Management of Overweight Children

By: Hazwani Md Noor Supervisor: Dr. dr. Aryono Hendarto

Clinical Scenario
8-years-old, Female Came to RSCM for Chemotherapy followup Diagnosed with ALL since 2 months ago High-dose dexamethasone therapy Increased appetite, Ate 5x/day meal, Sleep Increased 10 kg BW

Clinical Scenario
Normal vital signs Moon face Central Obesity Purple Striae BMI 20.1 (89th %) = Overweight

Parents concerned about weight problems How to manage?

Overview
Increasing rates of overweight & obesity in Indonesia Associated with higher social status Increase cardiovascular risk factors, chronic diseases (e.g. T2DM, HT, stroke) Current management: lifestyle, pharmacotherapy, surgical intervention Effective management still uncertain
Usfar A, Lebenthal E. Obesity as a poverty related emerging nutrition problems: the case of Indonesia. Obesity Reviews. 2010;11(12):924-8.

Clinical Question
Population Intervention Comparator Outcome : Overweight children : Overweight management :: Weight reduction

Question: What is the management of overweight problem in children?

Methods
Literature search conducted using Pubmed, EMBASE and National Guideline Clearinghouse on 19th September 2011.

Articles obtained using children, overweight, management and their synonyms as the entry terms.

Methods
Engine PubMed Search Terms ((children OR pediatric) AND overweight AND management Hits 2546

EMBASE

(('child':ab,ti) OR ('pediatric':ab,ti)) AND overweight:ab,ti AND management:ab,ti

194

National Guideline Clearinghouse (NGC)

(children OR pediatric) AND overweight AND management

1393

Pediatric OR Children

A N D

Overweight

A N D

Management

Pubmed

EMBASE

NGC

2546

194

1393
Exclusion criteria

Screening title/abstract

-Diagnostic, Etiologic & Prognostic Study -Animal study

252

83

428

-Text not in English

-Publication before year 2000

Screening title/abstract

Inclusion criteria -Therapeutic study -English language

206

16

112

-Full-text available

Screening full-text and duplicates

Selection criteria -Overweight management in children

Useful articles: 2

Date of search: 19th September 2011

Articles
August GP, Caprio S, Fennoy I, Freemark M, Kaufman FR, Lustig RH, et al. Prevention and treatment of pediatric obesity: an endocrine society clinical practice guideline based on expert opinion. Journal of Clinical Endocrinology & Metabolism. 2008;93(12):4576. [TES]
Logue J, Thompson L, Romanes F, Wilson DC, Thompson J, Sattar N. Management of obesity: summary of Scottish Intercollegiate Guidelines Network (SIGN) guideline. Bmj. 2010;340. [SIGN]

Critical Appraisal
Appraisal of Guidelines for Research & Evaluation II (AGREE II)
Domains SIGN Guideline 1.Scope & Purpose 2.Stakeholder & Involvement 3.Rigour of Development 4.Clarity of Presentation 66.7% 66.7% 47.5% 66.7% Score TES Guideline 60% 50% 55% 60%

5.Applicability 6.Editorial Independence

45% 50%

37.5% 50%

Results
Lifestyle Intervention -most effective -diet changes, increasing physical activity, decreasing sedentary behavior, behavioral interventions, family involvement Weight maintenance in overweight children
Logue J, Thompson L, Romanes F, Wilson DC, Thompson J, Sattar N. Management of obesity: summary of Scottish Intercollegiate Guidelines Network (SIGN) guideline. Bmj. 2010;340. August GP, Caprio S, Fennoy I, Freemark M, Kaufman FR, Lustig RH, et al. Prevention and treatment of pediatric obesity: an endocrine society clinical practice guideline based on expert opinion. Journal of Clinical Endocrinology & Metabolism. 2008;93(12):4576.

Results
Pharmacological Treatment -If intensive lifestyle modification fails and severe comorbidity -Only prescribed if doctor familiar with drugs potential side-effects (E.g.: Orlistat gastrointestinal side effects)
Logue J, Thompson L, Romanes F, Wilson DC, Thompson J, Sattar N. Management of obesity: summary of Scottish Intercollegiate Guidelines Network (SIGN) guideline. Bmj. 2010;340. August GP, Caprio S, Fennoy I, Freemark M, Kaufman FR, Lustig RH, et al. Prevention and treatment of pediatric obesity: an endocrine society clinical practice guideline based on expert opinion. Journal of Clinical Endocrinology & Metabolism. 2008;93(12):4576.

Results
Surgical Intervention (Bariatric Surgery) -Only in adolescents with extreme obesity and severe comorbidities despite lifestyle intervention with or without pharmacological management -Discuss with parents and children (readiness for long-term follow-up and lifestyle intervention)
Logue J, Thompson L, Romanes F, Wilson DC, Thompson J, Sattar N. Management of obesity: summary of Scottish Intercollegiate Guidelines Network (SIGN) guideline. Bmj. 2010;340. August GP, Caprio S, Fennoy I, Freemark M, Kaufman FR, Lustig RH, et al. Prevention and treatment of pediatric obesity: an endocrine society clinical practice guideline based on expert opinion. Journal of Clinical Endocrinology & Metabolism. 2008;93(12):4576.

Discussion
Weight maintenance
-Decrease BMI as Increase height

Dr. should prescribe lifestyle intervention Problems with pharmacological intervention

Lack of FDA approval Reduced efficacy over time Limited studies on efficacy and safety Risk of severe side-effects & long-term potential morbidity & mortality

Discussion
Oct 2010, FDA voluntarily withdrawn Sibutramine increase risk of heart attack and stroke Surgical intervention not recommended in young children -long term side-effects and complications for growing child still unknown.

Conclusion & Recommendations

Intensive lifestyle intervention most effective, safe, cost-saving Patient should undergo lifestyle intervention Improve diet calorie, fat, fast food, fibers, fruits, veg sugared beverages

 Prescribe at least 60 min of daily moderate to vigorous physical activity Limit screen time (watch tv, play videogames) 1 2 hr per day Maintain weight