management of obesity in pediatrics

1. Management of pediatric
obesity
YASSIN ALSALEH

2. (eat and drink but waste not)

3. Definitions
Percentile range (BMI) for age and
sex (2 years and above )
class
• > 85th
– 95th Overweight
≥30 • BMI ≥95th percentile Obesity I
≥35 • BMI ≥120 percent of the 95th
percentile (≈98th percentile. )
Severe
obesity
II
≥40 • BMI ≥140 percent of the 95th
percentile
Severe
obesity
III

5. Epidemiology (obesity )
over
988
million
in 2020
. World Obesity Atlas 2023

9. SAUDI ARABIA
• Pediatric :
• (11.2%- 13.4%) overweight.
• (9.4% - 18.2% ) obese.
Al Hussaini A, et al. Overweight and obesity among Saudi children and adolescents: Where do we stand today? Saudi J Gastroenterol 2019;25:229-35.
‑
Aljassim and Jradi Journal of Health, Population and Nutrition (2021) 40:15

10. Al-Hazzaa HMPrevalence of overweight and obesity among saudi children: A comparison of two widely used international
standards and the national growth references. Front Endocrinol (Lausanne). 2022 Aug

11. the Eastern Province
• among high school children
obesity and overweight :
25.7% .
• 35% of the study’s students
have either elevated blood
pressure or hypertension.
Albaker W,. What is the current status of childhood obesity in Saudi Arabia? Evidence from 20,000 cases in the Eastern
Province: a cross-sectional study. Medicine 2022

12. • prevalence :
• overweight :10.8%
• Obese : 18.8%
• Risk factors:
• early childhood obesity.
• parental obesity
• mother's employment
• number of snacks and fast food consumption
• physical inactivity, and time spent in watching
television.
Saleh AAA. Prevalence of obesity in school children and its relation to lifestyle behaviors in Al-Ahsa district
of Saudi Arabia. Glob J Health Sci. 2017;9(12):1–80.8. BY SAJJAD

13. AlEnazi S, et al. Prevalence of obesity among children and adolescents in Saudi Arabia: A multicenter population based study.
‑
Saudi J Med Med Sci 2023.

14. Childhood
obesity
adolescent
obesity
Adulthood
obesity

16. psychological
neurological
endocrine
renal
CVS
Pulmonary
Musculoskeletal
GIT

17. Obese, chubby, fat unhealthy weight
Diet Healthy eating

20. Case scenario
• children ≥2 years with BMI ≥85th percentile or obese .
• mostly exogenous (primary), familial.
• Monogenic causes excluded .
• Non syndromic .
• No endocrine disorders .
• No psychiatric disorders.
• No drug .

21. •health behavior and
lifestyle counseling

22. health behavior and lifestyle counseling
•Recreational screen time:
• <2 years – Little or no screen time
• ≥2 years – Maximum 1 hour daily

24. • physical activity
• Preschool-aged : ≥2 hours of unstructured activity daily
• School-aged and older : ≥1 hour moderate or vigorous structured
physical activity daily

25. SLEEP
• There is abundant evidence to support the relationship between sleep
deprivation, sleep problems, and childhood obesity.
• up to an 80% increase likelihood of obesity
Copyright 2023.sleepeducation.org
Tung JYL, Obesity in children and adolescents: Overview of the diagnosis and
management. Chronic Dis Transl Med. 2023
Veronica R. Johnson. Strategies in the Management of Adolescent Obesity. Curr
Pediatr Rep. 2020 June ; 8(2): 56–65
.

27. DIET

28. Diet
•red foods to be eaten sparingly.
•Yellow foods to be taken in
moderation
•Green foods to be eaten often

30. Diet
• Intake of balanced diet, foods rich in fibre content.
• limited intake of high-calorie foods and sugar sweetened
beverages.
• Having regular meals and increasing intake of water
• Avoid serving fried foods at meals.
• Eliminate high-calorie snack foods from the house
• encouraging the consumption of whole fruits rather than
fruit juices
• 1 or fewer take-out or fast food meals weekly.
Mittal M, Jain V. Management of Obesity and Its Complications in Children and Adolescents. Indian

31. • Juice drinks, flavored
sweetened milk and yogurts,
chocolate-coated cereals etc.
that are commonly marketed as
‘healthy foods’ are laden with
sugar.
• Skipping breakfast is associated
with obesity in children.*
*
Monzani A, A Systematic Review of the Association of Skipping
Breakfast with Weight and Cardiometabolic Risk Factors in Children
and Adolescents. What Should We Better Investigate in the Future?
Nutrients. 2019 Feb
Diet

32. Controlling the portion size should be made a habit.

33. Diet
• Low calorie high protein diets
‑ ‑
• Hyperlipidic low calorie diets
‑
• vegetarian and vegan diets
Maffeis et al. Italian Journal of Pediatrics (2023)
no sufficient evidence to
recommend in pediatric

34. Diet
•there is no emphasis on
one particular diet or
eating pattern to
promote weight loss
Johnson VR, Food as Medicine for Obesity Treatment and Management. Clin Ther. 2022 May;44(5):671-681
..

35. •Focus more on
what the child
should eat, rather
than only listing
foods to be avoided

36. • Involvement of entire family in
adopting healthy lifestyle is the
initial strategy to manage
overweight or obesity in children
• role modelling.
• reinforcement, restriction and
monitoring
• Avoiding pressure and criticism
Herouvi, D.; Paltoglou, G.; Soldatou, A.; Kalpia, C.; Karanasios, S.; Karavanaki, K. Lifestyle and Pharmacological Interventions and Treatment
Indications for the Management of Obesity in Children and Adolescents. Children 2023

37. • Intermittent fasting is another
nutrition intervention for
treatment of obesity

39. Economic and cultural considerations
• Income
• Misperception

40. and cultural considerations

41. • combination of improving diet and physical activity for a higher
chance of success.
1
+
1
=
3

42. Goals of weight loss
• 6–11 y:
• 0.5–2 kg per month
• ≥ 12 y :
• 1 kg per week
• targeting 10% weight reduction

43. • no improvement in BMI trend despite
a basic counseling intervention
OR
• For children with severe obesity (BMI
≥120 percent of the 95th percentile)

44. • maximum intensity of health behavior
and lifestyle modification

45. Veronica R. Johnson. Strategies in the Management of Adolescent Obesity. Curr Pediatr Rep. 2020 June ;
8(2): 56–65.
lifestyle interventions provided by primary
care provider
Prevention Plus Stage 1
monthly visits with a primary care provider
and support from registered dietitian
Structured Weight
Management
Stage 2
intensive weight loss program composed
of weekly visits for a minimum of 8–12
weeks at a pediatric weight management
center
Comprehensive
Multidisciplinary
Intervention
Stage 3
use of medical diets, medications, and
surgery in addition to Stage 3 interventions
Tertiary Care
Intervention
Stage 4

46. Pharmacotherapy
Weight loss surgery

47. Pharmacotherapy

48. •No evidence supports
weight loss medication
as therapy alone.
•it is recommended as an
adjunct when intensive
behavior interventions
alone have failed.

49. Indications of pharmacotherapy
• have not properly responded to lifestyle modification
12
years or older
-BMI ≥ 95th
percentile (30)
with weight-related comorbidities
BMI ≥ 120% of the 95th
(35)

50. •GLP-1
•Glucagon
like peptide

51. Copyright © 2023 Paleo Leap
↑Insulin
↓glucagon
delayed gastric
emptying
acting on
hypothalamus,
amygdala, and
the cortex

52. Daily GLP Liraglutide

53. Liraglutide
• a GLP-1 analog.
• weight loss : (modest) BMI -1.58 kg/m2
• change in weight -4.50 kg
• daily subcutaneous injections
• approved for weight loss in adolescents 12 years and
older with obesity and weight ≥ 60 kg
saxenda
December 2020

54. • Common side effects :
• nausea, abdominal pain
• Hypoglycemia
• pain at the injection site.
• Other side effects :
• angioedema, pancreatitis.
Side effects

55. • contraindicated in patients with:
1- personal or family history of medullary thyroid carcinoma (MTC)
2- multiple endocrine neoplasia syndrome type 2. (MEN2)
Contraindicated in pregnancy
Contraindication
Vandana Raman, Pharmacologic Weight Management in the Era of Adolescent Obesity, The Journal of Clinical Endocrinology & Metabolism, Volume 107,
Issue 10, October 2022

57. Weekly GLP
Semaglutide

58. • (GLP-1) analog
• FDA approves December 23, 2022.
• once-weekly subcutaneous injection
• change in BMI -6 kg/m2
• approved for weight loss in adolescents 12 years
and older with obesity
Semaglutide Wegovy
December 2022

59. • The mean change in BMI from baseline to week 68 was -16.1% with
semaglutide
• At week 68, a total of 95 of 131 participants (73%) in the semaglutide
group had weight loss of 5% or more.
Weghuber. Once-Weekly Semaglutide in Adolescents with Obesity. N Engl J Med. 2022 Dec 15;387(24):2245-2257. doi: 10.1056/NEJMoa2208601. Epub
2022 Nov 2.

61. • Side effect :
• Gastrointestinal disorders :nausea, vomiting, and diarrhea) ( 62%)
• Contraindication:
• Similar to liraglutide

63. • An oral form of semaglutide (Rybelsus) is available
• approved for type 2 diabetes in adults.

66. Metformin
• is a biguanide
• MOA: drug that reduces blood glucose levels
1- decreasing blood glucose production in the liver
2- decreasing intestinal absorption
3- Increasing insulin sensitivity
• is a first-line treatment in 10 years and older with
type 2 diabetes.
• patients modest reductions in BMI: -1.3 -2.70 kg/m2
• this is an off-label use in obesity .
Hampl SE. Clinical Practice Guideline for the Evaluation and Treatment of Children and Adolescents With Obesity. Pediatrics. 2023 Feb

67. • Metformin is generally well tolerated
• D-lactic acidosis .(very rare)
• the recommended starting dose is 500 mg, once or twice daily,
maximum total daily dose of 2500 mg.
Hampl SE. Clinical Practice Guideline for the Evaluation and Treatment of Children and Adolescents With
Obesity. Pediatrics. 2023 Feb

69. Orlistat

70. • it has low efficacy (BMI reduction of <1 kg/m2)
• MOA: inhibiting pancreatic lipases.
• gastrointestinal side effects . limit its acceptability for many
patients.
• Deficiency of fat-soluble vitamin
Orlistat → Orlistat → Oily stool

71. • its clinical use is fairly limited due to its modest efficacy
• about a 2.61 kg reduction after 1 year of treatment)
• BMI had decreased by 0.55 kg/m2 with orlistat
Chung YL, Rhie Y. Severe Obesity in Children and Adolescents: Metabolic Effects, Assessment, and Treatment. JOMES 2021

72. Phentermine
• amphetamine analog is a norepinephrine
reuptake inhibitor
• MOA: reduces appetite and may increase energy
expenditure.
• it is approved for short-term use (12 weeks)
• in adolescents older than 16 years of age.
• modest effect on BMI.
• side effects : increased heart rate and blood pressure

75. Qsymia(Phentermine-topiramate)

76. Qsymia
• The combination of phentermine and topiramate
• topiramate : suppress appetite through an increase
in gamma aminobutyric acid (GABA) activity.
• Treatment resulted in a modest BMI reduction
• for the higher dose (15 mg/92 mg: BMI -5.3 kg/m2.
• Phentermine-topiramate is approved in for treatment
of obesity in individuals 12 years and older
27
June 2022

77. • Weight loss: 8% for mid-dose and 10% for high- dose in 1 year
• Recommended starting dosage is:
• 3.75 mg/23 mg (phentermine mg/topiramate mg) daily for 14 days;
• then increase to 7.5 mg/46 mg daily
Kim A, Nguyen J, Babaei M, Kim A, Geller DH, Vidmar AP. A Narrative Review: Phentermine and Topiramate for the Treatment of Pediatric Obesity.
Adolesc Health Med Ther. 2023 Aug 23

78. • Side effect :
• paresthesia, dizziness, dysgeusia, insomnia, constipation, and dry mouth.
• Depression
• suicidal ideation
• Ophthalmologic Adverse Reactions
• CONTRAINDICATIONS:
• Pregnancy
• Glaucoma
• Hyperthyroidism
• History of CVD

79. melanocortin-4 receptor
(MC4R) agonist

80. • analog of endogenous melanocortin peptide alpha-melanocyte
stimulating hormone acting on MC4 receptors.
• MC4 receptors in the brain are involved in regulation of hunger,
satiety, and energy expenditure.
• MOA: reverse hyperphagia and promote weight loss through
decreased caloric intake and increased energy expenditure
Setmelanotide

81. Indications Bardet-Biedl syndrome (BSS)
proopiomelanocortin (POMC)
proprotein convertase
subtilisin/kexin type 1 (PCSK1)
leptin receptor (LEPR) deficiency
.
• chronic weight
management
• in pediatrics 6 years of
age and older
November 25, 2020

82. Bardet-Biedl syndrome (BSS)
©
2008-2023
ResearchGate GmbH. All rights reserved
Obese + polydactyl + blind

83. proopiomelanocortin (POMC)
Copyright © 2023 Elsevier B.V
.
Obese
+
red hair

84. proprotein convertase subtilisin/kexin type 1
(PCSK1)
Early malabsorptive diarrhea
+
Obese
+
endocrinopathy

85. Setmelanotide
• Dose :SUBQ:
• Children ≥6 years to <12 years:
• Initial: 1 mg once daily for 2 weeks, Maximum daily dose: 3 mg/day.
Children ≥12 years and Adolescents:
• Initial: 2 mg once daily for 2 weeks.
• Adjust every 2 weeks.

86. • Weight loss target :
• 1 to 2 kg/week
• Medication should be continued if ≥ 5% BMI reduction from baseline
at 12 weeks
• Discontinue therapy if ≥5% of baseline body weight or 5% of baseline
BMI has not been lost after 12 to 16 weeks of therapy
Setmelanotide

87. Side effects
• injection site reaction (96%),
• skin hyperpigmentation (78%),
• nausea (56%)
• disturbances in sexual arousal
• New or worsened depression or suicidal ideation .
Pressley H, Cornelio CK, Adams EN. Setmelanotide: A Novel Targeted Treatment for Monogenic Obesity. Journal of Pharmacy Technology. 2022
;
Trapp CM, Censani M. Setmelanotide: a promising advancement for pediatric patients with rare forms of genetic obesity. Curr Opin Endocrinol Diabetes
Obes. 2023 Apr 1;

88. Withdrawn medication
• 1- a methionine aminopeptidase 2 (MetAP2) inhibitor (Belorani),
• 2- Rimonabant (endocannabinoid receptor CB1 antagonist)
Kühnen P, Biebermann H, Wiegand S. Pharmacotherapy in Childhood Obesity. Horm Res Paediatr. 2022;95(2):177-192
.

89. Vandana Raman, Pharmacologic Weight Management in the Era of Adolescent Obesity, The Journal of Clinical Endocrinology & Metabolism, Volume 107, Issue 10, October 2022

91. Bariatric surgery

92. • Bariatric surgery is
the ultimate
solution
• surgery is undertaken
only after sustained
efforts to manage
obesity through
lifestyle and counseling
interventions

94. Indication
• comorbidity of obesity :
• type 2 diabetes mellitus, idiopathic intracranial hypertension, obstructive
sleep apnea nonalcoholic steatohepatitis, Blount disease, slipped capital
femoral epiphysis, gastroesophageal reflux disease, arterial hypertension,
insulin resistance, or reduced health-related quality of life
Class II obesity (BMI ≥120 percent of
the 95th percentile
or
BMI ≥35 kg/m2, whichever is
lower), with an obesity-related
comorbidity
Class III obesity (BMI ≥140 percent of
the 95th percentile
or
BMI ≥40 kg/m2, whichever is lower),
with or without an obesity-related
comorbidity

95. • anatomically reducing the caloric intake
of the individual.
• decrease levels of ghrelin
• increase anorexigenic glucagon like
peptide-1 (GLP-1)
• Decreasing appetite and improving
insulin sensitivity
Bariatric surgery
Peripheral
and central

97. Sleeve gastrectomy
• The SG (also known as vertical sleeve gastrectomy)
• removes 80% of the stomach creating a sleeve volume of 60–100 mill-
liters.
• accounts for more than 80 % of bariatric procedures in adolescents.
• less complex than RYGB
• lower theoretical risk of micronutrient deficiencies.

98. • 91 morbidly obese adolescents in Qatar who underwent LSG (2011–2014),
• with 1- and 5-year follow-ups.
• a mean total weight loss of 35.8%
• No patients developed postoperative leaks,
• 64% of obstructive sleep apnea patients were cured,
• all prediabetic patients had total remission
• 50% of the diabetic patients were cured.
• At 5 years, 75% of the diabetic adolescents had complete remission.
• The only patient with hypertension showed complete resolution
• three patients had endoscopic dilatation due to stenosis.
El-Matbouly, M.A., Khidir, N., Touny, H.A. et al. A 5-Year Follow-Up Study of Laparoscopic Sleeve Gastrectomy Among Morbidly Obese
Adolescents: Does It Improve Body Image and Prevent and Treat Diabetes?. OBES SURG 28, 513–519 (2018).
Sleeve gastrectomy

101. Roux-en-Y gastric bypass
• creates a small (less than 30 mL) proximal gastric pouch that is divided
and separated from the distal stomach and anastomosed to a Roux-
limb of small bowel
• The surgery was the most commonly performed bariatric procedure.
• The rate of abdominal reoperations was significantly higher among
adolescents than among adults
Inge TH, et al.Five-Year Outcomes of Gastric Bypass in Adolescents as Compared with Adults. N Engl J Med. 2019;380(22):2136–2145.

103. Laparoscopic gastric banding
• BMI loss: -11.40 kg/m2,
• Weight loss : -31.60 kg
• A total of 28% of the adolescents undergoing gastric banding required
a 'revisional procedure.*
• 50% of patients requiring additional surgery
• LAGB is not an ideal option for treatment of adolescent obesity
• only approved for patients aged 18 or older
*TorbahnG,. Surgery for the treatment of obesity in children and adolescents.
Cochrane Database of Systematic Reviews 2022, Issue 9.

104. Paulus GF, de Vaan LE, Verdam FJ, Bouvy ND, Ambergen TA, van Heurn LW. Bariatric surgery in morbidly obese
adolescents: a systematic review and meta-analysis. Obes Surg. 2015 May
RYGB
16.6
kg/m2
SG
14.1
kg/m2
AGB
11.6
kg/m2
Mean BMI loss

105. RYGB SG
↓
adverse
events
↓
complexity
BMI loss
↑
Adverse
events
↑
BMI loss

109. •Prevention is
better than
cure

111. Fecal microbiome transfer (FMT)
• No evidence
• no effect on weight loss
• was observed
Leong KSW, Jayasinghe TN, Wilson BC, et al. Effects of fecal microbiome transfer in adolescents with obesity: the gut bugs
randomized controlled trial. JAMA Network Open. 2020;3(12):
Tung JYL, Poon GWK, Du J, Wong KKY. Obesity in children and adolescents: Overview of the diagnosis and management.
Chronic Dis Transl Med. 2023

113. Herbal and other
•
‫أو‬ ‫المدرة‬ ‫الزهرة‬ ‫أو‬ ‫مخزنية‬ ‫مدرة‬
‫أو‬ ‫مخزنية‬ ‫مكنانة‬ ‫أو‬ ‫الماعز‬ ‫سذاب‬
‫كاليكة‬
Galega officinalis
) )
•
‫أو‬ ‫الرعد‬ ‫إله‬ ‫كرمة‬ ‫جذر‬
Tripterygium
Wilfordii
•
‫ذو‬ ‫جنكو‬ ‫أو‬ ‫ة‬َ‫ك‬ْ‫ن‬ِ‫ج‬‫ال‬ ‫بيلوبا‬ ‫جنجو‬ ‫أو‬ ‫جنكو‬
‫شجرة‬ ‫أو‬ ‫الفصين‬ ‫ذو‬ ‫جنكو‬ ‫أو‬ ‫الشقين‬
‫الثنائي‬ ‫الجنكو‬ ‫أو‬ ‫ة‬َ‫ل‬َ‫ب‬ْ‫ع‬َ‫م‬‫ال‬ ‫أو‬ ‫المعبد‬
(( ‫الشفتين‬ ‫أو‬ ‫الفلقة‬
Ginkgo biloba
•
‫يتم‬ ‫طبيعي‬ ‫زيت‬ ‫هو‬ ‫كاالنوس‬ ‫زيت‬
‫العوالق‬ ‫من‬ ‫خاص‬ ‫نوع‬ ‫من‬ ‫عليه‬ ‫الحصول‬
( ،‫الحيوانية‬
Calanus finmarchicus
)
Gasmi, A.; Pharmacological Treatments and Natural
Biocompounds in Weight Management. Pharmaceuticals
2023, 16, 212.

115. BMI LOSS kg/m2 in adolescent
0.55 orlistat
1.3-2.7 metformin
1.8 liraglutide
6 semiglutide
3.7-5.3 Qysemia
11.6 Gastric banding
14.1 Sleeve
16.6 RYGB

116. ‫ها‬ُ‫ب‬ُ‫ق‬‫أر‬ ِ‫باآلمال‬ ‫النفس‬ ُ‫ل‬ِّ‫أعل‬
َ‫ق‬‫أضي‬ ‫ما‬
ِ‫ل‬َ‫م‬‫األ‬ ُ‫ة‬‫فسح‬ ‫لوال‬ َ‫ش‬‫العي‬