The more we know about paediatric obesity, the better we understand how important timely and persistent treatment is. “The problem doesn’t usually go away with growth in height. More than half of obese children, and the majority of obese adolescents, will be obese also in adulthood,” Professor of Paediatrics Jarmo Jääskeläinen says.
According to Jääskeläinen, the newly revised Finnish Current Care Guideline for Obesity highlights obesity as a chronic illness that requires long-term treatment. The treatment of obesity in children, adolescents and adults has now been combined into a single guideline. Jääskeläinen was a member of the working group that was tasked with updating the guideline on the basis of most recent scientific evidence.
Obesity is a chronic illness that requires long-term treatment.
Jarmo Jääskeläinen
Professor
Obesity is known to increase the risk of type 2 diabetes and cardiovascular diseases, but it was previously thought that these adverse health effects weren’t visible in childhood.
“Unfortunately, we now know that only a minority of obese children are metabolically healthy. This was unrecognised earlier, because adults’ reference values were used to assess children’s health. When obese children are compared to normal-weight children, they have higher blood pressure, higher fasting glucose and liver enzyme levels, and worse blood lipids. This is also something we have seen in our own studies conducted among children here in Eastern Finland.”
“More attention is now paid to the risk of fatty liver also in children. The reference value of the ALT enzyme, which is indicative of liver function, has been drastically lowered in children, because signs of fatty liver can be seen in obese children way before their ALT enzyme levels become alarming,” Jääskeläinen says.
Previously, the risk threshold value of ALT in children was 40 U/l, but the new risk threshold values are 22 for girls, and 25 for boys.
No need to bring up obesity with children
In accordance with the new Current Care Guideline, the treatment of obesity in children is family-centred and aims at permanent changes in dietary habits and exercise, one step at a time.
“When we are dealing with very young children or children still in primary school, most of the support and motivation is targeted at parents. There is no need to bring up the subject of weight with the child. Moreover, parents aren’t just bluntly informed that their child is obese; instead, the situation is illustrated with the help of growth reference curves.”
Jääskeläinen emphasises that shaming, making people feel guilty or scaring them with risks isn’t part of the treatment of obesity in any age.
“Everything starts from the promotion of well-being.”
“Earlier this year, Canada, too, published new guidelines for the treatment of obesity in adults, and the focus is more on the prevention of long-term adverse health effects than on weight. It is likely that this approach will gain more footing also in Finland, and will have an impact on how obesity is addressed in health care. For instance, there is no reason to bring up a patient's obesity if their visit is not linked to obesity, or if no treatment is available.”
In other words, if a patient is seeking care for a sore throat or an ear infection, it is not appropriate to suggest losing weight or to give tips on how to eat or exercise. Lifestyle changes cannot be dictated from above, they require internal motivation and time.
“Studies show that successful treatment of obesity takes more than 25 hours of counselling. In other words, repetition and persistence play key roles.”
Timely treatment works best
Often when a child is obese, the entire family is in need of a change of lifestyle.
“In the case of severely obese children, at least one of the parents is usually also severely obese. Genes contribute to weight, but they rarely make anyone obese. Rather, they tend to influence our appetite, enjoyment of food, and activeness of lifestyle.”
The treatment of obesity is best begun early: the younger a person is when treatment begins, the better and more permanent the results. Jääskeläinen’s research group has compared the outcomes of obesity treatment in specialised health care in children who were both under and over 10 years of age.
“In children under 10 years of age, their age-adjusted BMI reduced and this reduction persisted in our three-year follow-up. Treatment begun later helped to slow down weight gain, but in the long term, the children's weight nevertheless increased.”
According to Jääskeläinen, treatment in younger children tends to be more successful because their obesity-promoting lifestyle habits aren’t rooted too deep yet, and parents still have good control over their child’s life.
“Later, children and adolescents make more independent choices about what they eat and how they exercise, and parents play a smaller role.”
In the treatment of obesity, it is not usually realistic to strive for normal weight, and weight loss isn’t often even necessary in children who are still growing.
“If we can achieve a moderate reduction in the age-adjusted BMI, we’ll also see positive changes in glucose and lipid metabolism. This requires that the child’s weight in kilograms increases only slightly as they grow.”
In adolescents, the treatment of obesity calls for particular sensitivity.
“Adolescence in general is a sensitive time, and adolescents tend to compare themselves to others and to ideals from the media. Many have also been hurt by ‘well-intended’ comments from friends or relatives. When discussing the well-being and possible treatment of an adolescent, their viewpoints must be taken into serious consideration.”
Almost one in three obese adolescents is suffering from a diagnosable psychological disorder, such as depression or attention-deficit hyperactivity disorder, which can make it difficult to control one's eating.
“Finding the right time to start a lifestyle-changing treatment is something we have to think about. If an adolescent is having difficulties or there is a crisis in the family, psychological support must come first.”
According to Jääskeläinen, the treatment of obesity in children and adolescents should at least include an opportunity to see a psychologist or a psychiatrist. The patient is treated by a multi-professional team that also includes a physical therapist and a nutritionist, or at least a nurse who has been trained in weight management.
“The role of the physician in this team is to support the initiation of the treatment, exclude the possibility of rare obesity-causing illnesses, and chart any possible comorbidities and treatments they require.”
New treatments could become available
In adults, the treatment of obesity can also involve bariatric surgery or drug therapy.
“One drug, orlistat, has been approved for the treatment of obesity in children and adolescents. It prevents dietary fat from being digested, but it is not used very frequently, because it can cause stomach ache and diarrhoea when eating foods that are high in fats. With low-fat foods, on the other hand, the benefits are marginal,” Jääskeläinen says.
However, Jääskeläinen says that liraglutide, a drug intended for the treatment of diabetes, may in the future be also used to treat obesity in children. In adults, it has already been approved for the treatment of obesity.
“Bariatric surgery may also be an alternative for adolescents who are very severely obese and have comorbidities, and who have almost finished growing in height. The new Current Care Guideline takes a slightly more positive stance towards bariatric surgery.”
In Finland, more than one in four boys, and nearly one in five girls in the age group of 6–12 are at least overweight. Their weight gain should be stopped; however, actual treatment is not available until the threshold to obesity has been crossed.
“Obesity is a social phenomenon that cannot be prevented by measures taken in the health care sector alone. We need new models that cover our entire society, ranging from grocery stores to school transportation, and to smart devices,” Jääskeläinen says.
Obesity in children, adolescents and adults. Current Care Summary (2020). Working group appointed by the Finnish Medical Society Duodecim, the Finnish Association for the Study of Obesity, the Finnish Paediatric Society.
