REVIEW

CURRENT
OPINION Update on childhood/adolescent obesity and
its sequela
Taisa Kohut, Jennifer Robbins, and Jennifer Panganiban

Purpose of review
We aim to describe current concepts on childhood and adolescent obesity with a strong focus on its
sequela. Childhood obesity is a national epidemic with increasing prevalence over the past three decades
placing children at increased risk for many serious comorbidities, previously felt to be only adult-specific
diseases, making this topic both timely and relevant for general pediatricians as well as for subspecialists.
Recent findings
Childhood obesity develops through an interplay of genetics, environment, and behavior. Treatment
includes lifestyle modification, and now metabolic and bariatric surgery is more commonly considered in
carefully selected adolescents. The off-label use of adjunct medications for weight loss in childhood and
adolescent obesity is still in its infancy, but will likely become the next logical step in those with lifestyle
modification refractory obesity. Obesity can lead to several comorbidities, which can persist into adulthood
potentially shortening the child’s lifespan.
Summary
Efforts should be focused primarily on reducing childhood and adolescent obesity, and when indicated
treating its sequela in effort to reduce future morbidity and mortality in this precious population.
Video abstract
http://links.lww.com/MOP/A36.
Keywords
childhood/adolescent obesity, lifestyle modification, metabolic and bariatric surgery, obesity-related
comorbidities, weight loss medications

INTRODUCTION greater than 2 years of age, BMI percentiles (which

Obesity is a complex disease characterized by excess
body weight compared with height, with adipose
tissue dysfunction contributing to many of the
metabolic consequences [1]. Rates of obesity among
children and adolescents remain high globally, with
recent data suggesting a rise in severe obesity in the
&
United States [2 ,3]. Though the most common cause
of obesity is because of caloric intake exceeding
energy expenditure, secondary causes should be
considered throughout clinical evaluation. Treat-
ment options for obesity largely consist of lifestyle
modification; however, emerging therapies and
weight loss surgery should be considered and may
be indicated specifically for adolescents with signifi-
cant comorbid conditions.
DEFINITIONS OF OBESITY
BMI [weight (kg)]/[height (m)]2, is an indirect mea-
sure of body fat used to define obesity. In children
utilize age and sex information) are noted. CDC
normative data should be used for child weight
classification as follows [4–6]:
(1) Normal weight: BMI between the 5th and
85th percentile
(2) Overweight: BMI between the 85th and 95th
percentile
(a) Class I obesity: BMI at least 95th percentile –
BMI less than 120% of the 95th percentile or
a BMI less than 35 kg/m2, whichever is lower
Division of Gastroenterology, Hepatology, and Nutrition, The Children’s
Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
Correspondence to Jennifer Panganiban, MD, The Children’s Hospital of
Philadelphia, 34th and Civic Center Boulevard, 3rd Floor Wood Building,
Philadelphia, PA 19104, USA. Tel: +1 215 590 2346;
e-mail: panganibaj@E-Mail.chop.edu
Curr Opin Pediatr 2019, 31:645–653
DOI:10.1097/MOP.0000000000000786

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Gastroenterology and nutrition
KEY POINTS
 Childhood obesity is prevalent in the United States with
one-third of children either overweight or obese, and
develops through a multifactorial interplay of genetics,
environment, and behavior.
 Treatment of childhood obesity primarily includes
lifestyle intervention with dietary modification and
increased physical activity, but is difficult to achieve
and maintain in practice.
 Pharmacological therapy for childhood and adolescent
obesity is still in its infancy, but the use of off-label
adjunct medications for weight loss is a logical next
step in those with lifestyle modification
refractory obesity.
 With the increasing rates of severe obesity, more
adolescents are being considered for metabolic and
bariatric surgery.
 Obesity can lead to several cardiometabolic and
noncardiometabolic comorbidities, which can persist
into adulthood causing significant morbidity
and mortality.
(i) Severe obesity includes classes II and
III obesity
(ii) Class II obesity: BMI at least 120% of
the 95th percentile or a BMI at least
35 kg/m2, whichever is lower – BMI less
than 140% of the 95th percentile
(iii) Class III obesity: BMI at least 140% of
the 95th percentile or a BMI at least 40,
whichever is lower
For children and adolescents with BMI above the
99th percentile, special CDC obesity growth curves
should be used for tracking of weight status over
time [6].
EPIDEMIOLOGIC TRENDS
Overweight and obesity are present in over one-third
of the pediatric population aged 2–17 years, with
obesity affecting 17.4% of United States children.
Using the NHANES 2013–2014 data, 10% adoles-
cents had severe obesity [7]. In the 2015–2016
NHANES cycle, there has been a notable increase in
Class I obesity among 2–5-year olds. Prevalence of
obesity also varies by race, affecting African American
and Hispanic youth more than White and Asian
&
Americans [2 ].
Generally, in highly developed countries, low-
income is a risk factor for obesity [3,8,9]. In the
United States, a recent meta-analysis by Weaver
646 www.co-pediatrics.com
Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.
et al. suggests that among white, Hispanic, and other
race/ethnic groups, those from low-income house-
holds had a higher risk of overweight and obesity
compared with those from middle-income or high-
income households. Income level was not associ-
ated with increased overweight and obesity among
&&
Black youth [10 ].
RISK FACTORS
Risk for obesity begins in the prenatal period, with
maternal obesity and excessive gestational weight
gain conferring increased risks for macrosomia,
large for gestational age, and neonatal adiposity
[11,12]. Maternal smoking during pregnancy is also
a well established risk factor [13,14].
Weight trajectories in early life confer increased
risk for adolescent and adult obesity. In the postna-
tal period, early excessive weight gain and specifi-
cally early adiposity rebound have been associated
with increased risk of adolescent obesity, worse
cardiometabolic outcomes, and persistence of obe-
& &&
sity into adulthood [15 ,16 ,17]. Breastfeeding has
been shown to decrease risk with dose–response
protection [18–21].
Modifiable risk factors for early obesity and
persistence into adulthood, broadly include: dietary
intake, eating behavior, activity, sleep duration,
&
television watching, and parenting styles [22 ].
PRIMARY VS. SECONDARY CAUSES OF
OBESITY
Primary causes of obesity account for the majority of
all pediatric cases. This occurs when exogenous,
multifactorial influences result in energy intake
exceeding energy expenditure, leading to excess
weight gain. Primary obesity may be related to die-
tary quality, physical activity, psychosocial status,
and environment, which can all negatively impact
overall energy balance.
Secondary causes of obesity should be suspected
when obesity classification is severe and when the
presentation suggests an underlying cause. Decreased
height velocity is found in many secondary causes of
obesity; the presence of developmental delay may
help to distinguish between various syndromes,
neurologic causes, and endocrinopathies, along with
specific clinical features (Supplementary Figure 1,
http://links.lww.com/MOP/A37) [23 ].
&
Notably, monogenic defects, such as in Melano-
cortin-4 receptor (MC4R) and Proopiomelanocortin
(POMC) are not associated with either short stature
or developmental delay. MC4R defects may account
for 6% of severe pediatric obesity, associated with
accelerated growth and hyperinsulinemia [24].
Volume 31  Number 5  October 2019
 Update on childho od/adolescent obesity and its sequela Kohut et al.
POMC defects can be distinguished by adrenal insuf-
ficiency, hypopigmentation, and often with distinc-
&
tive red hair [23 ].
Medications should also be evaluated as a sec-
ondary cause of obesity, as rapid weight gain is often
found with use of several classes of medications
including steroid hormones, psychotropic agents,
antiepileptics, and antidiabetes therapies [25].
CLINICAL EVALUATION
The clinical evaluation of an obese child includes a
complete history and physical exam directed at
identifying the cause and related comorbidities
(Table 1) [26,27]. The 2017 US Preventive Services
Task Force recommends BMI measurement to screen
for obesity in children at least 6 years. There is no
evidence regarding appropriate screening intervals,
although anthropometrics is routinely measured
during health maintenance visits [28]. General rec-
ommendations about laboratory screening tests and
when to screen in children with obesity are summa-
rized in Table 1 [26,29].
LIFESTYLE INTERVENTIONS
A stepwise approach to weight management in chil-
dren is recommended by the Expert Committee on
the Assessment, Prevention, and Treatment of Child
and Adolescent Overweight and Obesity (Table 2)
[26,30,31]. There is lack of agreement on the best
Table 1. Clinical evaluation of an obese child including key components of a complete history and physical exam and general
recommendations for laboratory screening
History
Dietary history
Physical activity assessment
Review of medications
Developmental history
Sleep history
Review of systems
Family history of obesity and related comorbidities
Psychosocial screening
Laboratory screening
Overweight (BMI 85th to 95th percentile)
All:
Fasting lipid profile
If 10 years AND 1 risk factor(s)a:
Fasting blood glucose or hemoglobin A1c
Aminotransferases (AST, ALT)
Repeat fasting lipid profile every 2 years:
10 years with risk factorsa
a
Risk factors: elevated blood pressure, elevated lipid levels, current tobacco use, or family history of obesity-related diseases.
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diet for weight loss in children. Modified carbohy-
drate intake diets are as effective as portion-con-
trolled diets for weight management in obese
children, but, have low adherence [32,33]. The Med-
iterranean-style diet (MSD) has been shown in
adults to decrease cardiovascular events, increase
life expectancy, and decrease metabolic syndrome
(MetSyn) [34,35]. Promising results have been seen
in obese children with MetSyn using the MSD with
improved anthropometric and metabolic para-
meters [36]. Although a low-fructose diet has been
shown to improve low-density lipoprotein choles-
terol (LDL-C) and nonalcoholic fatty liver disease
(NAFLD), it has not been shown to significantly
impact BMI in children [37]. Semistructured diet
regimens may be best used for weight loss in chil-
dren, focusing on family selection of higher nutrient
quality and lower energy density foods [38,39].
Decreased physical activity is a major contributing
factor to the prevalence of overweight and obesity in
childhood and adolescence. The American Academy
of Pediatrics (AAP) recommends that all children
and adolescents participate in at least 60 min of
moderate-to-vigorous physical activity per day,
and limiting screen time to 2 h or less per day for
children at least 2 years, and no screen time in those
less than 2 years [40].
Weight loss and maintenance of weight loss are
rarely achieved with lifestyle modification alone in
children with severe obesity; limitations are grounded
&&
in the biology of obesity favoring surplus [41 ,42,43].
Physical exam
Measurement of height and weight for BMI calculation
Blood pressure measurement with appropriate sized cuff
Assessment for dysmorphic features suggestive of a primary cause
Obese (BMI 95th percentile)
All:
Fasting lipid profile
If 10 years regardless of risk factors:
Fasting blood glucose or hemoglobin A1c
Aminotransferases (AST, ALT)
Repeat fasting lipid profile every 2 years:
10 years regardless of risk factors
www.co-pediatrics.com 647
Gastroenterology and nutrition
Table 2. Stepwise approach for the prevention and treatment of child/adolescent obesity with strong focus on behavioral
therapy (especially family-based), dietary modification, and physical activity
Stage 1 Prevention Plus: lifestyle intervention provided by a primary care provider
Stage 2 Structured Weight Management: monthly visits with a primary care physician and support from a registered dietician
Stage 3 Comprehensive Multidisciplinarya Intervention: intensive weight loss program composed of weekly visits for a minimum of 8–12 weeks
at a pediatric weight management center
Stage 4 Tertiary Care Intervention: use of medical diets, medications, and surgery in addition to Stage 3 interventions
Reproduced from Barlow [30].
a
Multidisciplinary team approach includes a medical provider, registered dietician, exercise specialist, mental health professional, nurse, and social worker.
However, lifestyle interventions can effectively treat
their comorbidities [44,45]. Accessibility to commu-
nity resources, improved legislation and regulations
on nutrition, physical activity, and obesity are instru-
mental to successful lifestyle intervention.
PHARMACOLOGICAL THERAPY
Pharmacotherapy, in conjunction with lifestyle
modification, may be the next logical step in the
treatment of pediatric obesity refractory to lifestyle
&& &&
modification alone [41 ,46,47 ]. Table 3 provides a
summary of Food and Drug Administration (FDA)-
approved adult obesity medications and off-label
drug use of medications in the pediatric obesity
&&
population [47 ,48].
METABOLIC AND BARIATRIC SURGERY
Metabolic and bariatric surgery (MBS) in adolescents
is at least as effective and well tolerated as in adults,
and FDA-approved procedures for adolescents more
than 13 years include Roux-en-Y gastric bypass
(RYGB) and vertical sleeve gastrectomy (VSG) [49–
53]. The adjustable gastric band (AGB) is not FDA
approved in patients less than 18 years and has been
&&
found to have a high failure rate [54 ,55]. The Amer-
ican Society for Metabolic and Bariatric Surgery
(ASMBS) outlined several indications and contrain-
dications in their 2018 pediatric MBS guidelines for
&&
adolescent MBS [54 ] (Table 4).
RYGB involves the creation of a small proximal
gastric pouch that is divided and separated from the
distal stomach and anastomosed to a Roux limb of
the small bowel resulting in restriction of caloric
intake and malabsorption of food along with vita-
mins and minerals. Possible complications include
‘dumping syndrome’ after consumption of foods
high in fat and sugar and micronutrient deficiencies
&&
because of malabsorption [26,54 ]. Studies have
shown a 90% success rate of losing and maintaining
&&
at least 10% of total weight [54 ].
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VSG involves the resection of a large portion of
the stomach along the greater curvature, reducing
this to about 15% of its original size, resulting in a
sleeve or tubular structure. The Teen-LABS study
showed comparable decreases in BMI in severely
obese adolescents undergoing either RYGB (from
54 kg/m2 at baseline to 39 kg/m2) or VSG (from
50 kg/m2 at baseline to 37 kg/m2) [56 ]. VSG has
&
become the most recommended operation in ado-
lescents given similar weight loss and a significantly
&&
lower complication rate [26,54 ].
SEQUELAE
The comorbidities of childhood obesity can affect
almost every body system. The severity of these
comorbidities, particularly cardiometabolic, directly
correlate with obesity severity [26,57]. Key cardio-
metabolic risks of childhood obesity are described
followed by important noncardiometabolic comor-
bidities.
Nonalcoholic fatty liver disease
Nonalcoholic fatty liver disease (NAFLD) is the most
common cause of chronic liver disease in children
[58]. Current estimates of NAFLD prevalence in
obese children range from 1.7 to 85%. Yu et al.
&&
[59 ] determined the prevalence of NAFLD in a
cohort of 408 obese children aged 9–17 years using
MRI measuring hepatic fat fraction to be nearly one-
third of boys and one-fourth in girls. NAFLD is
defined as macrovesicular fat accumulation in more
than 5% of hepatocytes on liver biopsy in absence of
other causes. Approximately 25% of children have a
progressive subtype called nonalcoholic steatohepa-
titis (NASH), and 7–10% may develop cirrhosis and
end-stage liver disease [60,61]. Children are usually
asymptomatic with mildly elevated liver enzymes,
although labs may also be normal. The use of two
times the sex-specific alanine aminotransferase
(boys: ALT 50 mg/dl, girls: ALT 44 mg/dl) in over-
weight and obese children at least 10 years has a
Volume 31  Number 5  October 2019
 Table 3. Summary of Food and Drug Administration-approved adult obesity medications and off-label drug use of medications in the pediatric obesity population
Drug name MOA FDA indication Off-label drug use Side effects Contraindications Adolescent weight-loss
and warnings outcomes data

FDA-approved
Orlistat Pancreatic and gastric lipase Obesity 12 years old Not indicated Flatulence, oily stools, diarrhea, Chronic malabsorption syndrome, Placebo-subtracted weight loss of
inhibitor vitamin/mineral deficiency cholestasis 2.61 kg at 1 year
Phentermine Sympathomimetic amine Obesity >16 years old ‘short <16 years old or long-term; Increases HR, BP, dry mouth, Cardiovascular disease, BMI reduction of 4.1% at 6
term’; combination beneficial in obesity with low insomnia, constipation, anxiety, hyperthyroidism, active drug months
phentermine/topiramate ER energy states, sleep apnea, irritability use, glaucoma, agitated states
approved for long-term hunger, decreased satiety
treatment of obesity in adults
Non-FDA-approved
for obesity
Metformin Activation of protein kinase 10 years old for T2DM PCOS, insulin resistance, Bloating, diarrhea, flatulence Hold 48 h prior to contrast, lactic BMI z-score reduction of 0.10 and
pathway prediabetes, MetSyn, acidosis BMI 0.86
antipsychotic-medication-
induced weight gain, stress
eating/emotional eating
Topiramate Modulation of various NTs Treatment of epilepsy >2 years Weight loss in adult and pediatric Cognitive dysfunction, kidney Inborn errors of metabolism with BMI reduction of 4.9% on
old and migraines >12 years patients; useful adjunct in binge stones, metabolic acidosis, hyperammonia and topiramate 75 mg daily for at
old; combination phentermine/ eating disorders and weight teratogenic – adolescents most encephalopathy, acute myopia least 3 months
topiramate ER approved for regain post bariatric surgery be counseled against and secondary angle-closure
long-term treatment of obesity in pregnancy because of glaucoma, rapid withdrawal
adults decreased efficacy of OCPs can precipitate seizures,
neuropsychiatric dysfunction,
metabolic acidosis
Exenatide GLP-1 agonist T2DM in adults <18 years old for polygenic Bloating, nausea and vomiting, Postmarketing reports: pancreatitis, BMI reduction of 3.42% at 3
obesity (presence of diabetes, abdominal pain, elevation renal impairment, severe months
hypothalamic, syndromic) pancreatic amylase and lipase gastrointestinal disease

Liraglutide GLP-1 agonist Saxenda (3 mg dose) approved <18 years old Abdominal pain, nausea, and Postmarketing reports: pancreatitis, Trials ongoing
for obesity in adults, Victoza vomiting, diarrhea, potential renal impairment, severe
approved for T2DM in adults hypoglycemia gastrointestinal disease
Lisdexamfetamine Central nervous system stimulant 6 years old for ADHD, short-term Beneficial for younger children Anorexia, decreased appetite, Serious cardiovascular reactions, In 6–12 years old group, mean
use of binge eating disorder in with ADHD and obesity or decreased weight, diarrhea, such as sudden death, BP and weight loss was 2.5 lb with

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adults binge eating disorder dizziness, dry mouth,
irritability, anxiety, insomnia,
nausea and vomiting, epigastric
abdominal pain
HR increases, psychiatric
adverse reactions, suppression
of growth, peripheral
vasculopathy (Raynaud’s),
serotonin syndrome with
serotonergic agents
70 mg dose over 4 weeks, in
13–17 years old group mean
weight-loss from baseline was
4.8 lb with 70 mg dose over 4
weeks

No pediatric data
Lorcaserin 5-Hydroxy-triptamine-receptor (R)
2C agonist
Naltrexone/buproprion SR Blockade of opioid-R-mediated Long-term treatment of obesity in
POMC auto-inhibition/selective
inhibition of reuptake of
dopamine and nor-adrenaline
Pending new FDA approval
Long-term treatment of obesity in <18 years old with obesity
adults
Children and adolescents:
adults warning for increased suicidal
ideation
Headache, dizziness, fatigue, dry Serotonin syndrome or neuroleptic Safety and outcomes data not
mouth, constipation, headache, malignant-like syndrome when available <18 years old
back pain, cough in diabetes co-administered with other
patients serotonergic or
antidopaminergic agents,
discontinue with signs of
valvular heart disease
Nausea, constipation, headache, Uncontrolled HTN, seizures, Safety and Outcomes data not
dizziness, insomnia, dry mouth, anorexia nervosa, bulimia, available <18 years old
diarrhea active alcohol or chronic opioid
use, angle-closure glaucoma,
increase suicidal thought and
ideation

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Setmelanotide Melano-cortin-4 R agonist Phase 3 trials for monogenic
obesity, FDA approval pending
for monogenic obesity in adults
and children
None; will be approved for
pediatric patients as well
Dry mild induration at injection
site, darkening of sin nevi
Caution use in structural heart
disease and arrhythmias
because of potential to increase
HR and BP
Sustainable reduction in hunger
and substantial weight loss of
20.5 kg after 12 weeks in one
patient and 51 kg in another
after 42 weeks

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BP, blood pressure; FDA, Food and Drug Administration; GLP, glucagon-like 1 receptor; HR, heart rate; MOA, mechanism of action; NTs, neurotransmitters; POMC, proopiomelanocortin; T2DM, type 2 diabetes
&&
mellitus. Reproduced from Srivastava et al [47 ].
Update on childho od/adolescent obesity and its sequela Kohut et al.

649
Gastroenterology and nutrition

Table 4. Indications and contraindications for adolescent metabolic bariatric surgery

Indications for adolescent MBS
BMI 35 kg/m2 or 120% of the 95th% with clinically significant comorbidities, such as OSA (AHI>5), T2DM, insulin resistance, HLD,
HTN, IIH, NASH, orthopedic disease, GERD, or depressed HRQoL
OR
BMI 40 kg/m2 or 140% of the 95th% (whichever is lower)
A multidisciplinary team must consider whether the patient and the family have the ability and motivation to adhere to recommended
treatment preoperatively and postoperatively

Contraindications for adolescent MBS:

A medically correctable cause of obesity
An ongoing substance abuse problem (within the preceding year)
A medical, psychiatric, psychosocial, or cognitive condition that prevents adherence to postoperative dietary and medication regimens
Current or planned pregnancy within 12–18 months of the procedure

AHI, apnea–hypopnea index; GERD, gastroesophageal reflux disease; HLD, hyperlipidemia; HRQoL, health-related quality of life; HTN, hypertension; IIH,
idiopathic intracranial hypertension; MBS, metabolic and bariatric surgery; NASH, nonalcoholic steatohepatitis; OSA, obstructive sleep apnea; T2DM, type 2
diabetes mellitus.

sensitivity of 88% and a specificity of 26% for diag- and treatment of obesity in childhood could reduce
nosing NAFLD [62]. Other forms of liver disease the adult incidence of cardiovascular disease (CVD)
must be ruled out in the presence of liver enzyme and mortality.
elevation.

Hypertension
Childhood obesity is strongly associated with
Hypertension (HTN). Studies report HTN prevalence
rates more than 10% in obese school children com-
pared with 0.8–3.2% in normal weight students
[63,64]. Parker et al. found a strong positive associa-
tion between increase in BMI and increase in blood
pressure (BP) percentile and risk of developing HTN.
Obesity confers a two-fold risk of developing HTN
compared with normal weight children and a four-
fold risk in the severely obese [65]. Carsley et al.
&&
[66 ] conducted a longitudinal study through the
Applied Research Group for Kids! (TARGet Kids!)
finding children with a BMI z-score greater than 3
had a significantly higher odds of having abnormal
BP. The 2017 AAP Clinical Practice Guidelines rec-
ommends BP to be checked in all obese children and
adolescents if at least 3 years at every healthcare
&
encounter [67 ].
Dyslipidemia
Fifty percent of all overweight and obese children
have at least one abnormal lipid value identified on
screening (CDC 2010). The dyslipidemia most com-
monly seen in this population is combined dyslipi-
demia of obesity (CDO), with elevated triglycerides,
low high-density lipoprotein cholesterol (HDL-C),
elevated non-HDL-C, and normal or mildly elevated
LDL-C. The TARGet Kids! study demonstrated an
association between a BMI z-score greater than 3 and
&& &
abnormal lipid levels [66 ]. Karaağaç et al. [69 ]
showed that total cholesterol, LDL-C, and triglycer-
ides were significantly higher and HDL-C was sig-
nificantly lower in obese children before diet and
exercise, and improved after 6-month weight loss
program. The Princeton Follow-up Study found that
those with elevated triglycerides and TG/HDL-C at
12 years were more likely to experience CVD in
adulthood [70]. Weight loss, restriction of simple
carbohydrates and increased physical activity have
been shown to improve CDO in children [71–74].

Cardiovascular disease
Obesity is associated with altered hemodynamics.
Studies show that obese children have subclinical
left ventricular diastolic dysfunction in all obesity
classes and disturbed systolic functions in early
&
stages of obesity [68]. Karaağaç et al. [69 ] showed
that weight loss resulted in improved systolic and
early diastolic ventricular functions in a prospective
cohort of 34 obese children. Successful prevention
Insulin resistance/type 2 diabetes mellitus
Insulin resistance results from the accumulation of
free fatty acids in the liver, adipocytes, skeletal
muscles, and pancreas in the setting of obesity.
Insulin resistance in the liver leads to its decreased
effect on suppression of glucose production. Resul-
tant hyperinsulinism causes increased transcription
of genes for lipogenic enzymes in the liver and

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 Update on childho od/adolescent obesity and its sequela Kohut et al.
&
increased triglyceride production [75,76 ]. Hagman
et al. [77] showed that the degree of obesity in
childhood and adolescence is strongly associated
with adipose tissue insulin resistance independent
of glucose tolerance. Type 2 diabetes mellitus
(T2DM) is a significant comorbidity of obesity in
adolescents characterized by the development of
hyperglycemia, insulin resistance, and impairment
of insulin secretion and diagnosed by specific crite-
ria (Supplementary Table 1, http://links.lww.com/
MOP/A37) [78]. Increased dietary fiber, reduction
in simple sugars and refined carbohydrates, and
increased exercise are all key components to
improved insulin and glucose regulation [79].
Metabolic syndrome
MetSyn is defined by a constellation of cardiovascu-
lar and metabolic risk factors increasing the risk of
premature CVD, T2DM, and all-cause mortality
&
[80 ,81]. The pathogenesis of MetSyn is not
completely understood but data suggests that inter-
actions between obesity, insulin resistance, and
inflammation play a key role [82]. No consensus
guidelines exist for diagnosing pediatric MetSyn. In
2007, the International Diabetes Foundation (IDF)
published a pediatric age-based definition of MetSyn
(Supplementary Table 2, http://links.lww.com/
MOP/A37) [83]. Treatment of pediatric MetSyn
focuses on weight reduction via lifestyle modifica-
tion and management of disease-specific compo-
&
nents [80 ]. Fructose has been identified as a key
player in MetSyn playing a role in insulin resistance.
In obese children with MetSyn, restriction of dietary
sugars improved SBP, triglycerides, LDL-C, insulin
sensitivity, and glucose tolerance [84].
Noncardiometabolic comorbidities
Obese adolescent girls are at higher risk of develop-
ing polycystic ovarian syndrome [85]. Childhood
obesity is associated with a much higher prevalence
of obstructive sleep apnea (OSA), and prevalence
and severity of OSA increases with increasing BMI,
and is associated with higher BP, CVD risk, and
&&
insulin resistance [86,87 ]. Obese children may
have musculoskeletal problems including impaired
mobility, increased fractures, and lower extremity
joint pain [88]. Obesity is a risk factor for slipped
capital femoral epiphysis and for osteochondritis
&
dissecans [89,90 ]. Low 25-hydroxy-vitamin D is
positively associated with obesity, and although
commonly associated with bone health, is also
associated with increasing severity of metabolic dys-
&&
regulation [91 ]. Psychosocial issues are common
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consequences of childhood obesity including anxi-
ety, depression, and decreased health-related qual-
&
ity of life (QOL) [92,93]. Whitaker et al. [94 ]
performed a study in a specialized obesity clinic
finding the degree of obesity negatively affected
QOL and sleep, and obese adolescents reported
more depression.
CONCLUSION
Childhood and adolescent obesity has become a
major public health issue. Both the cardiometabolic
and noncardiometabolic consequences of obesity
are significant placing our youth at risk of morbidity
and mortality not only during childhood but into
adulthood as well. There is a dire need for better
strategies, improved access, and more funding
toward prevention and treatment at all levels of
this chronic disease and the health repercussions
it causes.
Acknowledgements
None.
Financial support and sponsorship
None.
Conflicts of interest
There are no conflicts of interest.
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2. Skinner AC, Ravanbakht SN, Skelton JA, et al. Prevalence of obesity and
severe obesity in US children. Pediatrics 2018; 141:e20173459.
&
This article reviews most recent trends in childhood obesity using NHANES data
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