IMPORTANT NOTE: JAAPA CME activities consist of 2 articles. To obtain credit, you must also read Childhood obesity: Understanding the causes, beginning the discussion; the post-test will include questions related to both articles. AAPA Fellow members should complete and submit the post-test on the AAPA Web site by going to www.aapa.org and searching for keyword JAAPA post-tests. All others may complete and submit the post-test online at no charge at www.mycme.com. To obtain 1 hour of AAPA Category I CME credit, PAs must receive a score of 70% or better on each test taken.

KEY POINTS

■ Unmanaged obesity in children has the potential to cause significant physiologic and psychosocial complications that can lead to negative health consequences in adulthood.

■ No exact guidelines exist for when to start treatment. Because obesity can have such negative consequences, a wait-and-see approach is strongly discouraged.

■ Maintaining current body weight while the child continues to grow should be the goal for the large majority of obese children. Only in children with severe obesity should weight loss be encouraged.

■ Only adolescents who have not lost weight through lifestyle modifications should be considered for medication use and even then only when the adolescent has other comorbidities and is continuing to adhere to the previously discussed diet and exercise interventions.

An estimated 16.9% of children 2 to 19 years old in the United States are obese.1 In addition, the number of overweight and obese children has increased in almost all industrialized countries worldwide and in several lower-income countries.2 The epidemic of obesity is linked to a rise in other serious diseases and disorders in children, including insulin resistance, hypertension, cardiovascular disease, hyperlipidemia, and poor self-esteem.3 Given the increasing prevalence of childhood obesity and its related disorders, as well as the growing emphasis on exercise and proper nutrition in the medical literature and the media, clinicians must take an active role in recognizing, preventing, and managing childhood obesity.




COMORBIDITIES OF CHILDHOOD OBESITY


Approximately 80% of 10- to 15-year-olds who are overweight become obese adults by the age of 25 years.4 Obesity in children has the potential to cause significant physiologic and psychosocial complications that, if not managed in childhood, will lead to negative health consequences in adulthood.3 Physical complications can involve the cardiovascular, endocrine, GI, musculoskeletal, nervous, and respiratory systems. This article discusses the consequences and comorbidities of childhood obesity, treatment strategies, and when referral should be made.


Cardiovascular consequences As a result of the increase in childhood obesity leading to adult obesity, the prevalence of coronary heart disease (CHD) is estimated to increase 5% to 16% by 2035, with more than 100,000 cases of CHD attributed to the predicted increase in obesity.5 Obesity predisposes humans to changes in both cardiac structure and hemodynamics.6 Combined with excessive adiposity, obesity causes increased blood volume and cardiac output and can lead to cardiomyopathy. Two of the most common cardiac comorbidities of childhood obesity are dyslipidemia and hypertension.


According to results of the National Health and Nutrition Examination Survey (NHANES) for 1999 to 2006, the prevalence of dyslipidemia in children 12 to 19 years old was 20.3%.7 Typically, in obese children, serum low-density lipoprotein cholesterol (LDL-C) and triglycerides are increased and high-density lipoprotein cholesterol (HDL-C) levels are decreased.8 The proposed mechanism of dyslipidemia in obese children is an increase in free fatty acids produced by visceral adipocytes and hyperinsulinemia that promotes LDL-C and triglyceride synthesis by the liver.8 Fasting lipid profiles should be obtained every 2 years starting at age 10 years in patients whose body mass index (BMI) is in the 85th percentile or higher, regardless of risk factors.6 More information on specific levels and treatment can be found in Table: Comorbidities of childhood obesity and their findings, diagnostic workup, and treatment in the online version of this article. The mainstay of treatment for dyslipidemia is diet and exercise; however, appropriate referral should be made if conservative measures are not effective.9


Although hypertension is relatively rare in children, obese children have a threefold higher risk of hypertension than nonobese children.10 Contributing factors for hypertension in an obese child include hyperactivity of the sympathetic nervous system, insulin resistance, and abnormalities in vascular structure and function.10 Diagnosis of hypertension in children is based on BP tables that are adjusted for age, gender, and height.10 Hypertension is considered when a child has three systolic or diastolic BP readings above the 95th percentile.10 Treatment of hypertension in children should be aimed at behavioral approaches, such as diet and exercise, followed by medication in more refractory cases.10


While metabolic syndrome is common in obese adults and criteria for diagnosis in adults exist (Table 1), there are currently no criteria to diagnose metabolic syndrome in children.11,12 However, using modified adult criteria, the overall prevalence of metabolic syndrome is 38.7% in moderately obese children and 49.7% in severely obese children.11 Treatment consists of addressing dyslipidemia, hypertension, and type 2 diabetes mellitus (T2DM).6


Endocrine complications Because sex hormone-producing enzymes are expressed in adipose tissue, excess central adiposity can lead to high androgen activity or hyperandrogenemia.6 Up to 50% of free testosterone is derived from fat in young women.6 Hyperandrogenemia and abdominal obesity lead to hyperinsulinemia and insulin resistance, which stimulates androgen and estrogen production by the adrenal glands and the ovaries.6 In addition, lower concentrations of sex hormone-binding globulin (SHBG) in obese females lead to further increases in the levels of free testosterone.6 This increase in testosterone can result in menstrual abnormalities, such as amenorrhea, metrorrhagia, and polycystic ovary syndrome, in obese adolescent girls.6 Obese girls who experience hormone imbalance should be referred to a specialist in order to preserve fertility.9


Over the past two decades, the number of children with a diagnosis of type 2 diabetes mellitus, a disease that previously affected only adults, has increased 10-fold.13 Children who develop T2DM are at risk for microvascular and macrovascular changes, including retinopathy, nephropathy, neuropathy, and atherosclerosis, at younger ages than those who develop the disease later in life.6,13 Puberty is associated with increased secretion of growth hormone, which promotes a transient state of insulin resistance. Therefore, puberty increases a child's risk of progressing from insulin resistance to frank diabetes.13 


Children should be screened for T2DM if their calculated BMI is in the 85th percentile or higher for age and gender and they have additional risk factors for T2DM, such as family history or signs of insulin resistance.13 The diagnostic process for type 2 diabetes mellitus in children is the same as that for adults: fasting or random blood glucose 
measurements or oral glucose tolerance testing along with a glycosylated hemoglobin (A1C) determination.13 Treatment depends on the severity of the disease and starts with lifestyle modifications and/or metformin when the fasting blood glucose is between 126 and 200 mg/dL.13 Insulin therapy should begin in those children with a fasting glucose level greater than 200 mg/dL.13 Insulin should also be added when control cannot be achieved after 3 to 6 months of metformin therapy.13 As in adults, target glucose levels for children are between 70 and 100 mg/dL, A1C ranges should be below 6.5% or 7%, and renal function tests and a dilated retinal examination are required yearly.13 Ultimately, to reach their therapeutic goal, children with T2DM are best treated by a multispecialty team. 


GI effects Obesity, metabolic syndrome, and hyperinsulinemia are all risk factors for the development of cholelithiasis. Therefore, gallbladder disease should be part of the differential diagnosis for an obese adolescent with persistent right upper quadrant pain.6 


With an incidence of one in every three obese children, nonalcoholic fatty liver disease (NAFLD), or hepatic steatosis, is becoming more common.3,8 Although most cases are benign, the disease may result in increasing fibrosis and can rarely lead to cirrhosis.6 In NAFLD, the hepatic aminotransferase levels are often elevated as much as four- to fivefold, and the alkaline phosphatase level is generally elevated threefold.6 Liver function testing should be ordered every 2 years starting at age 10 years for children with a BMI in the 95th percentile or higher and in those with a BMI in the 85th to 94th percentile who have risk factors.9 Weight reduction leads to improvement in liver function and histologic features.9 Appropriate referral should be made when ALT or AST results are two times normal values on two different occasions.9 


Musculoskeletal complications Overweight and obese children are at greater risk of orthopedic complications than are normal weight children.14,15 Moreover, overweight children show a greater prevalence for fractures (hips), musculoskeletal discomfort, impaired mobility, and lower-extremity malalignment.14 Obesity that continues into adulthood can lead to osteoarthritis and articular cartilage breakdown.14 Childhood obesity can also predispose to several specific orthopedic problems, including slipped capital femoral epiphysis (SCFE) and Blount disease. SCFE results when the force of the capital femoral growth plate increases and the femoral head suddenly separates with an epiphyseal cartilage crack or when chronic force gradually causes a slip. The greater force is often caused by increased body mass.15 A slipped capital femoral epiphysis may cause hip or knee pain and decreased range of motion in the affected hip.9 Blount disease is caused by unequal or early weight bearing that stresses the medial tibial condyle, causing physis growth inhibition. The growth inhibition on the medial side produces a varus deformity of the tibia characterized by bowed legs and tibial torsion.3,8 Because overweight and obese children are more likely to have orthopedic complications, including discomfort with mobility, they also may be less likely to engage in physical activity, thus perpetuating the accumulation of excess weight.14 


Psychological impact In 2000, Strauss found that obese Hispanic and white females showed decreased levels of global self-esteem compared with their nonobese counterparts.16 The researchers also found that decreases in self-esteem in obese children led to increased rates of sadness, loneliness, and nervousness. Further, children with these problems were more likely to smoke and drink alcohol.16 Obese children are also more likely to be socially isolated and have higher rates of eating disorders, such as binge 
eating, as well as anxiety and depression.3 


At an early age, children associate obesity with negative characteristics, such as laziness and lower intelligence levels.6 This perception can lead to discrimination toward obese children, which can have negative effects later in life.17 Females who were overweight during adolescence complete fewer years of school, are less likely to be married, and have lower household incomes than those who were not overweight during adolescence.17 Also, males who were overweight during adolescence are less likely to be married.17 


Respiratory complications Over the past two decades, there has been an increase in prevalence of both asthma and obesity.2,18 From 1980 to 1994, the prevalence of asthma increased 75%.18 While the increasing rates were evident among all races, ages, and sexes, there was a substantial increase among children aged 0 to 4 years (160%) and children aged 5 to 14 years (74%).18 No cause-and-effect relationship between asthma and obesity has been clearly established, but the simultaneous increase in both conditions has led researchers to examine whether there is a link. Possible mechanisms for the development of asthma include diet, gastroesophageal reflux, mechanical effects of obesity, atopy, and hormonal influences.6,19 Symptoms of asthma in obese children are the same as in nonobese children. Pulmonary function testing should be performed on children who are suspected of being asthmatic.9 Treatment is the same as for nonobese children; however, guidance should be provided regarding physical activity so as to not limit the amount of exercise the child does.9


Characterized by episodes of apnea and hypoapnea during sleep, obstructive sleep apnea (OSA) is four to six times more likely to develop in obese children as it is in children of normal weight.20 OSA is an important risk factor, as its presence in adults is associated with the development of hypertension, cardiovascular disease, cerebrovascular disease, and poor quality of life. In addition, obstructive sleep apnea may contribute to pulmonary arterial hypertension.20 Symptoms of daytime sleepiness, snoring, and nocturnal enuresis can all be symptoms of OSA in children.20 The definitive test for OSA is polysomnography. The diagnosis is confirmed when the apnea-hypoapnea index is five or more incidents per hour.9,20 Treatment consists of adenotonsillectomy for patients with tonsillar or adenoid hypertrophy and referral to a pulmonologist if the surgery is not effective in relieving symptoms.9,20 


PREVENTING CHILDHOOD OBESITY


Interventions for childhood obesity should be implemented early, with prevention being the primary goal for all children.21 Obesity and the risk factors for its development should be addressed at all well-child visits.22 Even infants can overeat.23 Parents should be educated on healthy eating 
habits for infants and children. In its 2005 statement on childhood obesity, the Obesity Consensus Working Group put forth a number of suggestions for parents and families, health care providers, schools, local communities, and government and regulatory agencies.6 


Parents and families The working group suggested breastfeeding infants for at least 3 months and delaying the introduction of solid foods and sweet liquids.6 Pregnant women might reduce the risk of obesity for their unborn child by normalizing their body mass index before they conceive; not smoking; and exercising moderately, if possible.6 Patients with gestational diabetes should maintain strict glucose control.6 Among the preventive steps that families can take are (1) eating meals at a set time and place; (2) not skipping meals, particularly breakfast; (3) turning off the television at mealtime; (4) using small plates and keeping serving dishes on a counter or somewhere else away from the table; (5) avoiding sweet or fatty foods and soft drinks; (6) not allowing televisions in children's bedrooms; and (7) limiting the time children are allowed to watch television or play video games.6 


Health care providers One suggestion is to educate patients and parents about age-appropriate weight for children and the biological and genetic factors that contribute to obesity.6 In addition, working toward having childhood obesity classified as a disease will promote recognition of the problem and encourage reimbursement for care and a willingness to provide treatment.6 


Schools and communities On a broader basis, schools and the local community can help prevent childhood obesity too. Schools can (1) avoid using cookie and candy sales as fundraisers, (2) make sure vending machines contain healthy choices, (3) educate teachers and students about basic nutrition and the benefits of physical activity, and (4) mandate minimum standards for physical education.6 For their part, communities can increase family-friendly play and exercise facilities, discourage the use of elevators and moving walkways, and provide information on preparing healthier meals.6 


Industry The food industry could be called upon to provide age-appropriate nutritional labeling for children or use celebrities in advertising to promote regular meals. For its part, the toy industry might produce interactive video games that require children to exercise while they play.6 


Government and regulatory agencies Preventive approaches proposed for government and regulatory agencies include limiting food-related advertising to children and allowing tax deductions for the cost of weight loss and exercise programs.6 The working group also called for government support to classify childhood obesity as a disease. 


TREATMENT


If prevention fails, treatment should be initiated. Lifestyle and behavioral modifications are the focus of treatment for childhood obesity.23 Medication and bariatric surgery can be considered but should be reserved for more severe, refractory cases.23-25 Moreover, treatment should be individualized according to the child's age, weight, and current health status. No exact guidelines exist for when to start treatment.24 Because obesity can have such negative consequences, a wait-and-see approach is strongly discouraged.24 


Lifestyle modification Incorporating diet, exercise, or behavioral modifications and/or the combination of the three comprise first-line treatment for all children.23 Laying a good foundation for a healthy, well-balanced diet combined with adequate physical activity is the goal of prevention along with treatment. Additionally, the aim of treatment is to educate the child on how to continue this lifestyle into adulthood. Maintaining current body weight while the child continues to grow should be the goal for the large majority of obese children. Only in children with severe obesity should weight loss be encouraged.23,24 


Diets differ in structure and content, but whatever dietary intervention is used, reducing total caloric intake is the goal.25 Diets range from being low-calorie to low-fat to low-carbohydrate to low-glycemic-index, with no one diet being more successful than another.26 Teaching portion control, with emphasis on fruits, vegetables, and whole grains, is the mainstay of a healthy well-balanced diet.26 Sweetened beverages, empty-calorie sweets, and overly processed food should be eliminated from the diets of all overweight and obese children.23,27


Exercise is a key component in the treatment of obesity. While exercise alone can reduce weight, a child who stops the activity will regain the weight.25 In addition to weight loss, exercise has improved metabolic risk factors (ie, hypertension, hyperlipidemia, and T2DM).25 Physical exercise has led to lower lipid levels, reduced BP, increased bone mass and density, reduced depression and anxiety, and improved self-esteem.28 For children who are sedentary, exercise should be started slowly and increased gradually. Recommendations call for a child to exercise between 20 and 30 minutes a day in addition to the physical activity included in the school day.28 "The President's Challenge" is a good motivational tool used to get kids 6 to 17 years old to be active. The goal of the challenge is for the child to be active for 60 minutes a day for at least 5 days a week for 6 out of 8 weeks.29 Alternatively, the child can wear a pedometer and aim for a goal of 11,000 steps per day for girls and 13,000 steps per day for boys.29 Sedentary lifestyles are becoming more and more common in the American population. The time the child spends in front of a screen (TV or computer) should be limited to less than 1 hour a day.30 


Behavioral modification is aimed at changing behaviors that contribute to excess weight. Initiation of new dietary and physical activity behaviors as previously discussed will help the child lose weight.23,28 Education on nutrition should be addressed to the child and parents. A study done by Golan and Crow showed a significant difference in weight loss by children whose parents were involved and participated in the treatment modalities (diet, exercise, and behavioral modification) compared with those children whose parents were not involved.31 Having children complete a food diary allows them to become aware of what they are consuming.23 Studies suggest that eating together as a family at the table promotes healthier eating habits.22,23,26,27 Parents should limit fatty foods in the house and incorporate healthy meals for the whole family. Physical activity logs should also be kept.32 Setting reasonable goals and tracking weekly progress will allow children to become responsible for their own treatment. Verbal praise and tangible rewards (excluding food) will keep the child motivated.28 


A recent Cochrane review deduced that no one weight-management program has been proven superior to the others; however, a combined behavioral therapy/lifestyle intervention appears to have an advantage over standard, self-care dietary or activity interventions.33 Encouraging all members of the family to get involved and change their everyday lives will benefit not only the obese child, but also the entire family unit.23,27 Each overweight/obese child's treatment strategy will differ. The clinician should tailor the approach based on the patient's age, family involvement, socioeconomic status of the family, and current health status of the child.28 Recommendations can be modified for patients who are very young, patients with a low income, and patients who are severely obese with multiple health complications.9 


Medications Only adolescents who have failed to lose weight through lifestyle modifications should be considered for medication use and even then only when the adolescent has other comorbidities and is continuing to adhere to the previously discussed diet and exercise interventions.24 A child for whom all other attempts to lose weight have failed should be referred to an obesity treatment center, where specialized health care providers can tailor their treatments.9 


The two drugs currently considered for treatment of pediatric obesity are orlistat (Xenical, Alli) and metformin.24 Orlistat is the suggested first-line drug for obesity unresponsive to lifestyle modifications and is FDA approved for patients 12 years and older.24 Orlistat interferes with intestinal fat absorption and has a relatively low side-effect profile, with most patients complaining only of oily stools and flatulence. Metformin is FDA approved for the treatment of T2DM in children 10 years or older.13 Metformin has also stabilized weight or led to small reductions in weight in diabetic and nondiabetic adults.34 National Health and Medical Research Council guidelines state that metformin has a potential role in the treatment of adolescents and should be considered for obese adolescents with significant hyperinsulinemia and a family history of diabetes.34,35 Concurrent use of a multivitamin is suggested because of the effects of metformin on excretion of vitamins B1 and B6.34,35 Long-term studies currently under way will hopefully define the effects of metformin treatment on obesity-related disease risks in this population.9 


Bariatric surgery The caloric intake of a person who undergoes bariatric surgery is reduced via restrictive or malabsorptive actions on the GI tract. Roux-en-Y gastric bypass and laparoscopic adjustable gastric banding are the two main procedures.36 Use of bariatric surgery is highly controversial in the youth population. Consideration of bariatric surgery is recommended only for those adolescents who are finished growing and who have severe, high-risk obesity. Children being considered for surgery must be assessed by a multidisciplinary team and undergo medical, dietary, and psychological evaluations to determine if they are fit for surgery.37


CONCLUSION


Obese children are at risk of acquiring a multitude of complications,3 and comorbidities of obesity may also leave children at risk for cardiovascular disease and stroke in adulthood.6 Promoting healthy habits in young children to prevent childhood obesity and the medical consequences it brings is essential. Diet, exercise, and behavioral modification should serve as first-line therapy for overweight and obese children.23 Medication and surgery are reserved for severe, refractory cases.24,37 Considering that almost 17% of children in the United States are obese, the complications, prevention, and treatment of childhood obesity will remain the subject of research for years to come.1 JAAPA

Georgina Robinson and Megan Geier are former students in the Seton Hall University PA program in South Orange, New Jersey. Georgina Robinson is a hospitalist PA at Evangelical Community Hospital in Lewisburg, Pennsylvania. Denise Rizzolo is an associate professor in the Seton Hall PA program and works at the Care Station in Springfield, New Jersey. Mona Sedrak is an associate professor and program director of the Seton Hall PA program. The authors have indicated no relationships to disclose relating to the content of this article.



IMPORTANT NOTE: JAAPA CME activities consist of 2 articles. To obtain credit, you must also read Childhood obesity: Understanding the causes, beginning the discussion; the post-test will include questions related to both articles. AAPA Fellow members should complete and submit the post-test on the AAPA Web site by going to www.aapa.org and searching for keyword JAAPA post-tests. All others may complete and submit the post-test online at no charge at www.mycme.com. To obtain 1 hour of AAPA Category I CME credit, PAs must receive a score of 70% or better on each test taken.

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3. Ludwig DS. Childhood obesity—the shape of things to come. N Engl J Med. 2007;357(23):
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4. Whitaker RC, Wright JA, Pepe MS, et al. Predicting obesity in young adulthood from childhood and parental obesity. N Engl J Med. 1997;337(13):869-873.


5. Bibbins-Domingo K, Coxson P, Pletcher MJ, et al. Adolescent overweight and future adult coronary heart disease. N Engl J Med. 2007;357(23):2371-2379.


6. Speiser PW, Rudolf MC, Anhalt H, et al. Consensus statement: childhood obesity. J Clin Endocrinol Metab. 2005;90(3):1871-1887.


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9. Barlow SE; Expert Committee. Expert committee recommendations regarding the prevention, assessment, and treatment of child and adolescent overweight and obesity: summary report. Pediatrics. 2007;120(suppl 4);S164-S192.


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11. Weiss R, Dziura J, Burgert TS, et al. Obesity and the metabolic syndrome in children and adolescents. N Engl J Med. 2004;350(23):2362-2374.


12. Third Report of the National Cholesterol Education Program Expert Panel on Detection, Evaluation and Treatment of High Blood Cholesterol in Adults (Adult Treatment Panel III): Executive Summary. Bethesda, MD: National Heart, Lung, and Blood Institute; 2001. NIH publication no. 01-3670.


13. Hannon TS, Rao G, Arslanian SA. Childhood obesity and type 2 diabetes mellitus. Pediatrics. 2005;116(2):473-480.


14. Taylor ED, Theim KR, Mirch MC, et al. Orthopedic complications of overweight in children and adolescents. Pediatrics. 2006;117(6):2167-2174.


15. Wills M. Orthopedic complications of childhood obesity. Pediatr Phys Ther. 2004;16(4):230-235.


16. Strauss RS. Childhood obesity and self-esteem. Pediatrics. 2000;105(1):e15.


17. Gortmaker SL, Must A, Perrin JM, et al. Social and economic consequences of overweight in adolescence and young adulthood. N Engl J Med. 1993;329(14):1008-1012.


18. Mannino DM, Homa DM, Pertowski CA, et al. Surveillance for asthma—United States, 1960-1995. MMWR Surveill Summ. 1998;47(SS-1):1-28. 


19. Flaherman V, Rutherford GW. A meta-analysis of the effect of high weight on asthma. Arch Dis Child. 2006;91(4):334-339. 


20. Young T, Peppard PE, Gottlieb DJ. Epidemiology of obstructive sleep apnea: a population health perspective. Am J Respir Crit Care Med. 2002;165(9):1217-1239.


21. Wang G, Dietz WH. Economic burden of obesity in youths aged 6 to 17 years: 1979-1999. Pediatrics. 
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22. Barnerss L, ed. Pediatric Nutrition Handbook. 3d ed. Elk Grove Village, IL: American Academy of Pediatrics; 1993.


23. Moran R. Evaluation and treatment of childhood obesity. Am Fam Physician. 1999;59(4):862-868, 871-873.


24. Uli N, Sundararajan S, Cuttler L. Treatment of childhood obesity. Curr Opin Endocrinol Diabetes Obes. 2008;15(1):37-47.


25. Nemet D, Barkan S, Epstein Y, et al. Short- and long-term beneficial effects of a combined dietary-behavioral-physical activity intervention for the treatment of childhood obesity. Pediatrics. 2005;115;e443-e449.


26. Collins CE, Warren J, Neve M, et al. Measuring effectiveness of dietetic interventions in child obesity: a systematic review of randomized trials. Arch Pediatr Adolesc Med. 2006;160(9):906-922. 


27. Let's Move: America's Move to Raise a Healthier Generation of Kids. http://letsmove.gov. 
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28. Davis MM, Gance-Cleveland B, Hassink S, et al. Recommendations for prevention of childhood obesity. Pediatrics. 2007:120(suppl 4);S229-S253.


29. The President's Council on Fitness, Sports, & Nutrition. The President's Challenge. http://www.presidentschallenge.org. Accessed November 17, 2011.


30. Dietz WH Jr, Gortmaker SL. Do we fatten our children at the television set? Obesity and television viewing in children and adolescents. Pediatrics. 1985;75(5):807-812.


31. Golan M, Crow S. Targeting parents exclusively in the treatment of childhood obesity: long-term results. Obes Res. 2004;12(2):357-361.


32. Williams CL, Campanaro LA, Squillace M, Bollella M. Management of childhood obesity in pediatric practice. Ann N Y Acad Sci. 1997;817:225-240.


33. Oude Luttikhuis H, Baur L, Jansen H, et al. Interventions for treating obesity in children. Cochrane Database Syst Rev. 2009;(1):CD001872.


34. DeBusk B. Metformin plus weight loss intervention reduces symptoms of metabolic syndrome in obese children. http://www.medscape.com/viewarticle/576395. Published June 20, 2008. Accessed November 8, 2011.


35. Batch J, Baur L. Management and prevention of obesity and its complications in children and adolescents. Med J Aust. 2005;182(3):130-135.


36. Gastrointestinal surgery for severe obesity: National Institutes of Health Consensus Development Conference Statement. Am J Clin Nutr. 1992;55(suppl 2):615S-619S.


37. Apovian CM, Baker C, Ludwig DS, et al. Best practice guidelines in pediatric/adolescent weight loss surgery. Obes Res. 2005;13(2):274-282.



IMPORTANT NOTE: JAAPA CME activities consist of 2 articles. To obtain credit, you must also read Childhood obesity: Understanding the causes, beginning the discussion; the post-test will include questions related to both articles. AAPA Fellow members should complete and submit the post-test on the AAPA Web site by going to www.aapa.org and searching for keyword JAAPA post-tests. All others may complete and submit the post-test online at no charge at www.mycme.com. To obtain 1 hour of AAPA Category I CME credit, PAs must receive a score of 70% or better on each test taken.