Definition and epidemiology

The current epidemic of obesity in children in Italy is marked not only by the precocity of its onset, but also by its severity and persistence which have an enormous impact on health-care costs.

There is currently no consensus about the definition of severe pediatric obesity. The scientific community mainly adopts two criteria: body mass index (BMI) >99th percentile for age and sex, or BMI >1.2 times the 95th percentile of BMI curves [1–4]. While for the first criterion only the reference values provided by the CDC [5] or by the WHO [6] are available, the reference values of the Italian curves can also be used for the second criterion [7]. The 99th percentile of BMI has been considered a good reference cut-off point because the following symptoms were found above this value: a higher prevalence of cardiovascular risk factors, high levels of adiposity and higher probability of persistence of severe obesity in adulthood [8]; the value >1.2 times the 95th percentile of BMI corresponds to Class 2 adult obesity (BMI >35 or approximately 1.2 times the BMI of 30).

In Italy the only available data on the prevalence of severe obesity is contained in the “OKkio alla salute” survey carried out on 45,530 children aged 8–9 years which showed a prevalence of 5.4 % using the threshold of the 99th percentile of the WHO BMI [9]. In this case study, children with severe obesity accounted for 25 % of all children with BMI >95th percentile. The data is in line with the data found in the US population in which the prevalence of severe OB was 4.7 % in children aged 6–11 years and 4.9 % in the total sample of children aged 2–17 years [3].

In a multicenter study carried out by the Child Obesity Study Group of ISPED (Italian Society of Pediatric Endocrinology and Diabetology), we have recently shown that the criterion based on BMI >1.2 times the 95th percentile both of the CDC and the WHO has an advantage in identifying severely obese children with an increased cardio-metabolic risk compared to the 99th percentile [4]. Using the criterion of BMI >1.2 times the 95th percentile, the prevalence of severe obesity among obese patients who are treated in specialist care centers for pediatric obesity was 63.3 % (according to the CDC) and 80.4 % according to the WHO [4].

Since the onset of complications is not closely related to the severity of obesity, but is also affected by genetic, ethnic, racial factors as well as other factors related to the distribution of visceral fat, all forms of obesity with BMI >95th percentile associated with significant complications for the clinical impact or their potential irreversibility are also considered severe. It is of note, however, that many incongruities reduced the value of BMI as key element of the current classification system for obesity (e.g., the description of a phenotype characterized by metabolically healthy obesity or metabolically obese normal weight), indicating the need of a more updated characterization of weight excess [10]. In spite of this, the major complications of obesity, both organic and psychological, if already present in childhood, have a negative effect on the levels of autonomy, psychological well-being and the overall quality of life.

They include the following: hypertension (systolic/diastolic blood pressure values ≥95th percentile for gender, age and height) [11]; endocrine-metabolic disorders (insulin resistance, impaired glucose tolerance/type 2 diabetes mellitus, metabolic syndrome, dyslipidemia, polycystic ovary syndrome, hyperuricemia); hepatic steatosis or steatohepatitis; gastrointestinal disorders as gastro-oesophageal reflux; musculoskeletal disorders (epiphysiolysis of the femoral head, Blount’s disease, flat foot, valgus knee, scoliosis and limitations of gait); respiratory disorders (snoring, obstructive sleep apnea, daytime narcolepsy, asthma); psychopathological disorders (depression, anxiety, eating disorders); psycho-social adjustment (social stigma [12], peer victimization [13], social withdrawal, poor quality of life).

Pediatric obesity is associated with functional deficits, with a severe restriction of motor skills and psycho-social unease. These involve a reduction in the quality of life and constitute a true “state of disability” [14].

Main objectives of the rehabilitation

For the above-mentioned reasons severe/medically complicated obesity in childhood and particularly in adolescence, requires an intensive and continuous approach which should follow the procedures and schedule of rehabilitation medicine to achieve a reduction of long-term morbidity and cardiovascular mortality.

The first objective of treatment is to improve dysfunctional eating and sedentary lifestyle in order to avoid further increases in weight [15]. It is in fact well known how difficult it is to obtain a reduction of the percentile of BMI even with the best treatment programs currently available, particularly during adolescence [16]. The rehabilitation should be also designed to regain “a functional competence” (often reduced in children with severe obesity), “put a barrier to the progression of the associated metabolic and psychological complications, trying to modify the natural history of the disease” [17] through an improved lifestyle with treatment being extended to the psycho-socio-cultural sphere in which the growth process occurs or takes place. Given the age group to which it is addressed, it should also be noted that the rehabilitation program must be acceptable to be sustained in the long term [18].

The main aim of the treatment of obesity is to acquire and maintain a negative energy balance, based on a reduction in energy intake compared to energy requirements for a prolonged period of time sufficient to reach and stabilize the target weight and body composition and on the simultaneous increase in energy expenditure [19, 20]. Weight loss results in an improvement of all the metabolic abnormalities associated with obesity [21]. In order for the therapy to be successful it is essential to provide constant information to the patients and their families about issues related to food, physical activity, and more generally to a healthy lifestyle, which encourages lasting changes in behavior [22]. In specific and selected cases an intensive or semi-intensive approach is required, combining the educational process with a customized rehabilitation program designed to reduce already existing metabolic and functional complications and prevent more disabling ones in the future. The Guidelines of the Ministry of Health for rehabilitation activities [17] define rehabilitation as “a process of problem solving and education which helps an individual to achieve the best possible life standard at a physical, functional, social and emotional level with the least possible restriction of its operational decisions.”

This approach therefore applies to pediatric obesity, especially in its most severe forms.

Organization of care network

Similarly to what has been already highlighted in the Consensus SISDCA SIO-2010 [23] and in the Italian Standards for the Treatment of Obesity—ADI-SIO [24] for adult obesity, also for children and adolescents treatment of severe obesity should be based on the following:

  • Teamwork: integrated multidimensional, multi-disciplinary, multi-integrated approach involving pediatricians, nutritionists, psychiatrists, psychologists, dieticians, physiotherapists and nurses.

  • Multiple settings: from long-term outpatient management to intensive rehabilitation semi-residential and/or residential designed to treat cases of severe malnutrition by excess, periods of mental instability, somatic or psychiatric co-morbidities. Interventions should also provide a collaboration with professionals who work in the other microsystems where children live: first of all, the school where children and adolescents attend a large part of their daily-time and are out of the parental control.

  • Health-care network: integrated treatment involving various levels of care.

With regard to this last point, the care network is organized on three different levels of treatment, providing continuous care until late adolescence (Fig. 1).

Fig. 1
figure 1

The three-level health-care network

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First level treatment: it concerns the primary care pediatrician who selects the cases according to the level of assistance and care needed. In cases of severe obesity (due to excess weight or complications) the pediatrician will assess the possibility of referring the children to a more intensive level of care. In all cases, the pediatrician is the main point of reference for obese children/adolescents and their family, becoming a mediator between the various proposals for action and participating in the decisions where a more aggressive approach is proposed (e.g., hospitalization or surgery).

For this reason, the pediatrician should guarantee continuity of care for obese adolescents up to 18 years old and ensure an appropriate transition to the general practitioner (GP). The same tasks should be performed by the GP for child patients already entrusted to his/her care.

Second level treatment: this is carried out in outpatient services where families can find the advice of a pediatrician with documented experience in obesity who works with at least one of the following professionals: dietician/nutritionist, psychologist and/or child neuropsychiatrist. The task of these Second level Specialist Interdisciplinary Pediatric outpatient services is to define the clinical condition and begin a course of treatment that focuses on nutrition and physical education and a change in lifestyle. The second level treatment is initially an outpatient service and can be carried out by providing complex outpatient packages (COP), whose implementation and payment will be defined by the regional government [25].

The diagnostic assessment, which needs to be personalized in each case, includes the following:

  • Nutritional status (quantification of the degree of excess weight); assessment and measurement of food intake and eating behavior, evaluation of physical activity, sedentary activities, and body composition measurement.

  • Cardiovascular and respiratory risk (clinical examination, electrocardiogram, outpatient blood pressure monitoring, spirometry).

  • Endocrine-metabolic profile: blood tests, basal hormone dosage.

  • Functional limitations and orthopedic complications (clinical and instrumental examinations).

  • Psychological state, using psychometric instruments for assessing eating disorders (ED) and psycho-social adjustment (school achievement, peer relationships, weight-based victimization [26]).

Third level care intervention: this is carried out in Specialized Centers for Pediatric Obesity, of which there must be at least one per region. It is aimed at severely obese patients, obese patients with complications or resistant to treatment (who cannot lose weight) and to patients with secondary obesity (genetic, endocrine, etc.). The Center is organized to carry out outpatient clinical activity, day hospital and/or Day Service, with the possibility of hospitalization and residential intensive rehabilitation; alongside the checks provided for the second level, the Center carries out laboratory tests and hormonal dynamic tests (glycemic load curve, dexamethasone suppression test), genetic analysis, functional tests (walking test for 6 min), instrumental tests (echocardiogram, holter monitoring test, pH-impedance pH probe, transcutaneous saturometry during waking and sleeping, arterial blood gas analysis, whole-night polysomnography, pelvic ultrasound, ophthalmic, orthopedic and neurological instrumental tests, etc.), bariatric surgery, etc. The Center should have the skills to study and evaluate the possible presence of a secondary cause of obesity. The ideal multidisciplinary team and the list of the consultants of the third level are reported in Table 1.

Table 1 Ideal multidisciplinary team for children with medically complicated obesity in a third level care intervention setting
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In situations in which the frequency of co-morbidity is higher, the psychic equilibrium is more compromised and the impact of obesity on the disability and the quality of life of the patient is particularly significant, intensive rehabilitation (hospitalization and/or DH rehabilitation) is crucial in the service network, because it plays the following roles:

  • Setting of a multidisciplinary-integrated course of treatment.

  • Treatment of disabilities and obesity-related co-morbidities by concentrating on different types of treatment. The treatment of concomitant psychopathological disorders and eating disorders often associated with severe obesity in adolescents is included in this context.

  • Secondary prevention of further complications of obesity.

  • Use of pharmacological therapies in the context of specific protocols.

  • Preparation of the candidates for bariatric surgery and post-operative follow-up.

The therapeutic-rehabilitative course of treatment

The main goal of this type of treatment is to achieve an improvement of the health conditions through a permanent change in the patient’s lifestyle facilitating all those transformations that must take place in the patients and in their living environment to enable them to improve their eating habits, reduce sedentary behavior and increase physical activity [20]. To ensure that this happens professionals need to have expertise in the field of behavioral and cognitive-behavioral therapy, therapeutical education, motivating interviews and the principles of Family-Centered Care [27–32]. Since severe obesity in adolescents is a chronic disease where the chances of recovery are extremely rare, it should be noted that most of these patients will live with their weight problem for the whole of their lives and will have to be helped to implement strategies to ensure an acceptable quality of life [33].

The rehabilitation program is defined by an Individual Rehabilitation Project (IRP), developed by the pediatrician in charge (case manager) together with the various professionals of the interdisciplinary team, and shared between the levels of the integrated network [25]. The interdisciplinary integration of these skills may ensure a successful outcome.

The therapeutic-rehabilitative treatment is organized as follows:

  • Nutritional advice for both the patient and the caregiver, and, if possible, for the whole family (setting of specific food-therapy sessions [34], eating education courses, pre/post educational intervention evaluation questionnaires on food knowledge, individual and group meetings with a nutritionist and/or a dietician) aimed at the progressive reduction in body weight and the maintenance of the lean muscle mass [1, 19, 20].

  • Motor re-education by encouraging healthy physical activity and defining a physical activity program. The therapy will start gradually with cycles of physio-kinesiotherapy (if necessary) and structured gym activity and non-structured outdoor activity, whose purpose is to restore joint mobility, enhance muscle mass, increase energy expenditure, recover and improve cardiorespiratory performance as well as raise awareness in the patients and their families of the need for adequate physical activity to be continued over time [20, 21, 34].

  • Psycho-pedagogical and psychotherapeutic treatment, to be programmed both through the involvement of the family and by means of individual and/or group techniques (behavioral therapy with significant family involvement, food diary, self-monitoring, stimulus control, positive reinforcement, cognitive restructuring, autogenous training, dance-movement-therapy). The aims are (1) to improve self-esteem and one’s own body image in order to break the vicious circle leading obese children to cope with discomfort by overeating; (2) to contribute to the control and management of the diet, and (3) to increase the disease awareness and sustain the self-management both of the patients and their families in the long term [20, 30, 35].

  • Nursing rehabilitation carried out by nurses, social workers and occupational therapists to improve the patients’ responses to disability, change disease-generating lifestyles, increase environmental and social compensation, reinforce functional and relational skills, thus optimizing the participation in rehabilitation programs [36];

  • Pharmacological treatment for prescribing specific medicines that have already been tried out or for testing new pharmacological approaches within the context of randomized and controlled clinical protocols [37, 38];

  • Surgery: the increased safety and improvement of laparoscopic techniques and the experience of multidisciplinary teams as well as the confirmation of the benefits on co-morbidity, quality of life and mortality have made bariatric surgery a therapeutic option, even for adolescents with severe obesity. However, since its long-term effects are still unknown, the surgical approach in pediatric patients should be adopted with great caution, and only in hospitals with specific pediatric units, and the choice must stem from a multidisciplinary decision, carefully considering the balance between the possible risks and benefits. Bariatric surgery should be considered only as the last chance in patients who have not responded to all other treatments, and should be carried out with adequate resources and time for at least 12 months, especially if life-threatening complications occur. Therefore, the indications for bariatric surgery for children and adolescents involve even more restrictions and precautions than for adults [20] (Table 2). Age is not included in the criteria, but rather the achievement of full sexual maturity, due to the possible negative effects on height growth. The patient must have follow-up treatment that includes both a pre-operational educational phase and especially a very demanding and lengthy post-operational phase. Moreover, the patient must be made aware that an active lifestyle and healthy eating habits are crucial for the maintenance of the results obtained with the operation and to avoid complications. The support of the family, trained by the multidisciplinary team, and the involvement of the pediatrician/GP [20, 39–43] are also fundamental.

    Table 2 Indications and contraindications for bariatric surgery [20]
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Close monitoring of cases of surgery through a specific National Register of operated patients below the age of 18 is also necessary.

The objectives of the protocol of the rehabilitation intervention can be divided into short phases (6 months) and medium- to long-term phases (1–3 years); specific outcome indicators are identified for each of them in order to assess the effectiveness of the therapeutic program (Table 3).

Table 3 Objectives and indicators of the intervention
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The intervention carried out by the third level center should be structured in a sustainable way aimed at optimizing resources and the appropriateness and effectiveness of each treatment.

The second and third level care setting

The care setting is organized as follows.

Outpatient treatment

The outpatient clinic is the first step in the referral to the center. Clinical, laboratory and instrumental tests can be carried out here using a COP for diagnosis or for monitoring the treatment. It is the best way to ensure suitable follow-up of patients.

DH rehabilitation

One-day hospitalization is recommended for children and adolescents who require specific treatment programs (rehabilitation-metabolic, nutritional, psychological and motor treatments) which are carried out in several stages. The program must include, at every meeting, an interdisciplinary assessment, individual verification of eating and motor behaviors, educational group meetings at a nutritional and/or psychological level, physical activity sessions in the gym as well as any necessary instrumental and blood chemistry tests.

The rehabilitation phase in Day Hospital does not mark the completion of the treatment of obese patients, but represents an important step for achieving the objectives.

The protocol provides for at least one visit a month over a 3–6 month period, whose schedule may differ according to the hospital.

The objectives of the DH program are modeled on the short-term goals of the IRP. In particular, they include the following:

  1. 1.

    Improvement of the eating and motor behavior, assessed by means of the diary.

  2. 2.

    Reduction of BMI-SDS and/or abdominal fat (waist-to-height ratio) and/or fat mass/lean mass ratio (bioimpedance analysis).

  3. 3.

    Correction of any alterations to the following metabolic parameters:

    • lipids

    • HOMA-IR index

    • ALT

    • uricemia

    • HS-CRP

    • reduction of blood pressure

    • reduction of the motor limitation

    • reduction of sleep disorders

Rehabilitation/residential hospitalization

Hospitalization is decided by the third level team for those patients who have not responded to the above-mentioned treatments and whose degree of disability linked to the situation of severe and/or medically complicated obesity requires specific clinical, therapeutic and rehabilitation programs.

In particular, patients with the following clinical conditions may be eligible for this type of program:

  • Patients with severe physical disabilities related to obesity (sleep apnea, epiphysiolysis, Blount’s disease, pseudotumor cerebri).

  • Patients with severe psychological and/or psychiatric disorders or mood disorders with self or other damaging behavior.

  • Patients with severe/medically complicated obesity whose family is unable to cope with the situation or who lack self-control.

  • Patients with cardiovascular risk profile (hypertension with end organ damage, hyperlipidemia) Patients with severe metabolic disorders (diabetes mellitus, worsening liver disease, Non-alcoholic fatty liver disease/non-alcoholic steatohepatitis (NAFLD/NASH).

  • Patients eligible for surgery or in the post-surgical phase.

Hospitalization is structured as an “integrated” program whose duration is proportional to the overall situation of the patient. It includes diet therapy and assistance at mealtimes, individualized physical activity, physiokinetic therapy (where necessary), individual and/or group psychotherapy, nutritional and motor rehabilitation.

The rehabilitation program must take place according to the IRP outlined for each patient, which must provide a multidisciplinary approach decided in advance according to a scheme which includes the following:

7 days/week:

  • education to a healthy lifestyle

  • aerobic activity (non-structured)

  • supervised mealtimes

6 days/week:

  • clinical monitoring, medical records update, blood pressure measurement

  • non-structured aerobic activity • structured aerobic and anaerobic activity (bike exercise, recline bike, arm-ergometer, muscular strength and endurance exercises)

  • functional rehabilitation gymnastics (flexibility)

  • 2–6 days/week: physio-kinesitherapy (where required)

1 day/week:

  • anthropometric measurements (weight)

  • nutritional rehabilitation

  • educational meetings with families

  • psycho-educational meetings for patients

  • motor rehabilitation, assessment of the progress of the rehabilitation program.

During hospitalization, specific tests related to the clinical situation and the short- to medium-term objectives will also be carried out.

At the end of the hospitalization period, the case manager will prepare a detailed report for the patient/family and the pediatrician or the GP (who will include the tests carried out, the rehabilitation treatments provided, the treatment schedule, information about the following stages of rehabilitation and planned follow-ups). The request made to social services to support the family during and after the rehabilitation phase should also be taken into account.

Conclusion

A recent interest from the pediatric research and medical communities has been turned to severe/medically complicated obesity not only for its undesirable immediate consequences, but also for the relative resistance to current treatment approach. Concerning adult patients, detailed evidence-based recommendations have been recently developed, in order to facilitate high-quality care of patients with obesity and provide the basis for a rational management that optimizes health outcomes and safety [44]. Given the lack of a shared intervention protocol for the treatment of severe/medically complicated obesity in childhood and in adolescence, the present expert document suggested some milestones that clinicians should follow and implemented within the health-care system. In particular, we proposed to create a specific team to care the severe/medically complicated obesity as well as to adopt an intensive and continuous approach based on different levels of care intervention, in order to achieve a reduction of long-term morbidity and cardiovascular mortality.