Background
Methods
Diagnosis
Diagnostic criteria for defining overweight, obesity and severe obesity
The definition of overweight and obesity is based on the use of percentiles of the weight-to-length ratio or body mass index, depending on sex and age. LOE V-A
Age | 0–2 years | 2–5 years | 5–18 years |
Index | Weight-to-lenght ratio | BMI | BMI |
Reference | WHO 2006 | WHO 2006 | WHO 2007 |
>85th percentilea | At risk of overweight | At risk of overweight | Overweight |
>97th percentilea | Overweight | Overweight | Obesity |
>99th percentilea | Obesity | Obesity | Severe obesity |
The cut-off to define severe obesity is represented by the BMI > 99th percentile. LOE VI-B
Secondary obesity
The clinical suspicion of secondary obesity arises after careful anamnestic, anthropometric and clinical evaluations. LOE III-A
Comorbidities
Hypertension
Blood pressure measurement is recommended in all children with overweight or obesity from the age of 3 years. LOE I-A
The definition of high BP levels requires a precise methodology and the use of tables expressing by sex and age the percentile of systolic and diastolic blood pressure as a function of the height percentile. LOE III-A
Normal BP | SBP and DBP < 90th percentile by gender, age and height |
High normal BP | SBP and/or DBP ≥90th but <95th percentile by gender, age and height (BP > 120/80 mmHg even <90th percentile are considered as high normal BP). |
Hypertension (Stage I) | SBP and/or DBP ≥95th <99th percentile + 5 mmHg by gender, age and height. |
Hypertension (Stage II) | SBP and/or DBP ≥99th percentile + 5 mmHg by gender, age and height. |
Prediabetes and type 2 diabetes mellitus
Fasting blood glucose measurement is recommended in all children and adolescents with overweight and obesity since the age of 6, as the first step for screening prediabetes and type 2 diabetes. LOE V-A
Prediabetes Impaired fasting glucose: plasma glucose (after 8 h of fasting) between 100 (5.6 mmol/l) and 125 mg/dl (6.9 mmol/l) Impaired glucose tolerance: plasma glucose after 2 h of the OGTT between 140 and 199 mg/dl (7.8 mmol/l) HbA1c between 5.7–6.4% (39–47 mmol/mol) Type 2 diabetes Random glycemia ≥200 mg/dl (11.1 mmol/l) and symptoms suggestive of diabetes (glycosuria without ketonuria, polydipsia, weight loss). Confirmation with a second test is not necessary. If symptoms are lacking, diagnosis is made whether one of the following criteria is fullfilled: 1. Fasting glycemia ≥126 mg/dl after 8 h of fasting. 2. Glycemia ≥200 mg/dl after 2 h of the OGTT. 3. HbA1c ≥6.5% or ≥ 48 mmol/l (IFCC reference method using high-performance liquid chromatography (caution in pediatric age). If one test is positive, the diagnosis must be confirmed by a second test. Whenever the two tests are discordant, the patient should be strictly monitored and the positive test repeated within 3–6 months. If the diagnosis of diabetes is made, the assessment of the autoimmune markers (ICA, GAD, IA2, IAA o ZnT8) is needed to exclude type 1 diabetes. Genetic screening for monogenic diabetes is recommended in the rare cases presenting with obesity, diabetes, negative autoimmunity tests and family history for T2D. |
Children with fasting plasma glucose ≥100 mg/dl or HbA1c ≥5.7–6.4% (39–46 mmol/mol) Adolescents (> 10 years of age) or at onset of puberty with overweight (BMI > 85th percentile) and at least one of the following risk factors: - Family history of T2DM in first- or second-degree relatives; - Race/ethnicity (African American, Latino, Native American, Asian American, or Pacific Islander); - Signs or conditions associated with insulin resistance (hypertension, dyslipidaemia, polycystic ovary syndrome, acanthosis nigricans, or small for gestational age at birth) - Maternal history of diabetes or gestational diabetes during the child’s gestation - Non alcholic liver disease - TG/HDL-Cholesterol ≥2.2 - Fasting plasma glucose ≥86 mg/dl - TG > 100 mg/dl and fasting plasma glucose > 80 mg/dl |
Dyslipidemia
The measurement of cholesterol, HDL-cholesterol and triglycerides is recommended in all children and adolescents with obesity since the age of 6. LOE I-A
In the absence of national reference values, the diagnosis of dyslipidemia is based on the criteria proposed by the expert panel on integrated guidelines for cardiovascular health and risk reduction in children and adolescents. LOE III-B
Cathegory | Acceptable | Borderline-high | High |
---|---|---|---|
Total cholesterol (mg/dl) | < 170 | 170–199 | ≥200 |
LDL-cholesterol (mg/dl) | < 110 | 110–129 | ≥130 |
Non HDL-cholesterol (mg/dl) | < 120 | 120–144 | ≥145 |
Triglycerides (mg/dl) | |||
0–9 years | < 75 | 75–99 | ≥100 |
10–19 years | < 90 | 90–129 | ≥130 |
Acceptable | Borderline-low | Low | |
HDL-cholesterol (mg/dl) | > 45 | 40–45 | < 40 |
Gastroenterological complications
Non-alcoholic fatty liver disease
Gallstones
There is no evidence to recommend the screening for colelithiasis. LOE IV-C
Gastroesophageal reflux
Gastroesophageal reflux is suspected in the presence of evocative symptoms (such as pyrosis, heartburn, regurgitation). LOE VI-B
Polycystic ovary syndrome
The components of the polycystic ovary syndrome should be considered in all female adolescents with obesity. LOE VI-A
Respiratory complications
Respiratory symptoms and signs should be sought in children and adolescents with obesity. LOE V-A
Orthopaedic complications
Orthopaedic complications should be sought in the presence of musculoskeletal pain and joint limit ation at the lower extremity. LOE V-A
Although obesity may exhibit higher risk of fracture, the measurement of bone density is not recommended. LOE V-D
Renal complications
There is insufficient evidence to recommend screening of kidney complications in non-diabetic and non-hypertensive children and adolescents with obesity. LOE IV-D
Idiopathic endocranic hypertension
Headache, vomiting, photophobia, transiently blurred vision, diplopia should be sought in subjects with overweight/obesity, especially if adolescents. LOE V-A
Migraine and chronic headache
Promoting healthy lifestyle habits and weight control can be a protective factor of migraine and chronic headache. LOE V-B
Psychosocial correlates
Psychosocial discomfort may affect therapeutic success, therefore it should be identified as part of the multi-disciplinary assessment. LOE V-A
Binge eating disorder
The presence of binge eating disorder should be considered in the multi-professional assessment of an obese child or adolescent. LOE V-B
Treatment
Changes in diet and lifestyle leading to a negative caloric balance is recommended to gradually reduce the BMI. LOE I-A
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maintaining an appropriate growth rate and achieving an healthier weight-to-height ratio;
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reducing weight excess (without necessarily achieving the ideal weight), in particular the fat mass, while preserving the lean mass;
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maintaining or promoting good mental health (self-esteem, correct attitudes toward food and body image, health related quality of life);
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treatment and improvement/resolution of complications, if present, in the shortest time possible;
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achieving and mantaining a healthier weight-to-height ratio and preventing relapses.
Diet
A balanced and varied diet is recommended (LOE I-A)
Dietary advice
Efficacy of dietary regimens
Very low caloric diet
Traffic light and modified traffic light diets
Non-restrictive approach
Replacement meals
Exercise
It is recommended to associate physical exercise to diet. LOE I-A
The evidence is limited that exercising at higher intensity is more effective in modifying the body composition (LOE I-B).
Aerobic exercisesa | exercises on treadmill, cycle ergometer, elliptical trainer water activities (swimming or water aerobics) |
Resistance exercisesa | body weight exercise (push-ups, sit-ups, abdominal crunches), lifting free weights, using weight training machines and elastic resistance bands, circuit training |
Sedentary behaviors
It is suggested to reduce the time spent in sedentary behaviours (television viewing, videogaming, internet surfing). LOE II-B
Use of active video games may be suggested to increase daily energy expenditure in obese and sedentary children. LOE I-B
The systematic use of active video games for weight loss and improvement of body composition is not discouraged. LOE III-C
Cognitive and family-based behavioral therapy
Cognitive behavioral treatment or family-based behavioral treatment are both recommended to favor better adhesion to diet and physical activity. Cognitive behavioral treatment LOE III- B; family-based behavioral treatment LOE I- A
Indicators of successful treatment
The BMI standard deviation score is recommended to estimate weight loss. LOE V-B
Other behavioral indicators (related to diet, lifestyle, physical fitness or quality of life) can be considered if no substantial reduction in the BMI-SDS occurs. LOE VI-B
The scarce effect of treatment in the long term demands the development of long-lasting care models and their validation. LOE VI-B
It is necessary to monitor the possible onset of eating disorders, especially when the weight loss is rapid. LOE IV-A
Pharmacological intervention
Pharmacological therapy can only be applied after the failure of the multidisciplinary lifestyle intervention. LOE VI-B
Orlistat is the only drug available for the treatment of children and adolescents with severe obesity age. LOE II-B
Bariatric surgery
Bariatric surgery is the ultimate solution in adolescents with severe obesity and resistant to all other treatments, especially when serious complications are present. LOE VI-B
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BMI ≥35 kg/m2 with at least one severe comorbidity, such as T2D, moderate to severe obstructive sleep apnea (AHI > 15), idiopathic endocranial hypertension, NAFLD with significant fibrosis (Ishak score > 1).
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BMI ≥40 kg/m2 with less serious comorbidities, such as mild sleep apnea (apnea/hypopnea index > 5), hypertension, dyslipidemia, carbohydrate intolerance.
Surgery should be performed in a highly specialized center that guarantees the presence of an experienced multidisciplinary team. LOE III-A
Indication for surgery must be given on a case-by-case basis by the multidisciplinary team (LOE VI-A)
Care settings
For the multifactorial nature of obesity, variability in its severity, and the health implications, treatment should be conducted in multiple settings with different levels of treatment. LOE III-A
Primary care pediatricians represent the first level treatment. LOE III-A
Conditions | Responsabilities |
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Risk factors: Prenatal life: first-degree familiarity for obesity, low socioeconomic status; Neonatal life: small for gestational age, or macrosomic infant; Postnatal life: no breastfeeding, early complementary feeding, excessive weight gain in the first two years of life, early adiposity rebound | Monitoring the child’s weight and length linear growth Educating to a balanced diet and healthy lifestyle since the earliest years of life Assuring appropriate timing of complementary feeding |
Children and adolescents with overweight or moderate, uncomplicated obesity | Early identification of children’s excess weight Promoting parental awareness of children’s excess weight Motivating and supporting the family to change, possibly involving other professionals trained in childhood obesity |
Severe obesity or psychological co-morbidity, or additional risk factors, or biochemical alterations, or treatment failure within 4–6 months | Identification of severe obesity Promoting parental awareness of children’s excess weight Motivating and supporting the family to more intensive levels of care |
Suspicion of secondary obesity | Referral to specialized centers |
District or hospital outpatient services represent the second level of care. LOE VI-A
Specialized centers for pediatric obesity represent the third level of care. LOE VI-A
Transition
Pediatric obesity care should include a transition path from pediatric to adult care. LOE VI-B
Prevention
Prevention is based on behavioral modification starting from the prenatal age. LOE I-A
The family involvement is strongly recommended. LOE III-A
Prenatal age
Women should start pregnancy with appropriate weight and control their weight gain following an healthy lifestyle. LOE III-A
Tobacco smoke in pregnancy is banned. LOE III-A
Diet
First two years of life
Avoid excessive weight gain and/or increased weight-to-length ratio from the very first months of life. LOE III-A
From preschool age to adolescence
Physical activity
It is recommended that children/adolescents spend on average 60 min a day on moderate/vigorous physical activity. LOE III-A
Sedentary behaviours
The use of television and electronic games is discouraged in children < 2 years of age. LOE VI-B
Sedentary behavior, especially the time spent in front of a screen (TV, video games, computers, mobile phones, etc.) should be reduced to less than 2 h a day in children > 2 years of age. LOE III-B
Sleep duration and quality
Adequate sleep duration and quality should be promoted in infants, children and adolescents. LOE III-B
4–12 months | 12–16 h/day (including afternoon naps) |
1–2 years | 11–14 h/day (including afternoon naps) |
3–5 years | 10–13 h/day (including afternoon naps) |
6–12 years | 9–12 h/day |
13–18 years | 8–10 h/day |
Involvement of school settings for implementing preventive actions
It is recommended to include the school settings in obesity prevention programs. LOE I-A
Support school personnel’s strategies for implementing health promotion programs. Improvement of overall school food environment: Removal of vending machines selling sugar sweetened beverages or snacks high in fat, sugar or salt; banning sales of this kind of food; reformulation of school lunches to reduce high calorie unhealthy food. Provision of a healthy breakfast Provision of free or low-cost fruit Provision of free/low cost water Improvement of overall school physical activity environment: Increase of the daily formal PA session organized during and after school hours. Availability of school playgrounds for structured/unstructured PA during and after regular school hours |