**6. Management of child obesity**

Liver ultrasound is recommended for all obese children and adolescents. In children with confirmed ALT >40 IU/L or palpable liver, more thorough diagnostic tests are advisable with

Other laboratory tests such as thyroid function tests (if there is a faster increase in weight than height), pelvic ultrasound and hormonal doses in cases of suspected polycystic ovary

Psychological and psychiatric evaluations are essential to identify psychological disturbances including depression, loss-of-control eating, unhealthy and extreme weight control behaviors, and decreased health-related quality of life which are warning signs of bulimia nervosa

In patients with hypertension more diagnostic tests should be done: cardiac exam: ECG and echocardiogram, standard urinalysis, microalbuminuria, creatinine and potassium levels

We should realize screening for diagnosis of metabolic syndrome in the presence of at least three of the following situations: BMI indicate obesity or waist circumference/height ratio >0.5, systolic and/or diastolic blood pressure >95th percentile, fasting blood glucose >100 mg/dL,

According to International Diabetes Federation (IDF), the consensus definition of metabolic






serum level of triglycerides >95th percentile, serum level of HDL cholesterol [4, 41].

syndrome in children (older than 6 years) and adolescents are as follows:


cardiovascular disease, hypertension or obesity.

gamma-GT and differential diagnosis of hepatitis [41].

syndrome have been recommended [4, 41].

106 Adiposity - Epidemiology and Treatment Modalities

and binge-eating disorder [39].



type 2 diabetes mellitus




[4, 41].

obesity.

Prevention is the best cost/benefit approach for the management of obesity in children and, in the future, of adulthood. Childhood obesity is a multifaceted problem embedded in physiological, behavioral, genetic, socioeconomic, environmental and political contexts, and the actions to prevent childhood obesity must therefore be taken in multiple settings. Public awareness campaigns, social marketing and behavior-change communication related to nutrition and physical activity implemented in countries together are very important strategies regarding childhood obesity prevention. The critical periods of pediatric obesity characterized by important changes in adiposity growth velocity or obesity related behavior are represented by the first year of life, the preschool ("adiposity rebound") and adolescence years. The transition period from childhood to adolescence is characterized by important behavioral changes and decreased physical activity [44]. The obesity primary prevention begins in pregnancy period (healthy food diet), continuing with promoting the breastfeeding in the first 2 years of life, and then with support for healthy eating habits (low sugar consumption, eat breakfast every day, eat at home with family, avoid fast—food meals, avoid television in the first years of life and limit television to less than 2 h per day after then, etc. [4, 41, 45, 46].

Management of obesity should be based on risk factors, including age, severity of overweight and obesity and comorbidities, as well as family history and support. Management intervention strategies are available and include nutrition, physical activity, behavior and lifestyle changes, medication and surgical considerations. Treatment largely focuses on sustained lifestyle changes with family involvement. There are several broad principles of conventional management: management of comorbidities, family involvement, taking a developmentally appropriate approach, the use of a range of behavior change techniques, long-term dietary change, increased physical activity and decreased sedentary behaviors. The primary goal for all children with uncomplicated obesity is the long-term improvement of physical health through healthy lifestyles. In obese children with a secondary complication, specific treatment of the complication is an important goal. Effective weight reduction is one of the key elements in the treatment of comorbidities. In morbid obesity, bariatric surgery and laparoscopic sleeve gastrectomy have been used in adolescence [4, 34, 41].

In order to plan a developmentally appropriate approach, it is essential to consider the developmental age of the patient and the resultant level of parental engagement that will be required. Most successful interventions have been family based and take into account the child's developmental age. In preadolescent children, a parent-based program, without direct engagement of the child, might be more appropriate than a child centered approach.

Depending on the age of the child, the present of parents must be or not compulsory. For example, if we talk about adolescents, the present of parents in not recommended. However, the parents must participate at counseling session that are designed for them.

Because obesity is multifactorial, not all children and adolescents will respond to the same approach. Behavior therapy, healthy diet and increasing physical activity are the great sections of obesity treatment. Referral to multidisciplinary, comprehensive pediatric weight management programs is ideal for obese children whenever possible [4, 34].

Behavior modification strategy has a large effect on weight reduction. The set of techniques employed to change thought processes and actions associated with eating, physical activity and sedentary are components of behavior strategies. For the obese adolescent, there are several ways to help him acquiring a healthy lifestyle: to log daily his physical effort and food intake; to participate to motivational interview; to receive permanent psychological support for positive lifestyle changes [34, 41, 46].

Dietary interventions are usually part of a broader lifestyle change program can be effective in achieving relative weight loss in children and adolescents. Dietary interventions should follow national nutrition guidelines which have an emphasis on:








appropriate approach, the use of a range of behavior change techniques, long-term dietary change, increased physical activity and decreased sedentary behaviors. The primary goal for all children with uncomplicated obesity is the long-term improvement of physical health through healthy lifestyles. In obese children with a secondary complication, specific treatment of the complication is an important goal. Effective weight reduction is one of the key elements in the treatment of comorbidities. In morbid obesity, bariatric surgery and laparoscopic

In order to plan a developmentally appropriate approach, it is essential to consider the developmental age of the patient and the resultant level of parental engagement that will be required. Most successful interventions have been family based and take into account the child's developmental age. In preadolescent children, a parent-based program, without direct

Depending on the age of the child, the present of parents must be or not compulsory. For example, if we talk about adolescents, the present of parents in not recommended. However,

Because obesity is multifactorial, not all children and adolescents will respond to the same approach. Behavior therapy, healthy diet and increasing physical activity are the great sections of obesity treatment. Referral to multidisciplinary, comprehensive pediatric weight—

Behavior modification strategy has a large effect on weight reduction. The set of techniques employed to change thought processes and actions associated with eating, physical activity and sedentary are components of behavior strategies. For the obese adolescent, there are several ways to help him acquiring a healthy lifestyle: to log daily his physical effort and food intake; to participate to motivational interview; to receive permanent psychological support

Dietary interventions are usually part of a broader lifestyle change program can be effective in achieving relative weight loss in children and adolescents. Dietary interventions should



engagement of the child, might be more appropriate than a child centered approach.

the parents must participate at counseling session that are designed for them.

management programs is ideal for obese children whenever possible [4, 34].

follow national nutrition guidelines which have an emphasis on:




for positive lifestyle changes [34, 41, 46].

week.

fruit juices, sweet drinks).

sleeve gastrectomy have been used in adolescence [4, 34, 41].

108 Adiposity - Epidemiology and Treatment Modalities



Increasing physical activity can decrease risk for cardiovascular disease, improve well-being and contribute to weight loss:






Parental involvement is vital and may include monitoring and limiting television use, role modeling of healthy behaviors and providing access to recreation areas or recreational equipment.

Existing recommendations on management of pediatric obesity suggest that drug therapy can be used in the treatment of severely obese adolescents. Orlistat can be useful as an adjunct to lifestyle changes in severely obese adolescents and metformin can be used in older children and adolescents with clinical insulin resistance [4, 34, 41].

Bariatric surgery should be considered in adolescents with complete or near-complete skeletal maturity, who are severely obese with a body mass index of more than 40 kg/m<sup>2</sup> or weight exceeding 100% of ideal body, and a medical complication resulting from obesity, after they have failed 6 months of a multidisciplinary weight management program. Preoperative care and counselling is very important if we want to have good long-term results for bariatric surgery patients. This care must be provided by specialist in various medical fields: endocrinology, gastroenterology, cardiovascular, pneumology, etc. All this effort must by sustained with nutritional and psychological support [4, 34, 41,47, 48].

Childhood obesity treatment is based on sustained lifestyle changes with family involvement. Behavior therapy, healthy diet and increasing physical activity are the great sections of obesity treatment.
