Advancing Understanding and Care for Adolescent Obesity

Obesity affects about one in five U.S. children and adolescents, and obesity rates continue to increase for those age 12 and older. Educational efforts spearheaded by obesity-medicine experts, along with new pharmacologic treatments, have begun to raise awareness of the need for a comprehensive approach to management of the disease. As this patient population grows, however, it becomes more important than ever that primary care providers and pediatricians have access to best practices in assessing and treating adolescents with obesity.

Stigma, even among healthcare providers, has long been a barrier to better outcomes, but knowledge and attitudes are changing, says Lina Alkhaled, MD, a Cleveland Clinic endocrinologist who manages pediatric and adult obesity.

“Many of us in obesity medicine have been trying to raise awareness through grand rounds and other types of sessions, and we have seen the audiences for these grow bigger,” says Dr. Alkhaled. “I can see there are changes even in terms of the referrals. So there is a shift.”

Endocrinologists and obesity medicine experts play a key role in caring with adolescents with obesity. As a practical matter, however, the need for care extends beyond what specialists can meet.

“The prevalence of obesity in pediatrics is so high, obesity specialists will not be able to serve everyone in need,” she says. “It’s important that these patients’ conditions do not go unmanaged for long periods of time. Many initial steps can be well managed by a pediatrician. Then we as specialists are also happy to help.”

Recognizing obesity as a disease

Dr. Alkhaled emphasizes that obesity is a disease, not a lifestyle choice. This distinction is crucial, as it helps reduce the stigma associated with obesity and encourages a more empathetic approach to treatment.

“Obesity is a very complex disease,” says Dr. Alkhaled. “There are myriad factors that contribute to why people gain weight, and some of those factors start before a child is born. We can control a few, but we can't control all of them. It’s also important to understand that this disease is chronic. We need to make sure that we bring no stigma.”

Growth charts and screening

Multiple factors can indicate when a young patient has chronic obesity. One sign is that weight gain tends to start at an early age, Dr. Alkhaled says.

“But a lot of patients have some fluctuations of their weight, so whether they may be developing obesity depends on the degree of weight gain that they're experiencing,” she says. “If they gain a few pounds, and are still within a normal BMI range, that's OK. We can focus on lifestyle factors to help them continue to stay in that normal range.”

If a child has a BMI in the overweight category, more attention may be needed to keep weight gain from progressing.

Extended growth charts are useful for accurately assessing obesity in children. These charts include higher percentiles, which can help determine the severity of obesity. It’s also important to screen for comorbidities that accompany weight gain to manage adolescent obesity effectively, she adds.

Addressing genetic factors

Some patients with obesity may have genetic conditions that contribute to abnormal weight gain. Identifying these patients early on is crucial for providing appropriate treatment.

"For a small subset of patients, genetic mutation or a syndrome is causing extreme weight gain,” Dr. Alkhaled says. “These patients are different than our common exogenous obesity. These patients usually start to develop significant weight gain at a very young age, before age 5 most of the time. And usually it's severe obesity.”

Screening questions might include:

• When did the weight gain start?
• Were any hyperphagia behaviors present?
• Does the patient have any other conditions associated with it, such as developmental delays?
• Do they have any syndromic features on exam?

If any of these elements are present, the patient should be evaluated for the presence of a gene mutation that might be causing the weight gain. “Treatment in those cases will be different from treatment for patients with other causes of weight gain,” she says. “And those patients need to be identified early.”

Comprehensive management

At Cleveland Clinic’s Be Well Kids Clinic, patients ages 2 to 18 are seen by a provider who is specialized in pediatric obesity to address medical needs. A registered dietitian offers guidance on healthier eating habits and food choices, and a physical therapist helps patients find enjoyable physical activity. A pediatric psychologist or social worker works with patients on associated mental health issues, self-esteem, motivation, body image and issues such as bullying.

Decisions about whether to incorporate medications or bariatric surgery are made within that wider context. "Pharmacotherapy is not going to solve everything,” says Dr. Alkhaled. “It's one of the tools, not the whole solution.”

When medication is being considered, Dr. Alkhaled discusses risks and benefits with the patient and family. “I like to educate the patient that this is a lifelong treatment so they're not under a false assumption that this is going to be a quick good fix for a short period of time,” she says.

That said, anti-obesity medications can be an effective tool because they target the neuro-hormonal dysregulations that cause weight gain and prevent sustained weight loss. In addition, they aim to treat or prevent both obesity and its complications.

Selection of medications requires consideration of comorbidities, side effects, contraindications and the age of the patient. Before prescribing, however, it's important to look at the patient's current medication list. Many medications that people take on a daily basis can promote weight gain. In some cases, adjustments can be made in collaboration with other specialists.

Unfortunately, cost and insurance coverage also may play a large role in decision-making about medications. “We try to to be mindful of finding something that the insurance covers and fits our patients’ needs,” says Dr. Alkhaled.

Weight-loss surgery considerations

The American Academy of Pediatrics criteria for bariatric or metabolic surgery for children and adolescents age 13 and above are:

• Class 3 obesity: a BMI of 40 kg/m2 or 140% of the 95th percentile for age and sex, whichever is lower
• Class 2 obesity: BMI of 35 kg/m2 or 120% of the 95th percentile for age and sex, whichever is lower, with certain comorbid conditions

Healthcare providers working with patients and families should consider comorbidities associated with obesity, including:

• The psychosocial burden of obesity
• Orthopedic diseases
• Gastroesophageal reflux disease
• Cardiac risk factors
• Intracranial pressure risk
• Type 2 diabetes

Vertical sleeve gastrectomy (VSG) has become the most commonly recommended weight loss surgery for children and adolescents. It performs well in both weight loss and improvement of comorbidities compared to Roux-en-Y gastric bypass, allows for better iron absorption, and leads to fewer reoperations.

Stepwise management

The key to treating childhood and adolescent obesity is using stepwise management.

“Having a healthier lifestyle is the first step,” says Dr. Alkhaled, “but again, there’s no need to shy away from referring patients to weight-management specialists, especially if they have severe obesity or if they start to develop comorbidities.”