Vascular Risks and Management of Obesity in Children and Adolescents

Figures & data

Figure 1 Ranking of 34 countries according to the prevalence of overweight youth in 2001–2002 using the international classification system. Adapted from Janssen I, Katzmarzyk PT, Boyce WF, et al. 2005. Comparison of overweight and obesity prevalence in school-aged youth from 34 countries and their relationships with physical activity and dietary patterns. Obes Rev, 6:123–32. Copyright © 2005.

Figure 2 Comparison between the Centers for Disease Control and Prevention (CDC) and International Obesity Task Force (IOTF) body mass index classification systems for overweight and obesity in youth.

Figure 3 Waist circumference growth curves for the 5th, 10th, 25th, 75th, 90th, and 95th percentiles for (a) males and (b) females 11–18 years of age. Data source was the 1981 Canada Fitness Survey. Katzmarzyk PT. 2004. Waist circumference percentiles for Canadian youth 11–18 y of age. Eur J Clin Nutr, 58:1011-15. Copyright © 2004.

Table 1 Hypertension cut-points (corresponding to the 95th blood pressure percentiles) for males and females according to age and height percentiles. Adapted from tables published in National High Blood Pressure Education Program 2004

Age, y	Males							Females
	Systolic/Diastolic blood pressure, mm Hg							Systolic/Diastolic blood pressure, mm Hg
	Percentile of heighta							Percentile of heighta
	5th	10th	25th	50th	75th	90th	95th	5th	10th	25th	50th	75th	90th	95th
2	101/59	102/59	104/60	106/61	108/62	109/63	110/63	102/61	103/63	104/62	105/63	107/64	108/65	109/65
3	104/63	105/63	107/64	109/65	110/66	112/67	113/67	104/65	104/66	105/66	107/67	108/68	109/68	110/69
4	106/66	107/67	109/68	111/69	112/70	114/71	115/71	105/68	106/68	107/69	108/70	110/71	111/71	112/72
5	108/69	109/70	110/71	112/72	114/73	115/74	116/74	107/70	107/71	107/71	110/72	111/73	112/73	113/74
6	109/72	110/72	112/73	114/74	115/75	117/76	117/76	108/72	109/72	110/73	111/74	113/74	114/75	115/76
7	110/74	111/74	113/75	115/76	117/77	118/78	119/78	110/73	111/74	112/74	113/75	115/76	116/76	116/77
8	111/75	112/76	114/77	116/78	118/79	119/79	120/80	112/75	112/75	114/75	115/76	116/77	118/78	118/78
9	113/76	114/77	116/78	118/79	119/80	121/81	121/81	114/76	114/76	115/76	117/77	118/78	119/79	120/79
10	115/77	116/78	117/79	119/80	121/81	122/81	123/82	116/77	116/77	117/77	119/78	120/79	121/80	122/80
11	117/78	118/78	119/79	121/80	123/81	124/82	125/82	118/78	118/78	119/78	121/79	122/80	123/81	124/81
12	119/78	120/79	122/80	123/81	125/82	127/82	127/83	119/79	120/79	121/79	123/80	124/81	125/82	126/82
13	121/79	122/79	124/80	126/81	128/82	129/83	130/83	121/80	122/80	123/80	124/81	126/82	127/83	128/83
14	124/80	125/80	127/81	128/82	130/83	132/84	132/84	123/81	123/81	125/81	126/82	127/83	129/84	129/84
15	126/81	127/81	129/82	131/83	133/84	134/85	135/85	124/82	125/82	126/82	127/83	129/84	130/85	131/85
16	129/82	130/83	132/83	134/84	135/85	137/86	137/87	125/82	126/82	127/83	128/84	130/85	131/85	132/86
17	131/84	132/85	134/86	136/87	138/87	139/88	140/89	125/82	126/83	127/83	129/84	130/85	131/85	132/86

a Note: Height charts corresponding to the 5th, 10th, 25th, 50th, 75th, 90th, and 95th percentiles can be found in Kuczmarski et al 2002 or http://www.cdc.gov/growthcharts/.

Figure 4 Total cholesterol growth curves for the 50th and 75th percentiles for male and female children 8–15 years of age. Labarthe DR, Nichaman MZ, Harrist RB, et al. 1997. Development of cardiovascular risk factors from ages 8 to 18 in Project Heart Beat! Study design and patterns of change in plasma total cholesterol concentration. Circulation, 95:2636-42. Copyright © 1997.

Table 2 Classification of TC, LDL-C, HDL-C, and TG concentrations in children and adolescents 2–19 years of age as defined by the NCEP 2001

	Normal	Borderline–High	High
TC mmol/L	<4.4	4.4–5.15	≥5.18
LDL-C mmol/L	<2.85	2.85–3.34	≥3.37
HDL-C mmol/L	>1.16	0.91–1.16 (borderline–low)	<1.16 (low)
TG mmol/L
2–9 year olds	<0.85	75–99	≥100
10–19 year olds	<1.02	1.02–1.46	≥1.47

Abbreviations: HDL-C, high-density lipoprotein-cholesterol; LDL-C, low-density lipoprotein-cholesterol; NCEP, National Cholesterol Education Program; TC, total cholesterol; TG, triglycerides.

Table 3 Proposed pediatric and adult definitions of the metabolic syndrome. Adapted from de Ferranti SD, Gauvreau K, Ludwig DS, et al. 2004. Prevalence of the metabolic syndrome in American adolescents: findings from the Third National Health and Nutrition Examination Survey. Circulation, 110:2494-7. Copyright © 2004

Metabolic syndrome is present with ≥3 of the following:	Proposed pediatric definition	Percentile of adult definition	Adult definition
Hypertriglyceridemia (mmol/L)	≥1.1	75th in males 85th in females	≥1.65
Low HDL-C (mmol/L)	<1.3 (15–19 yr old males, <1.17)	40th	<1.04 in males <1.3 in females
High fasting glucose (mmol/L)	≥6.1	N/A	≥6.1
Waist circumference (cm)	>75th percentile for age and gender	72nd in males 53rd in female	>102 in males >88 in females
Hypertension (mm Hg)	Systolic or diastolic blood pressure >90th percentile for age and gender	N/A	Systolic ≥130 or diastolic ≥80

Table 4 Recommendations made by the Institute of Medicine Committee on Prevention of Obesity in Children and Youth

1. National priority	Governments at all levels should coordinate efforts with respect to budget, policies, and prevention programs.
2. Industry	Leisure and entertainment industries should provide opportunities that promote physical activity. Food and beverage industries should develop products that consider energy density, nutrient density, and standard portion sizes.
3. Nutrition labelling	Labels should be clear and understandable to parents and children. Labels should facilitate product comparisons and wise decision making.
4. Advertising and marketing	Establish guidelines for advertising and marketing of foods, beverages, and sedentary entertainment.
5. Mutimedia and PR campaign	Develop campaigns focused on building support for policy changes, provide information to parents and youth.
6. Community programs	Private and pubic efforts to eliminate health disparities and to address social, economic, and environmental barriers that contribute to increased prevalence of obesity. Youth-centered organizations to promote healthful eating behaviours and regular physical activity.
7. Built environment	Improve access to recreational facilities, parks, playgrounds, sidewalks, and walking and bike paths.
8. Healthcare	Pediatricians, family physicians, and nurses should engage in prevention efforts. Healthcare organizations and insurance companies should support individual and population-based prevention efforts.
9. Schools	Meal programs should meet nutritional standards.• Increased opportunity for physical activity through physical education classes, intramural sports, and other clubs, programs, and lessons. Increased health curricula addressing nutrition, physical activity, and reduced sedentary behaviors.
10. Home	Provide healthful food and beverage choices; educate children in making healthy choices regarding which foods, frequency, and portion control. Encourage regular physical activity; limit television viewing.

Figure 5 The change in weight throughout a 52-week intervention of orlistat (• symbols) and placebo (○ symbols). Lifestyle modification was prescribed to both groups. Chanoine JP, Hampl S, Jensen C, et al. 2005. Effect of orlistat on weight and body composition in obese adolescents: a randomized controlled trial. JAMA, 293:2873-83. Copyright © 2005.

Table 5 Selection criteria for adolescents to undergo bariatric surgery as a treatment for obesity. Reproduced with permission from Inge TH, Krebs NF, Garcia VF, et al. 2004. Bariatric surgery for severely overweight adolescents: concerns and recommendations. Pediatrics, 114:217-23. Copyright © 2004

Adolescents being considered for bariatric surgery should:

Have failed >6 months of available, organized attempts at weight management, as determined with the assistance of their primary care givers. Have attained or nearly attained physiological maturity. Be morbidly obese (BMI ≥40 kg/mg^2) with serious obesity-related comorbidities or have a BMI ≥50 kg/m^2 with less serious comorbidities. Demonstrate commitment to comprehensive medical and psychologic evaluations both before and after surgery. Agree to avoid pregnancy for at least 1 year postoperatively. Be capable of and willing to adhere to postoperative nutritional guidelines. Provide informed consent to surgical treatment. Demonstrate decisional capacity.

Abbreviations: BMI, body mass index.

Table 6 Key recommendations of review

Age and gender appropriate BMI growth curves (either CDC or IOTF) should be used to assess overweight and obesity status. Ideally, waist circumference should be measured in addition to BMI. In the clinical setting, the physical exam of obese youth should focus on diagnosis and treatment of obesity-related comorbidities such as hypertension, dyslipidemia, and type 2 diabetes. Obesity prevention strategies should involve behavior therapy, including dietary modification and increased physical activity. Preventative efforts should encompass family, school, and the community. Obesity prevention efforts are particularly important for at-risk youth including those with a family history of obesity, youth from disadvantaged homes, and ethic minorities groups. The treatment of obesity should focus on behavior therapy including dietary modification, decreased sedentary behaviors, and increased physical activity. Treatment strategies should be multidisciplinary, supportive, and ongoing. Parents should play an integral role in encouraging lifestyle changes. For obese children and adolescents who are still growing, slowing of weight gain or weight maintenance is a positive treatment outcome. Pharmacological therapy should only be prescribed if behavioral therapy has failed. Even still, pharmacological therapy should be used in conjunction with dietary modification and increased physical activity. Bariatric surgery should only be used as the last treatment option, after behavioral and pharmacological therapies have failed. Bariatric surgery should only be performed in morbidly obesity youth and surgeons should work in conjunction with a team of specialists that include psychologists, nutritionist, and physical activity instructors.

Abbreviations: BMI, body mass index; CDC, Centers for Disease Control and Prevention; IOTF, International Obesity Task Force.

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