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Obesity – Another Challenge for Children with Medical Complexity?

December 28, 2022

In a recently released issue of Pediatrics, Dr. Maria Peinado Fabregat and colleagues examine (10.1542/peds.2022-058684) the prevalence of overweight and obesity in children with medical complexity (CMC) in a large (n=41,905), retrospective cohort of children ages 2-18 years seen at one academic center over the course of a single year (2019). Interestingly, no prior studies have addressed this question, so this study is particularly informative and interesting.  CMC was defined using a schema proposed by Feudtner1, which relies on the International Classification of Diseases, Tenth Revision (ICD-10) diagnostic codes to identify CMC as those with at least one serious chronic condition, expected to last at least 12 months and to involve either 3 organ systems or one so severely as to require specialty care and some hospitalization. The authors further identified 12 subgroups of CMC based on organ system or main disease type, as well as those conditions which could be considered “obesogenic” (mainly endocrine and genetic conditions) and those children receiving “obesogenic medications” chronically (such as certain anti-epileptic and anti-psychotic medications). They were also able to include multiple other relevant independent variables such as sociodemographic details (for example, age, sex, insurance status), medical variables (for example, supplemental nutrition, technology dependence) and dietician visits. They calculated body mass index (BMI) for each child using height and weight from the first date during the study period at which both were recorded; the main outcome was BMI >85%.

Overall, the authors found that CMC are 27% more likely to be overweight (14.5% v. 11%, p≤.001) or obese (17.4% v. 7.4%, p ≤.001) as compared to their healthier counterparts who do not have chronic conditions. Among CMC with obesity or overweight, most (91.6%) did not have an “obesogenic” condition or medication. Obesity or overweight risk was greatest among those in one of three CMC subgroups, namely metabolic, gastrointestinal and oncologic, suggesting these CMC may have as yet unidentified biologic or iatrogenic risk factors. Specific sociodemographic factors were associated with increased risk for obesity and overweight, including Hispanic ethnicity, Black race, public insurance and Spanish as a primary language, suggesting that historical structural inequities play a role, but giving opportunity to design future interventions in collaboration with those most impacted. Numerous other associations are described in this fascinating paper which I hope you will explore.

I believe there are several key take home points for clinicians, including those pointed out by the authors. Due to mobility, spasticity and other factors, obtaining needed height or length and weight measures during clinical encounters can be a challenge, but should not be deferred or neglected. Clinicians, parents and patients cannot tackle a health problem, i.e., obesity or overweight, of which they are not aware, so taking the time to gently and carefully obtain the best measurements possible is important. Second, although children with medical complexity may have multiple specialty visits, and providers and parents face potential burnout due to these numerous appointments, visits with the dietician are critical. Ideally, this would be an ongoing relationship in support of a healthy BMI, which has potential to improve underlying health, since obesity contributes negatively to many health outcomes. Finally, I believe that increased awareness of the need to prioritize nutrition and healthy weight among CMC is helpful, even if most visits include an already packed agenda. If you are not focused on the nutritional wellbeing of your CMC population, this article is a time to refocus and prevent the rates of overweight and obesity from occurring in this population of patients we care so much about.

Reference:

  1. Feudtner C, Feinstein JA, Zhong W, Hall M, Dai D. Pediatric complex chronic 5 conditions classification system version 2: updated for ICD-10 and complex 6 medical technology dependence and transplantation. BMC Pediatr. 2014 7 Dec;14(1):199.
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