Abstract
In 2014, the Children's Hospital Association and the American Academy of Pediatrics Institute for a Healthy Childhood Weight (ihcw.aap.org) convened the Expert Exchange (EE). This workgroup of pediatric obesity specialists from tertiary care weight management programs across the United States, was charged with addressing important issues in the treatment of childhood obesity. The consensus of the group was that the treatment of severe obesity among young children represents an underrecognized and critical challenge.
Severe obesity is defined as a body mass index (BMI) ≥120% of the age and sex specific 95th percentile for children 2–18 years old. 1 While there is not a consensus on a definition for obesity among children younger than 2 years, a BMI percentile above the 97.7th percentile (using the World Health Organization growth charts) has been used as a surrogate for obesity in this age group. 2 Children with early onset severe obesity typically present with an increased weight gain trajectory by the age of 5 years. 3
The EE undertook two initial tasks with the potential to improve the care of young children with severe obesity. The first was to describe the characteristics of the population of children younger than 5 years old with severe obesity. This was done to more clearly define physical and behavioral characteristics that could lead to clinical subtyping and pave the way for new targeted interventions. The second was to examine ways to provide optimal pediatric obesity treatment across tertiary care, primary care, and community settings. The results of these efforts are presented in the articles in this special issue of Childhood Obesity.
It is well accepted that excess weight is the most common chronic condition of childhood; however, less attention is given to the problem of severe obesity. The prevalence of severe obesity is 3.9% in White children but ∼9.0% for African American and Hispanic youth, which parallels the racial and ethnic disparities found for obesity as a whole. The prevalence of severe obesity is higher among older children, but disturbingly, severe obesity among very young children in the United States is increasing and now affects almost 2% of children 2–5 years old, 1 a prevalence rate higher than other commonly recognized conditions such as sickle cell trait (1.5%) 4 and autism spectrum disorder (1.7%). 5
Treatment for children and adolescents with severe obesity has not been sufficiently successful. Behavioral interventions, which have only modest impact in general, are often less effective among children with severe obesity, and bariatric surgery is not usually considered to be appropriate for such young patients.6,7 Consequently, these children remain on a trajectory that will likely lead to a lifetime of severe obesity. 8 For the first time, we have a significant proportion of infants, toddlers, and preschoolers affected by a serious lifestyle-related chronic disease that virtually eliminates a period of normal weight gain during a vulnerable developmental stage.
The difference in treatment response in this subgroup may reflect characteristics that vary between the child with severe obesity, obesity, or overweight status. For instance, individuals with severe obesity may present with excess weight gain earlier in life, exhibit a more dysfunctional approach to food, carry genetic mutations, or have an increased susceptibility to weight gain in the absence of significant environmental risk factors.6–9 A recent analysis of the NHANES data revealed a progressive increase in severity of obesity with increasing disadvantages in social determinants of health. 10 Thus, identifying the characteristics of this subgroup is a crucial first step for mapping treatment options.
The literature review by Mirza et al. identified the trajectory and timing of weight gain in early childhood as an important characteristic that tends to differ between the child with early onset severe obesity and the child who has overweight or obesity. 11 Porter et al. found that shorter sleep duration, low intake of fruits and vegetables, increased intake of sugary drinks, and fast food intake more than three times a week were significantly associated with severe obesity in the very young. 12 In addition, both articles outline areas where there are still significant gaps in our understanding of the subgroup such as their growth trajectory, maternal/child relationship, microbiome, appetite regulation, prenatal risk factors, and their epigenetics. Gaffka et al. sought to capitalize on the invaluable knowledge that comes from clinical practice through their survey of interdisciplinary providers at tertiary care obesity programs. 13 This study revealed that providers commonly reported frequent complaints about hunger, food seeking, and lack of satiety in young children with severe obesity. 13
These observations challenge us to evaluate how we treat young children with severe obesity and to reflect on how children and adolescents with different degrees of excess weight are cared for, to ensure optimal short- and long-term outcomes that decrease the burden of obesity-related chronic disease. The implications of severe obesity in the young child for diminished lifelong health, altered psychosocial development, and increased risk for numerous adult chronic diseases, while not yet well understood, may have far-reaching effects. In light of the potential for such grim consequences, it is important to understand and implement best practices in care coordination with improved connections/communication between weight management programs and primary care providers.
To learn from interventions that have taken a comprehensive and successful approach to treating chronic illnesses, Christison et al. conducted a review of the literature addressing the medical neighborhood in pediatric care. 14 This review provides a strong basis for a framework of care for children with severe obesity. Certainly, other chronic conditions such as asthma have benefited from interventions that go beyond the clinic to involve community settings. Taking this broader view, Siegel's article goes further to explore ways in which connections and communication might be facilitated between all sectors related to a patient's daily regime in order to create a “web of care” that augments clinical efforts. 15 Such multisectorial collaboration offers the promise of increased weight loss and improved quality of life along with greater sustainability. Siegel et al., suggest that the use of technology may facilitate communication and connections in ways that were not previously possible and may help provide improved care to diverse populations thus diminishing disparities. 15
The EE has described a vulnerable group of children with early onset severe obesity while evaluating the need and process for a framework for care that enhances integration and communication across the family, health system, and community sectors. It is hoped that these articles will provide guidance to researchers and pediatricians in their efforts to advance obesity treatment and provide the best possible care for this population of patients who are at risk for a life of impaired health and poor quality of life.