Childhood and adolescent obesity continue to be a serious medical and social problem throughout the world. Previous clinical recommendations for the prevention and treatment of childhood obesity were published by the American Endocrinology Association in 2008. Over the past eight years since the last publication, new data have appeared on the issues of drug therapy and surgical treatment of obesity, and in this connection, in 2016 leading American and European experts agreed on the text of new clinical recommendations for diagnosing, treating and preventing obesity in children, which was published in the February issue of the Journal of Clinical Endocrinology and Metabolism .
Clinical recommendations are based on criteria of evidence. To assess the quality of evidence and their strength, a system of symbols is used.
The numbers indicate the strength of the recommendations presented:
– 1 – “strict” recommendations corresponding to the phrase in the text “we recommend”;
– 2 – “weak” recommendations, corresponding to the phrase in the text “we assume”.
The quality of evidence is expressed by the pluses inscribed in the circles: “+” – very low; “++” is low; “+++” is medium and “++++” is a high level of evidence, respectively. The text of the recommendations is outlined in a scheme that takes into account the GRADE hierarchy (Grading of Recommendations, Assessment, Development, Evaluation).
Diagnosis of obesity and overweight in children
- For the diagnosis of obesity and overweight in children older than two years, it is recommended to use the body mass index (BMI) followed by an estimate of the percentile corridors developed by the CDC (Centers of Disease Control), taking into account the sex and age of the child (1 / +++).
- Excess body weight in children older than two years is diagnosed with a BMI ? 85 percentile, but <95 percentiles for a given sex and age; Obesity – with a BMI value ?95 percentile; morbid obesity – with a BMI ? 120% of the 95th percentile or a BMI ? 35 kg / m² (1 / ++).
- In children under two years of age, obesity can be diagnosed at a weight value relative to the growth of ? 97.7 percentile according to the World Health Organization (WHO) (2 / +).
As a diagnostic criterion for overweight and obesity in children in Russia, the standard deviation of the body mass index (SDS BMI) is defined. According to federal clinical guidelines, taking into account the recommendations of the WHO, obesity in children and adolescents from 0 to 19 years should be defined as a BMI equal to or more than 2.0 SDS BMI and overweight – from +1.0 to +2.0 SDS BMI. Normal body weight is diagnosed with BMI values within 1.0 SDS BMI. Morbid obesity is diagnosed with the SDS value of BMI> 4.0.
Diagnosis of the cause of obesity and screening of complications
- It is not recommended to routinely conduct hormonal studies to exclude the endocrine causes of obesity in children in the absence of growth retardation, decrease in the rate of growth or clinical signs characteristic of the syndromic forms of obesity (1 / +++).
- It is possible to conduct molecular genetic studies in children with morbid obesity (with a debut before the age of 5) and who have clinical signs of syndromic obesity (especially pronounced hyperphagia) or a family history (2 / ++), burdened with morbid obesity.
- It is recommended that screening of metabolic disorders associated with obesity in children and adolescents with overweight is recommended. (1 / +++).
- It is not recommended routine study of insulin when examining children and adolescents with obesity (1 / +++).
The presence of complications of obesity does not depend on its degree, so the need for screening for metabolic disorders is justified already in diagnosing excess body weight in children and adolescents (Table).
Screening of metabolic disorders in children and adolescents with obesity and overweight
|Disorders of carbohydrate metabolism
– prediabetic level of glycated hemoglobin (HbA1c)
– impaired fasting glycemia
– impaired glucose tolerance
|HbA1c from 5.7 to 6.5%
the fasting glucose level is 5.6-6.9 mmol / l
the glucose level after 2 hours of OGTT corresponds to 7,8-11,1 mmol / l.
fasting glucose level> 7.0 mmol / l; or the level of glycemia after 2 hours OGTT ? 11.1 mmol / l
|Dyslipidaemia||Cholesterol total ? 5.18 mmol / l
LDL ? 3.3 mmol / l
HDL ? 1.03 mmol / l
0-9 years: ? 1.13 mmol / l
10-19 years: ? 1.46 mmol / l
|Prehypertension and hypertension||Office measurement of blood pressure with subsequent evaluation by the percentile corridors taking into account the growth, age and sex|
|Non-alcoholic fatty liver disease (NAWA)||ALT> 25 U / L (boys)
ALT> 22 U / l (girls)
|Polycystic ovary syndrome||The study of the level of total and free testosterone, SSSG (sex-steroid-binding globulin)|
|Obstructive sleep apnea||Night polysomnography, night oximetry (if polysomnography is not possible)|
The “gold standard” for the diagnosis of insulin resistance (EI) is the euglycemic and hyperglycemic clamp, as well as an intravenous glucose-tolerant test with frequent blood sampling, estimated using the minimal Bergman model. Unfortunately, these tests are not applicable in everyday practice, as they are very long, expensive and invasive, require specially trained medical personnel and complex statistical processing of the results. More often for the evaluation of insulin resistance in obesity in children and adolescents , various calculation indices ( HOMA , Matsuda , etc.) are used.
In view of the controversial nature of the evaluation of IR, as well as the lack of officially authorized effective drug therapy for this condition, the evaluation of insulin resistance should be carried out on strict indications and is not mandatory in routine clinical practice. Indications for evaluating insulin resistance include the presence of previously detected carbohydrate metabolism disorders, a burdened family history (for type 2 diabetes, hyperandrogenia, etc.), the presence of objective markers of insulin resistance – acanthosis nigricans, or pronounced hyperpigmentation of the skin folds of the neck, axillary or inguinal areas , clinical signs of hyperandrogenism.
Treatment of obesity in children
A. Lifestyle changes
- Doctors of all specialties should work with children with obesity to conduct motivational conversations (taking into account gender, age, cultural and racial characteristics), aimed at all family members and aimed at creating a healthy lifestyle and reducing BMI (1 / +++).
- To increase motor activity, moderate or high intensity loads of at least 20 minutes duration are recommended until the daily recommended duration of exercise is 60 minutes per day in combination with diet therapy (1 / ++).
- It should limit the time spent by a child in front of a television or computer screen, up to 2 hours a day and reduce the duration of other sedentary activities (2 / +).
- The tasks of a multidisciplinary team of specialists should include not only the education of children and parents for the principles of proper nutrition and the formation of a healthy lifestyle, but also the identification of psychological problems in obese children and their timely correction (2 / +).
Russian recommendations on nutrition for children, taking into account age, are presented in the clinical recommendations “Recommendations for diagnosis, treatment and prevention of obesity in children and adolescents” .
According to WHO recommendations, adequate physical activity for children and adolescents aged 6 to 17 years implies daily sessions of at least 60 minutes per day. Physical activity over 60 minutes per day provides additional health benefits.
The recommended daily duration of physical activity (60 minutes or more) can develop during the day from shorter loads (for example, 2 times a day for 30 minutes). Minimally effective are 10-minute periods of physical activity from moderate to high intensity.
To physical loads of light intensity are: household chores (ironing, cleaning, cleaning), walking walking (3 – 4 km / h); to loads of moderate intensity – drawing, walking moderate (4 – 6 km / h) and quick steps (more than 6 km / h), paired tennis, golf, cycling (16 – 19 km / h); to loads of high intensity – aerobics, cycling (19 – 22 km / h), swimming (45 m / min), single tennis and running (from 9 to 14 km / h).
B. Drug therapy
- The prescription of drug therapy for children and adolescents with obesity is possible only in the case of ineffective activities aimed at changing the lifestyle for weight loss or the progression of complications of obesity (2 / +).
- Children under 16 years of overweight should refrain from prescribing medication, except in cases limited to clinical trials (1 / +).
- Drug therapy for obesity is possible only in combination with lifestyle changes and only by a doctor who has experience of treatment with these drugs (2 / +).
- In the absence of a decrease in BMI / SDS BMI> 4% within 3 months of drug therapy at the full therapeutic dose, treatment should be considered ineffective and discontinued (2 / +).
The drug therapy of adiposity in adolescents is limited. The only drug allowed for the treatment of obesity in children over 12 years in the world and the Russian Federation is orlistat. Orlistat is an inhibitor of gastric and pancreatic lipases, which are involved in the hydrolysis of triglycerides and are necessary for the absorption of fats in the small intestine. As a result of the action of the preparation, the digestion of food fats is violated and their absorption is reduced. After the drug is discontinued, its effect is quickly stopped, and lipase activity is restored. The efficacy of orlistat in the complex therapy of obesity in adolescents is evaluated in numerous controlled clinical trials. The use of metformin drugs in the pediatric group is allowed for patients older than 10 years with an established diagnosis of type 2 diabetes mellitus.
The use of drugs octreotide, leptin, growth hormone is limited to the scope of clinical and scientific research and can not be recommended for use in general practice. The use of sibutramine in children is prohibited in connection with the identified fatal side effects.
B. Bariatric surgery
- The use of bariatric surgery is not recommended: to children who have not entered the pubertal period, to pregnant or nursing adolescent girls, to families with low adherence to adherence to the principles of a healthy lifestyle, to people with mental illness, severe depression or eating disorders (uncontrolled or uncompensated) ( 2+).
- Use of bariatric surgery as a method of treatment of morbid obesity in adolescents is possible if the following conditions are met:
– Achievement of 4-5 stages of sexual development according to Tanner and final or close to final growth;
– BMI> 40 kg / m² or BMI> 35 mg / m² + presence of severe comorbid conditions (type 2 diabetes, non-alcoholic steatohepatitis, sleep apnea syndrome);
– Persistence or progression of morbid obesity complications, despite sufficient adherence to treatment (regardless of the presence / absence of drug therapy for obesity);
– psychological examination of the patient and members of his family, aimed at identifying previously not diagnosed mental disorders, assessing the quality of life and the possibility of long-term compliance (2 / ++).
Surgical methods for the treatment of obesity (bariatric / metabolic surgery) in adolescents are becoming more prevalent in the world in recent decades. The main advantages of bariatric surgery are rapid weight loss, improvement of metabolic parameters and quality of life of patients with morbid obesity.
An uncertain safety profile, the frequent development of a persistent deficit of vitamins and trace elements, the need for surveillance by a multidisciplinary team of specialists and low compliance limit the widespread introduction of metabolic surgery as an acceptable method of treating morbid obesity in adolescents. In the Russian Federation, bariatric surgery for the treatment of obesity in persons under the age of 18 is prohibited.
Prevention of obesity in children
- Doctors of all specialties should actively participate in teaching children, their family members, preschool and school environment of children to the principles of healthy eating and to combat hypodynamia (2 / +).
- Doctors of all specialties should inform the obese and overweight children about the basic principles of healthy eating: refusal of sugary drinks, fast food, foods with high fat and salt content, sweet whole-grain breakfasts, preference of natural fruit to freshly squeezed juices (1 / ++).
- For adolescents with obesity and overweight, regular moderate-intensity motor activity of at least 20 minutes per day (optimally 1 hour per day) at least 5 times a week is recommended to improve health and reduce the risk of obesity (1 / ++).
- Support breastfeeding (2 / +).
- It is necessary to monitor sleep disorders in children and adolescents, as they can contribute to the development of obesity due to changes in eating behavior (2 / ++).
- The most effective in preventing obesity and overweight are programs aimed at motivational learning not only of the child, but also of his family (2 / +).
- Methods aimed at preventing childhood obesity should be integrated into pre-school and school general education programs to achieve the maximum coverage of the target audience (1 / ++).
- Dennis M. Styne, Silva A. Arslanian, Ellen L. Connor, Ismaa Sadaf Farooqi, M. Hassan Murad, Janet H. Silverstein, Jack A. Yanovski; Pediatric Obesity – Assessment, Treatment, and Prevention: An Endocrine Society Clinical Practice Guideline. 2017 jc.2016-2573. doi: 10.1210 / jc.2016-2573
- Recommendations for the diagnosis, treatment and prevention of obesity in children and adolescents. – Moscow: Practice, 2015. – 136 p.