Interventions to improve cardiovascular risk factors in obese children.

The prevalence of obesity is increasing at dramatic rates in children and adolescents all over the world in the last several decades (1,2). Obesity in children and adolescents represents a public health priority, and prevention should be the optimal approach. However, the prevention programs that have been adequately assessed do not show enough evidence about their efficacy (3). Certainly, we must contribute to improve the existing programs and to develop new ones (4). In the meantime, a great number of patients are arriving at our pediatric clinics, and more will arrive. We should also be ready to treat these patients following evidence-based best practice criteria. The Working Group Report of the First World Congress of Paediatric Gastroenterology, Hepatology and Nutrition established that obesity treatment should aim at long-term stabilization of body weight and body fat content within the normal range (5). The Working Group Report of the Second World Congress of Paediatric Gastroenterology, Hepatology and Nutrition proposed as an objective the development of effective interventions for the complications of overweight and obesity in children and adolescence (6). Obesity can be defined as an excess of fat in the human body with health consequences for these patients. Even if it is not a perfect measure, the most widely used tool to estimate the excess of body fat is the body mass index (BMI, kg/m). However, if we wish to be precise with the diagnosis, we should try to describe the patient’s body composition. To achieve this goal, we need to have adequate tools, useful in clinical settings and ageand sex-specific reference standards. For anthropometry and some body composition techniques such as bioelectrical impedance, we start to have reference standards with which we can compare our patients (7Y9). As body fat distribution is likely to be associated with obesity comorbidities, it is also important to use some techniques that can be easily measured in our clinics, such as waist circumference (10). Obesity in children and adolescents is accompanied by multiple and diverse complications affecting different body systems. Metabolic complications and high blood pressure levels are the most deleterious consequences, at least in the medium to long term. Frequently, obese children and adolescents present with a cluster of cardiovascular risk factors, usually called the metabolic syndrome (11,12). Treatment of pediatric obesity can take advantage of growth and increases in lean body mass as well as weight change. Instead of shrinking adipose cells, treatment at an early age prevents the development of excess adipose cells. In terms of treatment goals, it seems that losing weight is not the optimal approach in growing individuals. That is why stabilizing the BMI has been proposed as a therapeutic objective. Because BMI is a poor indicator of excess fat, mainly during childhood and adolescence (13), and because the complications of obesity will be the cause of the increased morbidity and mortality in these patients, maybe other therapeutic objectives could be proposed. One of these goals could be to improve the cardiovascular risk factor profile. This approach must be based on the best possible evidence. Ambulatory treatment forms the basis of most intervention programs for obese children and adolescents. Stationary treatment in obesity camps, hospitals or rehabilitation centers also has been used to a more limited extent (14,15). However, the efficacy of inpatient therapy relative to outpatient treatment, in the absence or presence of specific complicating factors, has not been adequately evaluated. The article published by Reinehr et al. (16) in this issue provides relevant information about the effect of 2 different treatment approaches on cardiovascular risk factors in obese children. The authors compare the effect of a 1-year outpatient intervention, based on lifestyle changes, with another inpatient intervention based on dietary restriction and exercise therapy, during 6 weeks. Received June 28, 2006; accepted June 21, 2006. Address correspondence and reprint requests to Dr Luis A. Moreno, Escuela Universitaria Ciencias de la Salud, Universidad de Zaragoza, C/Domingo Miral s/n, 50009 Zaragoza, Spain (e-mail: lmoreno@ unizar.es).