme has been described to cause alterations such as insulin resistance. The objective of this work was to study the relationship between obesity, oxidative stress, HO-1, and insulin in children aged 3 to 5 years.

METHODS

To achieve our objective, we studied a control group of children (n = 50) and a group of obese children (n = 50) who underwent an anthropometric evaluation. Additionally, we quantified peroxidized lipids, oxidized low-density lipoproteins (Ox-LDLs), oxidized and reduced glutathione, HO-1, and insulin. We also calculated the homeostasis model assessment of insulin resistance (HOMA-IR), HOMA-%B, and HOMA-%S indices. According to the data distribution, nonparametric and Spearman's rank correlation coefficient tests were conducted.

RESULTS

The results demonstrate that obese children show a statistically relevant increase in BMI/age, serum concentrations of peroxidized lipids, Ox-LDLs, oxidized glutathione, HO-1, and insulin (p < 0.005). In addition, there was an increase in the HOMA-IR and HOMA-%B (p < 0.0001) indices and a decrease of reduced glutathione, as well as a reduction in the HOMA-%S, compared with the children of the control group (p < 0.003).

CONCLUSIONS

With the results obtained, we can conclude that obese preschool children show a chronic state of oxidative stress, an increase of HO-1, and an incipient state of insulin resistance. Finally, the increased reactive oxygen species could be one of the leading factors involved in insulin resistance and Ox-LDL increase from the preschool stage.