Addressing Obesity Care in Children With Chronic Health Conditions

Introduction

According to the CDC, chronic health conditions (CHCs) are defined as medical conditions that impede activities of daily living, require ongoing medical attention, and persist for 1 or more years. Obesity, a highly prevalent and challenging condition that is not always responsive to lifestyle interventions, affects 30%–50% of children affected by CHCs.^1–3 Although recent breakthroughs in antiobesity medications and surgical interventions show strong promise for pediatric populations, ⁴ we still have much to learn about how these novel approaches can be applied for all children.

Equitable care of these particularly vulnerable youth experiencing the intersection of obesity and CHCs raises important questions: (1) Do we understand the pathophysiology of obesity in children with CHCs? (2) Are we providing adequate obesity care for them? (3) Do we have evidence-based guidelines?

Multifactorial Etiologies for Obesity in Youth With CHCs

CHCs can contribute to excess weight gain by various mechanisms, ³ including (1) underlying pathology that directly affects appetite or energy expenditure (e.g., Prader–Willi syndrome and panhypopituitarism); (2) disease manifestations that impact feeding and exercise capacity (e.g., autism spectrum disorder, depression, and neuromusculoskeletal diseases); (3) significant time spent in contact with the health care system that limits time and resources to engage in routine healthy eating and exercise; (4) iatrogenic obesity related to treatment of CHCs (e.g., neuromusculoskeletal diseases, psychiatric conditions, epilepsy, Crohn's disease, rheumatological diseases, and organ transplants treated by weight-promoting medications such as steroids, antipsychotics, and anticonvulsants) and overnutrition through enteral feeds; (5) psychological stressors associated with CHCs^5,6 (e.g., depression and adjustment disorder) and consumption of highly palatable foods as a coping mechanism; and (6) caregivers of youth with CHCs who may contribute to excess weight gain through inconsistent expectations and overindulgence. ⁷

Specific Challenges for Clinicians

Clinicians face multiple challenges related to diagnosing obesity in children with CHCs. BMI is a widely accepted measure of obesity. However, recent data suggest that BMI has limitations in accurately estimating adiposity and metabolic risks. ⁸ The limitations of BMI can be exaggerated when utilized in children with CHCs. BMI is calculated from weight and height, and thus cannot be reliable when accurate height or weight measurements are not available. Children with CHCs face different challenges with anthropometric measurements such as inability to stand up or be disconnected from medical devices (e.g., wheelchair, ventilator, and feeding pump), or when there is disproportionate body habitus present (e.g., scoliosis, achondroplasia, and limb atrophy).

Humerus or tibia length has been proposed as surrogate markers for height ⁹ ; however, these measurements can be inconsistent across different measurers and conversion to height estimation may be inaccurate where there is disproportional growth. BMI may underestimate adiposity and metabolic risk in individuals with low muscle volume, ⁸ posing specific challenges for children with CHCs, in particular those with neuromuscular disorders or sarcopenia from chronic illness. Although waist circumference, dual-energy X-ray absorptiometry (DXA), and bioelectrical impedance analysis (BIA) are more predictive of metabolic risk, these are not readily accessible for repeated measurements and there are currently no defined pediatric reference ranges, hence limited clinical implications.

Interventional approaches for obesity in children with CHCs present additional challenges. For example, typical lifestyle interventions offered by pediatric weight management programs may not be relevant or even practical for children prescribed a restrictive diet or with limited exercise capacity. Likewise, careful consideration must be taken with situations specific to children with CHCs, such as acute decompensation of the condition or when there is no coping mechanism available other than food. Finally, as abovementioned, BMI loses validity as a measure of overweight or obesity when accurate height or weight data are not available. As such, sole dependence on BMI for making treatment decisions hinders the ability for clinicians to provide appropriate and equitable obesity care for children with CHCs.

Comprehensive pediatric weight management programs, which can include interventions ranging from behavioral lifestyle management to antiobesity medications and weight loss surgery, may be underutilized by children with CHCs. Health care providers' perception of obesity has been shown to influence obesity care for these youth,^10,11 and despite several effective and safe medical intervention options for pediatric obesity,^4,12 there remains widespread hesitancy in utilizing these options, particularly for children with CHCs.

Although these children often have regular visits with interdisciplinary clinics to receive comprehensive care from many different subspecialties, obesity care may not be incorporated or prioritized. Furthermore, referrals to weight management programs may be deferred to avoid additional family burden.

A major hindrance in utilization of antiobesity medications for children with CHCs and obesity is the lack of evidence or guidelines. Subsequently, the responsibility of considering the risks of unanticipated adverse events (e.g., worsening the baseline condition) and the benefits of using the medications often lie with providers and families. For example, there are discrepant data on the effect of liraglutide on cardiac or renal function or the association between liraglutide and thyroid or pancreatic cancer. ¹³ Such inconsistent findings raise a fear of prescribing the medications, especially in children with CHCs, even when those risks may be negligible compared with the potential health benefits.

In addition, these medications can be expensive and/or poorly reimbursed by insurance and can exacerbate medical financial burden for families. Similarly, bariatric surgery is rarely offered to children with CHCs due to limited data on safety profile and, therefore, concern for worse outcome.

Ideas for Future Approaches

Comprehensive obesity care, including lifestyle, medical, and surgical interventions, should be considered and equitably offered for children with CHCs and obesity for the following reasons: (1) risks of developing obesity-associated complications (e.g., diabetes, dyslipidemia, nonalcoholic fatty liver disease, depression, and orthopedic disorders) that will significantly worsen the prognosis of their CHCs; (2) social stigmas around CHCs can be exacerbated by coexistence of obesity; (3) impaired quality of life in children with CHCs can be further affected by obesity; and (4) children with CHCs deserve equitable access to evidence-based health care, including obesity care.

It is also worth noting that conventional lifestyle interventions are rarely feasible, and the alternative options are limited for this population. As such, consideration should be given to application of flexible and tailored lifestyle interventions ¹⁴ and proactive utilization of medical or surgical interventions.

Comprehensive and flexible approaches in addressing obesity in children with CHCs are critical to ensure appropriate implementation of obesity interventions in a timely manner and subsequently prevent poor outcomes in these populations (Table 1). Considering the limitations of BMI, further research is warranted to validate surrogate markers for obesity [e.g., body weight, waist circumference, body fat or muscle mass (BIA, DXA), and metabolic parameters] and their clinical applications for children with CHCs. Moreover, data on the safety of each obesity intervention in these populations will be necessary to fill this clinical gap.

For instance, adult studies propose bariatric surgery is safe and effective to promote weight loss for patients with severe obesity and end-stage kidney disease and is associated with lower mortality than nonsurgical care. ¹⁵ Such studies over time will serve as a foundation to develop effective and safe guidelines for obesity management among children with CHCs. It is imperative to improve accessibility of comprehensive obesity care for children with CHCs without increasing the pre-existing significant medical burden.

For example, a comprehensive weight management program can be incorporated into the multidisciplinary care teams or lifestyle interventions can be a part of complex home care programs. ¹² In parallel, both health care policies and insurance providers should adopt these changes and take the needs of CHCs into account.