Diagnosis, treatment and prevention of pediatric obesity: consensus position statement of the Italian Society for Pediatric Endocrinology and Diabetology and the Italian Society of Pediatrics

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hyperlipidemia 1 endocrinologydiseases
hypertriglyceridemia 1 endocrinologydiseases
obesity 110 endocrinologydiseases
polycystic ovary syndrome 2 endocrinologydiseases
type 2 diabetes mellitus 1 endocrinologydiseases
diabetes mellitus 2 endocrinologydiseases
hyperandrogenism 2 endocrinologydiseases
hyperglycemia 1 endocrinologydiseases
hypogonadism 1 endocrinologydiseases
metabolic syndrome 2 endocrinologydiseases
childhood obesity 2 endocrinologydiseases
congenital adrenal hyperplasia 1 endocrinologydiseases

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childhood obesity 17450 children and adolescents with obesity since the age of 6. LOE I-AThe dyslipidemic pattern associated with childhood obesity consists of a combination of elevated TG, decreased HDL-C, and low density lipoprotein cholesterol.
childhood obesity 53533 weightMotivating and supporting the family to change, possibly involving other professionals trained in childhood obesity Severe obesity or psychological co-morbidity, or additional risk factors, or biochemical alterations,
congenital adrenal hyperplasia 23448 [[83]]. Referral for specialist investigations is required to exclude other hyperandrogenic causes ( congenital adrenal hyperplasia , androgen-secreting tumors, Cushing syndrome/disease) [[80]–[84]].Respiratory complicationsRespiratory
diabetes mellitus 13316 to a specialist for further investigations and treatment [[31], [34], [35]].Prediabetes and type 2 diabetes mellitus Fasting blood glucose measurement is recommended in all children and adolescents with overweight and
diabetes mellitus 14938 considered in latter cases (LOE VI-B) (Table 4).Table 3Criteria for the diagnosis of prediabetes and diabetes mellitus Prediabetes Impaired fasting glucose: plasma glucose (after 8 h of fasting) between 100 (5.6 mmol/l)
hyperandrogenism 22774 in all female adolescents with obesity. LOE VI-APolycystic ovary syndrome (PCOS) is characterized by hyperandrogenism (acne, hirsutism and alopecia) and ovary dysfunction (oligo-amenorrhea). It is associated with increased
hyperandrogenism 23156 following criteria: a) oligo-ovulation and/or anovulation; b) clinical and/or biochemical signs of hyperandrogenism ; c) polycystic ovary [[82]]. Since there is no widely accepted definition for PCOS in the teenage, it
hyperglycemia 58088 fetal macrosomy and increased risk of obesity [[285]–[290]]. This effect is independent of maternal hyperglycemia , which is also a well-known risk factor for future obesity [[291]]. Recommended gestational weigh gain
hyperlipidemia 17684 of dyslipidemia among obese children was 46–50.4% [[48], [49]]. Because the association of obesity/ hyperlipidemia (expecially hypertriglyceridemia) is predictive of fatal and non fatal cardiovascular events in adult
hypertriglyceridemia 17711 children was 46–50.4% [[48], [49]]. Because the association of obesity/hyperlipidemia (expecially hypertriglyceridemia ) is predictive of fatal and non fatal cardiovascular events in adult life [[50]], the screening of dyslipidemia
hypogonadism 9014 child with delayed psychomotor development, cognitive deficiency, short stature, cryptorchidism or hypogonadism , dysmorphisms and characteristic facial features, ocular and/or auditory alterations, is suggestive
metabolic syndrome 22922 and ovary dysfunction (oligo-amenorrhea). It is associated with increased risk of infertility, T2D, metabolic syndrome and cardiovascular disease in adulthood [[80], [81]]. In adult women, the diagnosis is based on at least
metabolic syndrome 55355 test a transition model for adolescents with severe obesity and/or complications, particularly with metabolic syndrome , NAFLD, hypertension [[272]–[274]]. Unfortunately, the experience is extremely limited for the high
obesity 85 Title: Italian Journal of PediatricsDiagnosis, treatment and prevention of pediatric obesity : consensus position statement of the Italian Society for Pediatric Endocrinology and Diabetology and
obesity 1550 guidelines to deliver an evidence based approach to the disease. The following areas were reviewed: (1) obesity definition and causes of secondary obesity; (2) physical and psychosocial comorbidities; (3) treatment
obesity 1593 approach to the disease. The following areas were reviewed: (1) obesity definition and causes of secondary obesity ; (2) physical and psychosocial comorbidities; (3) treatment and care settings; (4) prevention.The main
obesity 2356 contains supplementary material, which is available to authorized users.BackgroundContrasting pediatric obesity is among the priority goals in the healthcare agenda of the Italian National Healthcare System. Beyond
obesity 2516 of the Italian National Healthcare System. Beyond the high prevalence and persistence of pediatric obesity [[1]], robust evidence demonstrates that physical and psychosocial complications are already present
obesity 2723 present in obese children [[2]] and worsen in adulthood. Therefore, prevention and treatment of pediatric obesity and complications are key strategic goals, in order to reduce morbidity, mortality, and expected costs
obesity 2914 and expected costs for the care of obese adults.The very fruitful scientific research on pediatric obesity of the last decade justified to update the guidelines, in order to provide the best evidence-based reccomendations.
obesity 3239 Pediatrics, with other Pediatric Societies joined in the common objective of contrasting pediatric obesity , made this Consensus on “Diagnosis, therapy and prevention of obesity in children and adolescents”,
obesity 3311 objective of contrasting pediatric obesity, made this Consensus on “Diagnosis, therapy and prevention of obesity in children and adolescents”, updating the document published in 2006 [[3]].MethodsFour main topics
obesity 3469 document published in 2006 [[3]].MethodsFour main topics were defined: 1) diagnostic criteria, secondary obesity ; 2) comorbidities; 3) treatment and care settings; 4) prevention. Coordinators were identified for each
obesity 4103 meta-analysis, consensus, recommendations, international and national guidelines published on pediatric obesity even prior to 2005 were considered and deemed useful to the Consensus. The level of evidence (LOE) and
obesity 5220 might have required a change in the statements.DiagnosisDiagnostic criteria for defining overweight, obesity and severe obesityThe definition of overweight and obesity is based on the use of percentiles of the
obesity 5239 a change in the statements.DiagnosisDiagnostic criteria for defining overweight, obesity and severe obesity The definition of overweight and obesity is based on the use of percentiles of the weight-to-length ratio
obesity 5279 statements.DiagnosisDiagnostic criteria for defining overweight, obesity and severe obesityThe definition of overweight and obesity is based on the use of percentiles of the weight-to-length ratio or body mass index, depending on sex
obesity 5467 index, depending on sex and age. LOE V-AIn children up to 24 months, the diagnosis of overweight and obesity is based on the weight-to-length ratio, using the World Health Organization (WHO) 2006 reference curves
obesity 6047 or groups, it has a greater sensitivity in identifying children and adolescents with overweight and obesity , in a period of particular seriousness of the pediatric obesity epidemic in Italy. On the contrary,
obesity 6111 and adolescents with overweight and obesity, in a period of particular seriousness of the pediatric obesity epidemic in Italy. On the contrary, the Italian BMI thresholds [[7]] underestimate the prevalence of
obesity 6220 epidemic in Italy. On the contrary, the Italian BMI thresholds [[7]] underestimate the prevalence of obesity compared to WHO, probably because they were based on measurements taken during the epidemic increase
obesity 6332 compared to WHO, probably because they were based on measurements taken during the epidemic increase of obesity [[8]].Table 1Diagnostic criteria to classify overweight and obesityAge0–2 years2–5 years5–18 yearsIndexWeight-to-lenght
obesity 6400 during the epidemic increase of obesity [[8]].Table 1Diagnostic criteria to classify overweight and obesity Age0–2 years2–5 years5–18 yearsIndexWeight-to-lenght ratioBMIBMIReferenceWHO 2006WHO 2006WHO
obesity 6664 overweightOverweight>97th percentileaOverweightOverweightObesity>99th percentileaObesityObesitySevere obesity athe 85th, 97th and 99th percentiles approximate z-scores of + 1, + 2 and + 3, respectivelyThe
obesity 6799 percentiles approximate z-scores of + 1, + 2 and + 3, respectivelyThe cut-off to define severe obesity is represented by the BMI > 99th percentile. LOE VI-BIt has been demonstrated that the 99th percentile
obesity 7022 identifies subjects with higher prevalence of cardiometabolic risk factors and persistence of severe obesity in adulthood with respect to the lower percentiles [[9]]. The WHO system provides the values of the
obesity 7235 percentile of BMI which approximate + 3 SDS from 2 years upwards. However, as for overweight and obesity classification, the WHO terminology for severe obesity differs between younger (0–5 years) and older
obesity 7290 2 years upwards. However, as for overweight and obesity classification, the WHO terminology for severe obesity differs between younger (0–5 years) and older children/adolescents (5–18 years): the 99th percentile
obesity 7419 younger (0–5 years) and older children/adolescents (5–18 years): the 99th percentile identifies “ obesity ” in the former group, and “severe obesity”in the latter. This cautious approach is motivated by
obesity 7465 children/adolescents (5–18 years): the 99th percentile identifies “obesity” in the former group, and “severe obesity ”in the latter. This cautious approach is motivated by the fact that the growth process differs between
obesity 7950 the age and sex 95th percentile of BMI or an absolute BMI ≥ 35 kg/m2 (equivalent to class 2 obesity in adults) as an alternative to the 99th percentile [[12]]. The impact of this system using the WHO
obesity 8123 impact of this system using the WHO thresholds has yet to be assessed in clinical practice.Secondary obesity The clinical suspicion of secondary obesity arises after careful anamnestic, anthropometric and clinical
obesity 8166 thresholds has yet to be assessed in clinical practice.Secondary obesityThe clinical suspicion of secondary obesity arises after careful anamnestic, anthropometric and clinical evaluations. LOE III-AObesity may be ascribed
obesity 8455 Therefore, clinical history, peculiar signs and symptoms must be accurately assessed such as: 1) onset of obesity before 5 years and/or rapid progression, especially in association with clues suggesting secondary
obesity 8892 (i.e. corticosteroids, sodium valproate, risperidone, phenothiazines, ciproeptadine) [[13]].Early-onset obesity occurring in a child with delayed psychomotor development, cognitive deficiency, short stature, cryptorchidism
obesity 9497 syndromes [[21]–[23]].The monogenic forms, albeit uncommon, are nevertheless the most frequent causes of obesity with early onset compared to endocrine and syndromic forms [[24]] and are due to dysregulated hunger
obesity 9890 investigations.ComorbiditiesHypertensionBlood pressure measurement is recommended in all children with overweight or obesity from the age of 3 years. LOE I-AObesity is the main risk factor for hypertension in children and adolescents
obesity 10046 main risk factor for hypertension in children and adolescents [[26], [27]]. The risk increases with obesity severity [[28]]. As blood pressure (BP) levels change according to sex, age, ethnicity and obesity,
obesity 10145 obesity severity [[28]]. As blood pressure (BP) levels change according to sex, age, ethnicity and obesity , the prevalence of high BP levels and especially hypertension is heterogeneous (7–30%) in obese children
obesity 11847 blood pressure, DBP Diastolic blood pressurePrimary forms of hypertension are mainly associated with obesity and more frequent in children > 6 years. Secondary forms are predominant in younger children. Nephropathy,
obesity 13024 concentric hypertrophy are associated with high BP levels and other comorbidities such as visceral obesity and atherogenic dyslipidemia [[36], [37]]. Weight loss and reduced sodium intake are recommended. If
obesity 13434 mellitusFasting blood glucose measurement is recommended in all children and adolescents with overweight and obesity since the age of 6, as the first step for screening prediabetes and type 2 diabetes. LOE V-AThe diagnosis
obesity 16225 diabetes.Genetic screening for monogenic diabetes is recommended in the rare cases presenting with obesity , diabetes, negative autoimmunity tests and family history for T2D.Table 4Indication for the oral glucose
obesity 16400 T2D.Table 4Indication for the oral glucose tolerance test in children and adolescents with overweight or obesity Children with fasting plasma glucose ≥100 mg/dl or HbA1c ≥5.7–6.4% (39–46 mmol/mol)Adolescents
obesity 17374 cholesterol, HDL-cholesterol and triglycerides is recommended in all children and adolescents with obesity since the age of 6. LOE I-AThe dyslipidemic pattern associated with childhood obesity consists of a
obesity 17460 adolescents with obesity since the age of 6. LOE I-AThe dyslipidemic pattern associated with childhood obesity consists of a combination of elevated TG, decreased HDL-C, and low density lipoprotein cholesterol.
obesity 17676 prevalence of dyslipidemia among obese children was 46–50.4% [[48], [49]]. Because the association of obesity /hyperlipidemia (expecially hypertriglyceridemia) is predictive of fatal and non fatal cardiovascular
obesity 19835 assessment of transaminases and liver ultrasound is suggested in all children and adolescents with obesity starting at age of 6 years. LOE V-BThe prevalence of NAFLD in obese children is 38–46% [[57], [58]].
obesity 22704 syndromeThe components of the polycystic ovary syndrome should be considered in all female adolescents with obesity . LOE VI-APolycystic ovary syndrome (PCOS) is characterized by hyperandrogenism (acne, hirsutism and
obesity 23653 [[80]–[84]].Respiratory complicationsRespiratory symptoms and signs should be sought in children and adolescents with obesity . LOE V-AThe prevalence of respiratory problems, such as asthma, obstructive sleep apnea syndrome (OSAS),
obesity 23770 V-AThe prevalence of respiratory problems, such as asthma, obstructive sleep apnea syndrome (OSAS), and obesity hypoventilation syndrome (OHS) is higher in obese children and adolescents compared to the general population
obesity 24802 growth delay, systemic hypertension pulmonary and artery hypertension have been reported in severe obesity [[91], [92]].OHS is characterized by severe obesity, chronic daytime alveolar hypoventilation (defined
obesity 24854 artery hypertension have been reported in severe obesity [[91], [92]].OHS is characterized by severe obesity , chronic daytime alveolar hypoventilation (defined as PaCO2 levels > 45 mmHg and PaO2 < 70 mmHg),
obesity 26519 the presence of musculoskeletal pain and joint limit ation at the lower extremity. LOE V-ASeverity of obesity and sedentary lifestyle influence the morphology of osteo-cartilaginous structures and growth plate,
obesity 27672 medial part of the foot, with more specific complaints after exercises or long walks [[105]].Although obesity may exhibit higher risk of fracture, the measurement of bone density is not recommended. LOE V-DThe
obesity 28077 to fall and consequently to fracture, especially of the forearm [[109]]. There is no evidence that obesity results in a reduction of bone density [[110]]: while some studies have described an increased or normal
obesity 28456 screening of kidney complications in non-diabetic and non-hypertensive children and adolescents with obesity . LOE IV-DIn adults, obesity is an independent risk factor for chronic kidney disease [[111]]. Obesity
obesity 28484 complications in non-diabetic and non-hypertensive children and adolescents with obesity. LOE IV-DIn adults, obesity is an independent risk factor for chronic kidney disease [[111]]. Obesity complication, (i.e. hypertension,
obesity 28749 inflammatory state, autonomous system dysfunction) indeed, can alter the kidney function [[112]]. Peculiar to obesity , the obesity-related glomerulopathy is a secondary form of segmental focal glomerulosclerosis occurring
obesity 28762 autonomous system dysfunction) indeed, can alter the kidney function [[112]]. Peculiar to obesity, the obesity -related glomerulopathy is a secondary form of segmental focal glomerulosclerosis occurring tipically
obesity 29463 recommended in non-diabetic and non-hypertensive obese children (LOE IV-D). Individual cases of severe obesity (BMI > 40) that may be associated with proteinuria in the nephrotic range remain to be evaluated
obesity 29745 vomiting, photophobia, transiently blurred vision, diplopia should be sought in subjects with overweight/ obesity , especially if adolescents. LOE V-AIdiopathic endocranial hypertension is rare but potentially serious
obesity 31645 control, weight concern, dysfunctional social relationships, inactivity due to problematic body image, obesity -related stigma, low self-esteem, academic failure) is crucial to promoting specific strategies that
obesity 31823 promoting specific strategies that improve the results in weight loss programs [[132]–[134]]. Although obesity is not a psychopathological and behavioral disorder, referral for specialist consult is needed in the
obesity 32311 V-BBinge Eating Disorder (BED) is the most common Nutrition and Eating Disorder found in pediatric obesity . It is indicative of psychopathology and is a serious risk factor for the development of obesity, especially
obesity 32408 pediatric obesity. It is indicative of psychopathology and is a serious risk factor for the development of obesity , especially in the presence of family history of obesity and marked negative experiences coupled with
obesity 32465 serious risk factor for the development of obesity, especially in the presence of family history of obesity and marked negative experiences coupled with factors predisposing to psychiatric disorders [[137]].
obesity 32656 disorders [[137]]. BED is often preceeded by uncontrolled eating since childhood, occasional bulimia, obesity , but also by an attention deficit and hyperactivity disorder [[136]–[138]]. Upon referral to appropriate
obesity 36226 multivitamins + minerals, water > 2000 ml/day), which can be prescribed in selected patients with severe obesity , under close medical surveillance and in specialized pediatric centers. The aim is to induce rapid weight
obesity 39187 rugby or require anaerobic and neuromuscular power, such as gymnastics or judo is encouraged. In severe obesity exercises that put constant weight or repeated impact on the child’s legs, feet and hips should be
obesity 40932 neither discouraged to obtain other effects (improvement in vascular response, heart rate and VO2max or obesity -related comorbidities; positive psycho-behavioral and psycho-social effects) [[182]–[184]].Cognitive
obesity 45452 nervosa [[215]–[218]]. Diet education undertakings can accentuate the perceived stigma in subjects with obesity , causing drastic strategies of weight control [[219], [220]]. In some cases, the onset is triggered
obesity 46103 be achieved through lifestyle-based interventions, use of drugs is considered, especially in severe obesity with cardiometabolic, hepatic or respiratory disorders [[222]–[226]]. Management of drugs should be
obesity 46342 [[225]].Orlistat is the only drug available for the treatment of children and adolescents with severe obesity age. LOE II-BFew studies, with small sample size and short duration, are available on the effects of
obesity 46456 LOE II-BFew studies, with small sample size and short duration, are available on the effects of anti- obesity medications in pediatric age [[227]–[230]]. Orlistat (tetra-hydro-lipstinate) is the only drug approved
obesity 46591 age [[227]–[230]]. Orlistat (tetra-hydro-lipstinate) is the only drug approved for the treatment of obesity in pediatric age. It seems producing significant weight loss and favoring behavioral changes [[231]–[233]].
obesity 46994 deficiency [[234]].Bariatric surgeryBariatric surgery is the ultimate solution in adolescents with severe obesity and resistant to all other treatments, especially when serious complications are present. LOE VI-BThe
obesity 47771 serious comorbidities [[223], [237]].Eligibility criteria are: adolescents with long lasting severe obesity ; a. previous failure of any dietetic, behavioral or pharmacological intervention (after at least 12 months
obesity 49542 that will warrant such care and follow-up; acute or chronic diseases even not directly associated with obesity threatening life in the short term; high anesthetic risk; pregnancy or planned pregnancy within the
obesity 51304 improvement of the quality of life [[244], [248]–[250]].Care settingsFor the multifactorial nature of obesity , variability in its severity, and the health implications, treatment should be conducted in multiple
obesity 52364 decisions, when a more aggressive approach is proposed (e.g., hospitalization or surgery). The efficacy of obesity treatment in the primary care setting is still modest [[261], [262]], but it might improve if pediatricians
obesity 52541 but it might improve if pediatricians are assisted by other professionals experienced in pediatric obesity (dieticians/nutritionist, psychologist) and trained in family education and interdisciplinary work [[258],
obesity 52824 responsibilitiesConditionsResponsabilitiesRisk factors:Prenatal life: first-degree familiarity for obesity , low socioeconomic status;Neonatal life: small for gestational age, or macrosomic infant;Postnatal life:
obesity 53320 timing of complementary feedingChildren and adolescents with overweight or moderate, uncomplicated obesity Early identification of children’s excess weightPromoting parental awareness of children’s excess
obesity 53543 weightMotivating and supporting the family to change, possibly involving other professionals trained in childhood obesity Severe obesity or psychological co-morbidity, or additional risk factors, or biochemical alterations,
obesity 53557 supporting the family to change, possibly involving other professionals trained in childhood obesitySevere obesity or psychological co-morbidity, or additional risk factors, or biochemical alterations, or treatment
obesity 53718 factors, or biochemical alterations, or treatment failure within 4–6 monthsIdentification of severe obesity Promoting parental awareness of children’s excess weightMotivating and supporting the family to more
obesity 53875 excess weightMotivating and supporting the family to more intensive levels of careSuspicion of secondary obesity Referral to specialized centersDistrict or hospital outpatient services represent the second level of
obesity 54122 centers, the multidisciplinary team (pediatrician, dietician and psychologist) experienced in pediatric obesity defines the clinical condition of children referred by the primary care pediatricians, and runs the
obesity 54588 compromised psychological balance or significantly impaired quality of life.Specialized centers for pediatric obesity represent the third level of care. LOE VI-AThird level centers are organized on a multidisciplinary
obesity 54824 for comorbidity management or bariatric surgery. They admit patients who are suspected of secondary obesity or require more specialistic diagnostic assessment and/or intensive care programs, including bariatric
obesity 55152 activities and intervention trials in the context of specific protocols [[267]–[271]].TransitionPediatric obesity care should include a transition path from pediatric to adult care. LOE VI-BIt is necessary to test
obesity 55307 pediatric to adult care. LOE VI-BIt is necessary to test a transition model for adolescents with severe obesity and/or complications, particularly with metabolic syndrome, NAFLD, hypertension [[272]–[274]]. Unfortunately,
obesity 55511 Unfortunately, the experience is extremely limited for the high drop-out, poor consideration about obesity as chronic illness, absence of pre-established pathways, possible transition to structures that follow
obesity 55763 hypertension), no availability of cost-effective models [[275]].PreventionGiven the multifactorial nature of obesity , preventive interventions should be designed to modify the environmental and social determinants. Health
obesity 58024 III-AAn excessive weight gain during pregnancy is associated with fetal macrosomy and increased risk of obesity [[285]–[290]]. This effect is independent of maternal hyperglycemia, which is also a well-known risk
obesity 58153 effect is independent of maternal hyperglycemia, which is also a well-known risk factor for future obesity [[291]]. Recommended gestational weigh gain is between 11.5 and 16 Kg in normal weight women, 7 to 11.5
obesity 58328 Kg in normal weight women, 7 to 11.5 Kg, in overweight and 5 to 9 Kg in those who with prepregnancy obesity [[292]].Tobacco smoke in pregnancy is banned. LOE III-AMaternal smoking in the perinatal age increased
obesity 58914 the very first months of life. LOE III-AEarly rapid weight gain increases the risk of overweight and obesity in childhood [[295]]. Prevention in infants is focused on quality, quantity and timing of food intake.
obesity 59750 weaning (which is associated with early satiety-responsiveness acquisition), are protective against obesity respect to usual complementary feeding mode [[312]–[314]]. LOE V-C.From preschool age to adolescenceLow
obesity 60669 III-AProspective studies have shown a negative association between levels of physical activity and overweight/ obesity [[323], [324]]. Even moderate physical activity is sufficient to improve aerobic fitness, an important
obesity 61601 age. LOE VI-BAlthough there are no specific studies on the effects of video exposure on overweight/ obesity in this age group, video exposure should be discouraged since it may disturb sleep regularity [[328],
obesity 61964 than 2 h a day in children > 2 years of age. LOE III-BThe association between sedentary behaviour, obesity and cardiometabolic risk factors is weak, and it is reduced when corrected for physical activity levels
obesity 62206 evidence based on prospective studies and RCTs show a strong relationship between television hours, obesity and cardio-metabolic risk factors, presumably because overfeeding frequently occurs [[331], [332]].Several
obesity 63206 children and adolescents. LOE III-BA short sleep duration is a potential risk factor for overweight/ obesity through neuroendocrine and metabolic influences [[336], [337]]. One meta-analysis of longitudinal studies
obesity 63340 metabolic influences [[336], [337]]. One meta-analysis of longitudinal studies indicated a risk of obesity more than doubled in children with a sleep duration lower than recommended [[338]]. Three intervention
obesity 63516 recommended [[338]]. Three intervention studies aimed at changing sleeping hours within a multicomponent obesity treatment were not effective in reducing the BMI [[339]]. Waiting for stronger evidence, we endorse
obesity 64275 school settings for implementing preventive actionsIt is recommended to include the school settings in obesity prevention programs. LOE I-AThe school is institutionally devoted to the education of children and is
obesity 64638 and physical activity at school prevent excessive weight gain and reduce the prevalence of overweight/ obesity [[341], [342]]. The most effective and promising changes are summarized in Table 9. [[334]].Table 9Effective
obesity 64802 are summarized in Table 9. [[334]].Table 9Effective environmental strategies to prevent pediatric obesity at schoolSupport school personnel’s strategies for implementing health promotion programs.Improvement
obesity 65577 regular school hoursConclusionsThis paper is a Consensus position document on the care of pediatric obesity in children and adolescents produced by experts belonging to the Italian Society for Pediatric Endocrinology
obesity 65824 Italian Society of Pediatrics, and endorsed by the main Italian scientific societies involved in tackling obesity and its complications.Consistent evidences suggest that the disease-burden of obesity on the overall
obesity 65910 involved in tackling obesity and its complications.Consistent evidences suggest that the disease-burden of obesity on the overall health starts very early in life and is particularly serious for the development of cardiometabolic
polycystic ovary syndrome 16905 Islander); - Signs or conditions associated with insulin resistance (hypertension, dyslipidaemia, polycystic ovary syndrome , acanthosis nigricans, or small for gestational age at birth) - Maternal history of diabetes or gestational
polycystic ovary syndrome 22626 impedance monitoring) and treatment is required [[79]].Polycystic ovary syndromeThe components of the polycystic ovary syndrome should be considered in all female adolescents with obesity. LOE VI-APolycystic ovary syndrome (PCOS)
type 2 diabetes mellitus 13309 referred to a specialist for further investigations and treatment [[31], [34], [35]].Prediabetes and type 2 diabetes mellitus Fasting blood glucose measurement is recommended in all children and adolescents with overweight and

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