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Guidelines extreme obesity

See also: www.a-g-a.de

Preliminary remarks

Special treatment is required for People with extreme obesity because they will suffer from severe physical and mental problems, including restriction of body movements and problems in integration into peer groups. They also are at risk of dying at a young age. Therefore aggressive and focused treatment is needed as early as possible. Due to progress in molecular biology some of these patients may be diagnosed earlier.

It is established that the cost of medical care for adults with an average BMI of 30 kg/m² is twice as high as for someone with normal weight (BMI 22 kg/m²). It is therefore imperative that children and adults are treated as early as possible to reduce medical costs in adulthood.

Definition

As of to date there has been no standard definition of extreme obesity for children or adolescents, but following, the definition of extreme obesity for adults (>40 kg/m²). But now we are able to define extreme obesity for children and adolescents. Children and young adults with an age and sex-specific BMI above the 99.5 percentile should be called extremely obese.

Diagnosis

The following points should be considered when dealing with extremely obese children and adults.

Medical and Family History:

  • family tree which includes BMI values.
  • illnesses associated with obesity: diabetes mellitus, hypertension, disorders of lipid metabolism, hyperuricemia, polycystic ovarian syndrome.
  • eating habits: bulimia, binge eating, hyperphagia in infancy and childhood.
  • history of eating disorder including consumption of drinks.
  • previous treatment attempts and weight cycle.
  • questions about snoring, sleep apnoea, fatigue.
  • previous medications for treatment of obesity and psychiatric medications.

Required criteria for the diagnosis of extreme obesity:
Acanthosis nigricans (insulin resistance, diabetes mellitus), dental status including enamel defects associated with bulimia nervosa, signs of self-destructive behaviour, boderline personality, sexual precocity, irregular menstrual cycle (PCOS), breathing difficulties at night, fatigue, lack of concentration (sleep apnoea), nocturnal hyperventilation.

Additional examinations:
always obtain the following:

  • oral glucose tolerance - 75 g, 2 hour test
  • Serum lipoprotein (a) and homocystein
  • abdominal sonography (gallstones?)
  • in case of hypertension: 24 hour blood pressure profile
  • in case of snoring or fatigue: screening for sleep apnea
  • referall to an orthopedist, specialising in the care of children and adolescents. This is useful before initiating treatment.

Psychological evaluation contains:

  • eating disorders (ICD-10:F50)
  • psychological or family problems
  • too much or too little demand in school or at work
  • affective disorders (ICD-10:F30-F39)
  • anxiety disorders and social phobias (ICD:F41-F41.9, F40.1)
  • posttraumatic stress disorder
  • self mutilation
  • abuse of alcohol, cigarettes and recreational drugs
  • disorders of social behavior
  • deliquency and criminal record
  • low self-esteem
  • high risk sexual behavior
  • enuresis nocturna

Therapy

Successful treatment of extreme obesity requires a team approach and cooperation between physicians, psychological counselors, dietitians and physical therapists. We recommend long term outpatient treatment, prolonged in house treatment or a combination of both. An individualized therapeutic program should be established including attending a school or practical education in the job (Siegfried W, 1999, Boeck M., 1993). A program as such should also include a psychological assessment and psychotherapy to improve self-esteem and body image as well as to increase social skills and responsibility. These different factors together treat affective disorders, post-traumatical disturbances and substance abuse effectively and support integration into a social community and a job and that finally prevents isolation and discrimination.

Alternative forms of therapy

There is a significant discrepancy between treatment options available and the growing prevalence of obesity in children and adolescents. Facing the serious health risks and the comorbidity when extreme obesity is treated pharmacologically and surgically should such options only be explored in cases where the above named strategies have failed.

References

These guidelines are based on the following references:

  • Barlow SE, Dietz WH. Obesity Evaluation and Treatment: Expert Committee Recommendations. Pediatrics 1998, 102, No. 3, p. e29
  • Britz B, Siegfried W, Ziegler A, Lamertz C, Herpertz-Dahlmann BM, Remschmidt H, Wittchen H-U, Hebebrand J. Rates of Psychiatric Disorders in a Clinical Study Group of Adolescents with Extreme Obesity and in Obese Adolescents Ascertained via a Population Based Study, Int J Obes Relat Metab Disord. 2000 Dec 4(12):1707-14.
  • Boeck M, Lublin K, Loy I, Kasparian D, Grebin B, Lombardi N. Initial experience with long-term inpatient treatment for morbidly obese children in a rehabilitation facility. Ann N Y Acad Sci 1993 Oct 29;699:257-9.
  • Epstein LH, Goldfield GS. Physical activity in the treatment of childhood overweight and obesity: current evidence and research issues Med Sci Sports Exerc 31 (11 Suppl.): 553-559, 1999
  • Husemann B. Extreme Adipositas, Chirurgische Verfahren, Indikation und Ergebnisse. Act. Ernähr. Med. 23 182-186, 1998
  • Mallory GB Jr, Fiser DH, Jackson R. Sleep-associated breathing disorders in morbidly obese children and adolescents, J Pediatr 1989 Dec;115(6):892-7
  • Power C, Lake JK, Cole TJ. Measurement and long-term health risks of child and adolescent fatness. Int J Obes 1997; 21: 507-526.
  • Siegfried W, Siegfried A. Langzeittherapie der hochgradigen Adipositas bei Jugendlichen. Kindheit und Entwicklung, 9 (2), 102-107.
  • Siegfried W, Siegfried A, Rabenbauer M, Hebebrand J. Snoring and sleep apnea in obese adolescents: effect of long-term weight loss-rehabilitation. Sleep and Breathing 1999; 3 (3): 83-87.
  • Strauss R. Childhood obesity. Curr Probl Pediatr 1999; 29: 5-29.

Authors:

W. Siegfried (Koordinator), C. Aigner, J. Bennek, S. Cechura, J. Hebebrand, T. Hirschmannn, W. Kiess, D. Kunze, H. Mayer, G. Müller, C. Vogl, M. Wabitsch, H. Weyhreter, K. Widhalm, K. Zwiauer.