Recommendations for Treatment of Child and Adolescent Overweight and Obesity

Data Limitations

Virtually no clinical trials examining the effects of any specific dietary prescription on body weight or adiposity in children control for the effects of potentially confounding factors, such as treatment intensity, behavioral intervention strategies, and physical activity. Although comprehensive approaches aiming to modify diet, physical activity, family behavior, and the social and physical environment are undoubtedly needed, studies involving multiple modalities cannot assess the efficacy of any specific component (eg, diet). In the absence of data on the relative efficacy of various dietary prescriptions in the treatment of obesity in children, it is sometimes necessary to make inferences from the childhood obesity prevention and adult treatment literature.

Food Groups and Childhood Overweight

Macronutrient Alterations

Breakfast Skipping

Evidence supports observations that obese children are more likely to skip breakfast or to eat smaller breakfasts than leaner children. The evidence seems to suggest that breakfast skipping may be a risk factor for increased adiposity, particularly among older children or adolescents. However, the strength of the evidence is limited because what constitutes a breakfast has not been defined consistently.¹³

Fifteen studies examining the link between breakfast skipping and adiposity were reviewed. Two studies were longitudinal studies,^38,86 2 were nationally representative, cross-sectional studies,^31,87 and 11 were other types of cross-sectional investigations.^9,35,88–96 Both longitudinal studies^38,86 found that, for girls, breakfast skipping was related to weight gain among those who had normal weight at baseline but was related to weight loss among those who were overweight at baseline. For boys, no relationship was found with breakfast skipping except for weight loss among those who were overweight at baseline in 1 of the 2 studies. The 2 nationally representative studies^31,87 did not find an association between breakfast skipping and reported BMI in younger children, but Siega-Riz et al,⁸⁷ who studied food intake patterns for adolescents, did find a positive association.

Of the remaining 11 studies, 5 found a positive association between breakfast skipping and a measure of adiposity,^{88,90–92,96} indicating that breakfast skippers were more likely to have a weight higher than normal. Four studies found no relationship between breakfast skipping and a measure of adiposity,^35,89,93,95 and 2 studies reported a negative relationship between breakfast skipping and a measure of adiposity, indicating that breakfast skipping was associated with lower measures of adiposity.^9,86

Population-based surveys have revealed that many children, particularly adolescents, skip breakfast and other meals but consume more food later in the day, and this pattern has increased in recent years. Overweight children and adolescents have been shown to be more likely to skip breakfast and to consume a few large meals each day than their leaner counterparts, who are more likely to consume smaller, more-frequent meals. Overweight children have also been reported to eat smaller breakfasts and larger dinners, in comparison with nonoverweight children. It has been suggested that eating breakfast reduces fat intake and limits snacking over the remainder of the day.⁸⁸

Snacking

In a review of the literature, the American Dietetic Association¹³ found that snacking frequency or snack food intake might not be associated with adiposity in children. The majority of the studies reviewed found no association between snacking and adiposity.^{35,36,88,96–99} Francis et al¹⁰⁰ found no relationship between snacking and changes in BMI among girls with nonoverweight parents. Among girls with overweight parents, only fat intake from energy-dense snacks was associated with increased BMI over the 4-year study. However, mixed results were reported among the 7 case-control and other cross-sectional studies that examined the amount of snack food consumed in relation to adiposity. Two found a positive relationship,^35,98 whereas 5 found no relationship.^{8,10,88,97,98} Comparisons of the findings from those studies are limited because there was no clear definition of what constituted a snack or snack food. The best evidence suggests that snacking frequency is not associated with adiposity in children; however, studies that examined total snack food intake produced more-mixed results.

According to national surveys, although the average size of snacks and the energy per snack remained relatively constant, the frequency of self-defined snacking increased from 1977 to 1996 among children in all age groups between 2 and 18 years. Reportedly, between one fourth and one third of the energy intake of adolescents is derived from snacks.³⁹ Furthermore, snacks tend to have higher energy density and fat content than meals, and frequent snacking has been associated with high intakes of fat, sugar, and energy. The primary snacks selected by teens include potato chips, ice cream, candy, cookies, breakfast cereal, popcorn, crackers, soup, cake, and carbonated beverages.

Eating Out

Evidence shows that consuming food away from home, particularly at fast food establishments, may be associated with adiposity, especially among adolescents. A total of 12 observational studies were reviewed, including 2 longitudinal studies with children and 1 longitudinal study with adults,^38,101,102 2 nationally representative, cross-sectional studies,^31,103 and 7 other cross-sectional studies.^{89,92,104–107} Study sample sizes ranged from just over 50¹⁰⁴ to >60000.¹⁰¹ The majority of studies focused on older children and adolescents. In a longitudinal study of girls, Thompson et al¹⁰¹ reported a positive association between eating at fast food establishments and BMI z scores for elementary school-aged girls but no association with eating at coffee shops or other types of restaurants. Taveras et al¹⁰³ found, in a study of >14000 girls and boys, that greater consumption of fried foods eaten away from home was evident for heavier adolescents and that increasing consumption of fried foods eaten away from home over time led to an increase in BMI. In addition, the frequency of eating fried foods away from home was associated with greater intakes of total energy, sugar-sweetened beverages, and trans fats, as well as less consumption of low-fat dairy foods and fruits and vegetables. The other longitudinal study,³⁸ which was conducted in Japan, found no relationship between eating out in general and BMI among preschool-aged children. A nationally representative study by Lin et al³¹ found no association between food eaten away from home and reported BMI. Pereira et al¹⁰² found in the Coronary Artery Risk Development in Young Adults (CARDIA) study that consumption of fast foods was associated directly with body weight and insulin resistance over 15 years among young black and white adults. Findings from the other studies were mixed, ranging from positive associations to inverse relationships. Because both the largest longitudinal study and the largest cross-sectional study took place outside the United States (in Japan and Iran, respectively), their findings are not directly applicable to the US fast food environment. However, the limited evidence currently available suggests that frequent patronage of fast food restaurants may be a risk factor for overweight/obesity in children¹³ and fast food ingestion year after year may accumulate into larger weight gains that can be clinically significant.¹⁰³

Use of Balanced-Macronutrient/Low-Energy Diets

As stated previously, limited research exists for evaluating dietary treatment programs in isolation. However, a few dietary components have been evaluated. Although the outcomes are mixed, evidence does suggest that, in both the short term and the long term, a reduced-energy diet (less energy than required to maintain weight but not less than 1200 kcal [5040 kJ]/day) may be an effective part of a multicomponent weight management program in children 6 to 12 years of age.^108–113 Use of a reduced-energy diet (not less than 1200 kcal [5040 kJ]/day) in the acute treatment phase for adolescent overweight is generally effective for short-term improvement in weight status; without continuing interventions, however, weight is regained.¹³

Six studies that used a reduced-energy diet (not less than 1200 kcal [5040 kJ]) for 6- to 12-year-old youths were reviewed. The studies indicated that the majority of treatment groups decreased in ≥1 measure of adiposity.^108–112 Only 2 studies reported an increase in weight at posttreatment or follow-up assessments.^112,113

Six studies used an energy-deficit dietary treatment for adolescents. Five focused exclusively on adolescents,^{62,68,114–116} whereas the sixth provided treatment for 11- to 16-year-old youths.¹¹⁷ Five of the 6 studies reported a decrease in ≥1 measure of adiposity. Saelens et al¹¹⁴ reported a statistical difference in posttreatment weight status among teens who received a behaviorally based treatment, compared with a single-session, energy-deficit and activity approach, but differences diminished at the 3-month follow-up assessment. Only 2 studies reported follow-up periods of ≥1 year.^62,117 In both of those studies, follow-up weight status was not higher than baseline. Generalizing the results of these studies is difficult because of differences in the treatment environment, duration, and intervention strategies. Treatment settings were outpatient clinics or boarding schools, whereas interventions ranged from computer-based programs with additional nutrition and activity counseling to health center-based, multicomponent programs. In addition, the length of the programs ranged from 3 weeks to 9 months.¹³

Traffic Light Diet

Much of our current understanding of individual/family treatment of pediatric overweight comes from 4 long-term, family-based studies conducted by Epstein et al.^118–123 The studies by Epstein et al^118–123 targeted children 6 to 12 years of age. The traffic light diet (sometimes called the stoplight diet) was developed by Epstein et al^118–123 for use in research on overweight. Perhaps because of the groundbreaking nature of their research, the traffic light diet has become broadly recognized and in some cases copied. The traffic light diet is part of a larger core package of interventions that generally includes family components, physical activity, and interactions with a behavioral therapist. The core intervention program was used in all studies, whereas other variables were manipulated. This presents a problem in trying to isolate the independent effects of the specific dietary intervention on weight loss.

The goal of the traffic light diet was to provide the most nutrition with the lowest energy intake. Daily energy intakes ranged from 900 to 1200 kcal (3780–5040 kJ), with later studies increasing intake to 1500 kcal (6300 kJ)/day.¹²² Food groups were divided into 3 categories, namely, green, yellow, and red. Low-energy, high-nutrient foods (eg, most fruits and vegetables) are considered “green” and may be eaten often. Moderate-energy foods (eg, most grains) are considered “yellow” and may be eaten in moderation, whereas high-energy, low-nutrient foods are considered “red” and should be eaten sparingly. Families were instructed to stay within a prescribed energy range and to reduce “red” food servings to less than a prescribed value for the week (eg, <4 times per week). In addition to the basic diet, and depending on the arm of the intervention study, participants might have been given self-monitoring training and support, praise and modeling, therapist contact, and/or behavioral contracting, in which children were given rewards for meeting dietary and activity goals. Once children/families met their weight goals, counseling was provided to ensure consumption of a balanced diet that would maintain a healthy weight.

The intervention and research program by Epstein et al^118–123 demonstrated modest sustained weight loss in children 5 years and even 10 years after the intervention.¹²³ However, not all of the behavioral interventions provided sustained weight loss.¹²³ It remains unclear what part the diet itself played in these overall results. Because the research by Epstein et al^118–123 focused primarily on white, middle-class, intact families with younger children (6–12 years of age), it is also unclear how well results may be generalized beyond this population.¹³

Food Guide Pyramid

The Food Guide Pyramid was designed as a general guide for diet and exercise and not as a weight loss tool. Although it may be used as a component of a comprehensive childhood weight management program, the evidence does not indicate that, by itself, the Food Guide Pyramid is an effective weight loss tool. Only 1 study was identified that used the pyramid as a weight loss tool. Saelens et al¹¹⁴ found that adolescents who used the Food Guide Pyramid as part of their weight management program gained weight over the course of treatment and at follow-up evaluations. This was compared with adolescents in the control group who ate a balanced, lower-energy diet, whose weight either stabilized or decreased slightly.

Importance of Physical Activity

Although obesity has a complex development, involving environmental, physiologic, and genetic factors, the basic cause of this condition is an imbalance between energy intake and energy expenditure. Physical activity is the only modifiable component of the energy expenditure portion of the energy balance equation. Consequently, increasing physical activity has the potential to improve weight loss and maintenance. Studies indicate that an increase in sedentary activities, particularly television viewing, and an overall decrease in physical activity are contributing to an increased incidence of overweight and obesity in children and adolescents.^124–127 Strategies to increase physical activity should include increases in structured and nonstructured physical activity and reductions in the amount of time spent in sedentary activities. Schools have a unique combination of factors, including facilities, fitness instructors, and contact with large numbers of young people for many hours each day during much of the year, that make them a good environment in which to study physical activity interventions for weight management and to implement proven approaches.¹²⁸

Role of Physical Activity in Weight Management

Noting that accurate measurement of physical activity is complex and that comparisons between studies are difficult because of differences in designs and methods, some researchers have questioned whether it is possible to demonstrate an effect of physical activity in reducing obesity.¹²⁹ Because it is easier to reduce energy intake by 500 to 1000 kcal (2100–4200 kJ)/day than to increase energy expenditure by a similar amount, physical activity has less impact on weight loss than does dietary intervention.

In adults, increasing physical activity did not result in significant weight loss over a 6-month period. Most weight loss occurred as a result of decreased energy intake. Sustained physical activity did reduce the risk of weight regain and also decreased cardiovascular and diabetes risk factors, independent of the reductions in these risks that are associated with weight loss.¹³⁰

Several but not all studies have demonstrated that increased physical activity is associated with decreased BMI in children and adolescents.^131–133 The largest of those studies¹³³ examined the association between changes in BMI over 1 year and same-year changes in self-reported recreational physical activity and in recreational inactivity (television, videotapes, and video games) among 11887 boys and girls 10 to 15 years of age. After correction for growth- and development-related changes in BMI, an increase in physical activity was associated with decreasing relative BMI for girls (−0.06 kg/m² per 1-hour increase in daily activity; 95% confidence interval [CI]: −0.11 to −0.01 kg/m² per 1-hour increase) and for overweight boys (−0.22 kg/m² per 1-hour increase; CI: −0.33 to −0.10 kg/m² per 1-hour increase). Conversely, higher levels of inactivity were correlated with increased BMI in girls (+0.05 kg/m² per 1-hour increase in television, videotapes, and video games; CI: +0.02 to +0.08 kg/m² per 1-hour increase). One study found a relationship between inactivity in overweight preschool-aged boys but not girls.¹³² The third study, involving 47 boys and girls 5 to 10.5 years of age, measured total energy expenditure directly by using the double-labeled water technique and calculated basal metabolic rate by using the Schonfield equation. It used these measurements to calculate physical activity levels, as follows: physical activity level = total energy expenditure/basal metabolic rate. Body fat and BMI were used to estimate body composition. Body fat and BMI were found to be significantly inversely correlated with physical activity levels.¹³¹

Studies that use weight loss as the only criterion with which to assess the value of increased physical activity may miss other important benefits this confers. In a meta-analysis, P. McGovern, PhD (unpublished data, 2006) found that physical activity decreased fat mass but not BMI. Other studies indicated that exercise also improved cardiovascular risk factors.^134,135

Risks of Physical Inactivity

Physical activity may play a role in preventing weight gain and other health problems. Physical inactivity has been shown to be a risk factor for obesity and insulin resistance in school-aged children.¹³⁶ Inactive children may be at increased risk of developing health problems later in life. Several studies suggest that sedentary children are more likely than active children to become sedentary adults and to have increased risks of obesity, diabetes, hypertension, dyslipidemias, and cardiovascular diseases.^{129,135,137,138} A sedentary lifestyle is also associated with increased risks of several cancers common in adults.¹³⁹

Structured Versus Nonstructured Physical Activity

There is some debate in the literature regarding whether structured or unstructured activities should be promoted as a means to increase physical activity. The position of the American Academy of Pediatrics on physical fitness and activity in schools advocates increases in both forms of activity.¹⁴⁰ It states that the development of a physically active lifestyle should be a goal for all children. Opportunities to be physically active should include team, individual, noncompetitive, and lifetime sports, as well as recreational activities. The opportunity to be active on a regular basis, as well as the enjoyment and competence gained from activity, may increase the likelihood that a physically active lifestyle will be adopted.¹⁴⁰

Beyond the school setting, increasing physical activity, even unstructured physical activity, seems to be beneficial.¹³³ It is thought that increasing the frequency or intensity of physical activity can reduce sedentary activities, particularly television viewing. This, in turn, can reduce excess energy balance effectively.¹⁴¹ The goal is not to eliminate television watching; data suggest that children and adolescents can engage in both television viewing and physical activity as long as sedentary behavior is not at the expense of physical activity.^142–145

Amount of Physical Activity

Since 2000, the US Department of Agriculture has recommended that children and adolescents participate in ≥60 minutes of moderate-intensity physical activity most days of the week, preferably daily.¹⁴⁶ This position was reaffirmed in the 2005 Dietary Guidelines for Americans¹⁴⁷ and is supported by the American Academy of Pediatrics¹⁴⁰ and the Centers for Disease Control and Prevention (CDC).¹⁴⁸ The American Academy of Pediatrics recommends that 30 minutes of this activity occur during the school day.¹⁴⁰ Very obese children may need to start with shorter periods of activity and gradually increase the time spent being active. The CDC suggests that parents can help children meet this activity goal by serving as role models, incorporating enjoyable physical activity into family life, monitoring the time their children spend watching television, playing video games, and using the computer, and intervening if too much time is spent in sedentary pursuits.¹⁴⁸

Barriers to Physical Activity

Barriers to physical activity for the pediatric population include lack of opportunities for activity during the school day and environmental factors, such as lack of access to facilities in which to be active and urban environments designed for vehicular transportation that limit activity outside of school.^149–156 In the past decade, schools have been urged to spearhead improvements in childhood wellness through changes in the food and activity programs they offer. The amount of time spent on physical education, however, has decreased in the past 15 years. Between 1991 and 2003, the percentage of high school students enrolled in daily physical education classes decreased from 41.6% to 28.4%. Only 8% of elementary schools, 6.4% of middle/junior high schools, and 5.8% of senior high schools provided daily physical education or allocated the recommended amount of time per week (150 minutes for elementary and 225 minutes for junior and senior high schools), according to a 2000 study.¹⁴⁹

More consideration needs to be given to the types of activities performed during physical education class, because time spent in class does not correlate with activity. Data for 37000 students collected by the CDC as part of the annual Youth Risk Behavior Surveillance Survey found that high school students were active for only 16 of the 50 minutes in an average gym class. Spending more time in physical education classes did not help. When states required an extra year of physical education classes for high school students, which is ∼200 more minutes of physical education per week, male students reported, on average, another 7.6 minutes per week spent exercising or playing sports in gym class. Female students reported, on average, an extra 8.1 minutes per week spent exercising in class.¹⁵⁰

Increasing the intensity of activity during gym class can improve fitness and reduce body fat measurably. Fifty overweight (BMI of ≥95th percentile) children in middle school were assigned randomly to lifestyle-focused, fitness-oriented, gym classes or standard gym classes for 9 months. The children were evaluated for fasting insulin and glucose levels and body composition and assessed with maximal oxygen consumption treadmill testing at the beginning and at the end of the school year. Overweight children who participated in the fitness-oriented gym classes for 9 months showed significant improvements in body composition, fitness, and insulin levels.¹⁵¹ These studies^149–151 indicate that public health policies should focus on revising school curricula to include adequate time for and intensity of physical activity.

Safety concerns, such as heavy traffic and high crime rate, lack of equipment, lack of space, and urban development that favors vehicular transportation are barriers to activity outside of school.^152–156 The World Health Organization has identified transport-related physical activity as an important intervention with which to address the global obesity epidemic, as well as environmental issues such as traffic congestion and its associated pollutants.¹⁵² In the United States, a decrease in transport activity parallels the increase in pediatric obesity. Walking or biking to and from school can help students meet their physical activity needs. However, heavy traffic, lack of bicycle lanes, unmarked intersections, and other obstacles have reduced the number of children who transport themselves to school today, compared with previous generations.

Currently, only one third of students who live within 1 mile of school walk or bike there and <3% of students who live within 2 miles of school walk or bike there. Initiatives such as the government-sponsored, community-implemented, Safe Routes to School program may help reverse this trend. A pilot study conducted in Marin County, California, found that the number of children walking to school increased from 14% in 2000 to 23% in 2002 and the number riding bicycles more than doubled, from 7% to 15.5%, in the same period. Similar results have been observed in other communities around the country. These experiences highlight the need for parents and other interested community members to take an active role in reducing barriers to physical activity.¹⁵³

Lack of access to safe exercise environments is of particular concern in low-socioeconomic status and minority communities, because this may account for racial and economic disparities in health, obesity, and physical activity rates. Burdette and Whitaker¹⁵⁴ found an inverse association between neighborhood safety and television viewing among preschool-aged children. Parents who rated their neighborhoods as unsafe were more likely to report that their preschool-aged children watched >2 hours of television daily. No association was found between television viewing and obesity in these young children; however, early television viewing may establish a pattern of sedentary activity that leads to obesity in later childhood. An observational study examined the associations between community physical activity-related settings (eg, sports areas, public pools and beaches, parks and green spaces, and bicycle paths) and race, ethnicity, and socioeconomic status in 409 communities throughout the United States.¹⁵⁵ The researchers reported that higher median household incomes and lower poverty rates were associated with increasing levels of available physical activity-related facilities and settings. Communities with greater proportions of ethnic minorities had fewer physical activity-related settings. Using data from the first wave of the National Longitudinal Study of Adolescent Health (N = 20745), Gordon-Larsen et al¹⁵⁶ demonstrated a direct relationship between decreased access to physical activity facilities and overweight. They found that communities with low socioeconomic status and large minority populations had reduced access to recreational facilities. These factors were associated with decreased physical activity levels and increased incidence of overweight. These associations suggest that lack of opportunities for physical activity may contribute to the disproportionately greater incidence of obesity in ethnic minority groups and groups with low socioeconomic status.¹⁵⁶

Other researchers have found that schools with large minority populations are less likely to have programs that support healthy eating and physical activity.^157–159 A survey of 3600 households with children 9 to 13 years of age that was conducted by the CDC in 2002 found that non-Hispanic black parents and Hispanic parents cited concerns about transportation, lack of local facilities, and expense as barriers to their children participating in physical activity and organized sports outside of school more often than did non-Hispanic white parents.¹⁶⁰ There are many communities and neighborhoods in which inadequate school wellness programs, lack of access to facilities for physical activity outside of the classroom, and lack of discretionary income may contribute to the high obesity rates seen among economically disadvantaged individuals.

Higher economic status does not guarantee that people will live in neighborhoods that encourage more activity. Built environments in suburban communities often are not conducive to walking, biking, and other physical activities. Neighborhood comparison and correlational studies with physical activity transport outcomes suggest that residents from communities with higher density, greater connectivity, and more land use mixture have higher rates of walking/cycling for utilitarian purposes than do low-density, poorly connected, and single-land use neighborhoods. Environmental variables seem to add to the variance accounted for beyond sociodemographic predictors of walking/cycling for transport.¹⁶¹

In what is thought to be the first study to examine the link between obesity in rural communities and environmental factors, Boehmer et al,¹⁶² from the St Louis University School of Public Health, found that residents of rural communities who felt isolated from recreational facilities, stores, churches, and schools were more likely to be obese than were those who thought they were closer to such facilities. Closeness counted; people who thought that safe walking and/or biking routes were within 10-minute walking distance of their homes were more likely to be active. Approximately 25% of the population in states in the South and Midwest live in rural environments.¹⁶² To ensure that people of all income levels have opportunities to be physically active as part of their daily routines, community leaders and environmental planners need to address safety and access issues.

Psychosocial barriers such as perceptions of class rank and self-esteem, and their impact on physical activity, have been studied but are not well understood. Physical activity self-efficacy (confidence in one's ability to participate in exercise) has been widely studied as a potential psychosocial correlate of increased levels of physical activity. However, this association is not clear for children and adolescents.¹⁶³

Reducing Sedentary Activities

As a first step toward addressing neighborhood safety barriers to activity, the American Academy of Pediatrics recommends that activities that can be performed indoors, such as exercising to videotapes, using hula hoops, and dancing to popular music, should be encouraged.¹⁶⁴ A complementary strategy for promoting physical activity among children and adolescents is to decrease their inactivity by decreasing the time spent in sedentary activities such as television viewing, leisure time use of the computer, and video game playing. Staying active while watching television by stretching, performing calisthenics, or using exercise equipment can also reduce the time spent in sedentary pursuits. Television viewing may have a negative effect on both sides of the energy balance equation. It may displace active play and physical activity time and it is associated with increased food and energy intake, as an accompaniment to television viewing and as a result of food advertising.¹⁶⁵

Summary

Addressing childhood obesity requires a comprehensive holistic approach. Although the evidence is limited, increased physical activity alone has not improved children's weight status substantially. Promotion of routine physical activity in children from preschool age on may help prevent the development of overweight and obesity and has other benefits, including reductions in cardiovascular disease risk factors. Particular consideration should be given to methods of increasing activity in adolescents. Studies suggested that time, cost, availability, and convenience were key factors that influenced what adolescents ate and whether they were physically active.^166,167 Students reported that social support from friends and family members, as well as teachers and adults who modeled healthy behaviors, enhanced their likelihood of eating healthy foods and being physically active.^168–170 Finally, the American Academy of Pediatrics¹⁴⁰ recommends that (1) all children meet the goal of 60 minutes of moderate activity per day; (2) schools be provided with the necessary resources to incorporate 30 minutes of moderate to intense activity into each student's daily schedule; (3) clinicians instruct parents on techniques for increasing activity in the home environment, including reducing time spent in sedentary activities; and (4) health care providers become involved in the community to address access and safety issues.

Television Viewing and Obesity

Investigators have examined many aspects of diet and physical activity, but some of the strongest evidence of a behavioral risk for overweight in children points to the impact of television viewing. Epidemiologic and experimental evidence from the past decade supports decreased television viewing as a primary preventive intervention for the reduction of overweight and other chronic disease risks. Many cross-sectional^{136,171–177} and longitudinal^{133,173,178–180} observational studies in the United States document the effect of television viewing on overweight. These studies are reinforced by others in at least 12 other countries.^{173,181–190} The observational studies have been corroborated by randomized, controlled trials designed to reduce levels of both television viewing and overweight. In a randomized, controlled trial, Gortmaker et al¹⁹¹ showed that reductions in television viewing were associated with decreased obesity. Among girls, each 1-hour reduction in television viewing predicted reduced obesity prevalence. Guillaume et al¹⁹⁰ found a significant relationship with BMI and systolic blood pressure for television viewing in boys. In a randomized, controlled, school-based trial, Robinson¹⁹² showed that intervention groups had statistically significant decreases in BMI with reductions in television viewing and eating meals in front of the television. That author also found reductions in waist circumference and waist/hip ratios. In a randomized trial, Epstein et al¹⁹³ found that, at 1-year follow-up assessments, children who were counseled regarding decreasing sedentary activities versus increasing physical activity or a combination of the 2 had a greater decrease in the percentage of overweight than did children from the other 2 groups. In fact, children in the sedentary activity-reduction group increased their liking for high-intensity activity and reported lower energy intake than did children in the exercise group.

Influences on Diet, Physical Activity, and Chronic Disease Risks

Television viewing is likely to influence overweight by replacing more vigorous activities, as well as affecting diet.^144,178,194 Foods are heavily advertised in children's television programming,¹⁰⁵ and television viewing is associated with children's between-meal snacking.¹⁹⁵ A randomized trial indicated that increased television viewing resulted in increased energy intake and decreased energy expenditure.¹⁹⁶

Other studies documented similar effects of television viewing on overweight among preschool-aged children.¹⁹⁷ Reducing excess television viewing among youths is a national health objective for 2010.¹⁹⁸ Since 1986, the American Academy of Pediatrics has recommended limiting television viewing to no more than 2 hours/day for children ≥2 years of age.¹⁹⁹ The American Academy of Pediatrics has broadened this guideline by recommending no television viewing for children <2 years of age and suggesting that total entertainment media time be limited to no more than 1 to 2 hours/day for children >2 years of age.²⁰⁰ Other studies demonstrated that having a television in the room where a child sleeps is a major predictor of television viewing^{177,180,201,202} and that, once in the room, televisions often are not removed.²⁰³ These data point to the utility of early intervention strategies to limit television viewing.

An important fact about television viewing is that it correlates only minimally with measures of moderate and vigorous physical activity²⁰³ and therefore is an independent risk factor for overweight. Similar findings on the impact of television viewing on overweight, independent of the effects of moderate and vigorous physical activity, have been reported in prospective studies of adults^204,205 and in studies of television viewing, physical activity, and diabetes incidence among men and women.^206,207

Several studies also indicated that television viewing has substantial effects on other risk factors for chronic disease, including smoking,²⁰⁸ reduced fruit and vegetable consumption,²⁰⁹ increased aggression,²⁰⁰ and less time spent reading and doing school homework.²¹⁰ During the developmental period in which television viewing becomes an entrenched habit (ie, the preschool/early primary school years),²¹¹ children also are developing physical activity skills and learning to read. Other potential benefits of reduced television viewing in this age group may be increased physical activity and reading.

Socioeconomic Status, Ethnicity/Race, Television Viewing, and Overweight

The prevalence of childhood and adolescent overweight in the United States has grown most rapidly among black and Hispanic youths, and health disparities have widened in the past decade.²¹² The treatment writing group strongly supports the Healthy People 2010 goal of eliminating gender-, race/ethnicity-, and socioeconomic status-associated disparities in health status, risks, and use of preventive services. Groups with lower socioeconomic status and racial/ethnic minority groups generally are at greater risk of morbidity and death resulting from chronic diseases, including cardiovascular disease, stroke, and diabetes mellitus.^213–216 Therefore, reducing television viewing among young ethnic minority children in the United States has the potential to reduce excess chronic disease among youths, as well as to reduce adult rates of morbidity and death resulting from chronic illnesses.¹³⁶ Several studies have noted substantially higher levels of television viewing among ethnic minority children, particularly black children, and among boys, compared with girls.^{175,177,217,218} A number of studies also reported stronger associations between television viewing and overweight among girls, compared with boys,^{126,191,210,219,220} including a randomized trial that found that the strongest effects of reduced television viewing were in black girls.²¹⁹ These differences according to gender and ethnicity²²¹ indicate the need to focus on cultural diversity²²² in developing interventions, as well as increasing awareness that efforts to reduce television viewing have the potential to reduce ethnic and gender disparities in overweight.

Other Media Usage

In the past 5 years, media use by children has increased significantly. However, limited research is available on uses of “screen time” other than television, such as computers, video games, DVDs, and instant messaging. In a recent study of parents of children 0 to 6 years of age, Vandewater et al²²³ found that, on a typical day, 75% of children watched television and 32% watched videotapes/DVDs, for ∼1 hour and 20 minutes, respectively, on average. New media also are making inroads with young children; 27% of 5- to 6-year-old children used a computer (for 50 minutes, on average) on a typical day. Many young children (one fifth of 0- to 2-year-old children and more than one third of 3- to 6-year-old children) also have a television in their bedrooms. The most common reason given was that this frees up other televisions in the house so that other family members can watch their own shows (54%). The majority of children 3 to 6 years of age fell within the American Academy of Pediatrics guidelines, but 70% of 0- to 2-year-old children did not.

Another study of older children and adolescents²²⁴ found that approximately one half (53%) of all 8- to 18-year-old youths said that their parents gave them no rules about television watching. Nearly one half (46%) said that they did have rules regarding screen time but only 20% said that the rules were enforced most of the time. Most importantly, youths with rules that were enforced reported 2 hours less of media exposure per day than did those in homes without this supervision. Despite the concerns parents express about the impact of media on their children, this study did not find much evidence of major parental efforts to curb or to monitor viewing habits.

Summary

Epidemiologic and experimental evidence from the past decade supports decreased television viewing as a primary preventive intervention for the reduction of overweight and other chronic disease risks. Screen time for children >2 years of age should be limited to no more than 1 to 2 hours/day. Television viewing is not recommended for children <2 years of age. Parents need to take an active role in setting total screen time limits and monitoring their children's viewing habits. Health care professionals should encourage parents not to put a television in the room where their child sleeps and to remove the television if it is already there.

Techniques

Behavioral therapy for pediatric obesity uses a number of techniques that modify and control children's food and activity environments in ways that bring about weight loss. These techniques include removing unhealthy foods from the home, monitoring behavior by asking children or parents to keep track of the foods consumed, setting goals for energy consumption and physical activity, and rewarding children's and sometimes parents' successful changes in diet and physical activity. Additional behavioral approaches include training in problem solving and other parenting skills. These techniques have been described in detail elsewhere.²²⁵

Subjects, Settings, and Delivery Formats

Most published trials of behavioral interventions have taken place in specialty treatment centers staffed by physicians, nutritionists, exercise therapists, and/or psychologists. The programs studied were conducted or designed by a multidisciplinary team of providers, including a psychologist, and included children and adolescents 5 to 17 years of age. These programs generally included behavioral interventions in conjunction with changes in diet and physical activity, delivered at least in part in a group setting. Comparative data that identify the optimal frequency of visits do not exist. However, most outpatient-based interventions included 8 to 16 initial weekly group sessions lasting 45 to 90 minutes, followed by visits of decreasing frequency for a total duration of 4 to 12 months.

In one trial, group-only treatment was as effective in producing weight loss and was more cost-effective than combined group and individual family sessions.²²⁶ Two inpatient programs based in Belgium and an 8-week summer camp program in Massachusetts showed efficacy in producing weight loss and improved psychological well-being.^227–229 Another trial, conducted in Germany in an inpatient treatment program with 9- to 19-year-old obese adolescents, compared self-management of weight and muscle relaxation training as additions to a structured exercise and diet program and found no added benefit beyond inpatient effects.²³⁰

Few studies of pediatric obesity treatment have been conducted as part of primary care. One trial of overweight adolescents included a single session with a primary care provider, followed by either telephone- and mail-based behavioral intervention or no additional treatment. There was some evidence of better efficacy among the behaviorally treated adolescents, although absolute efficacy was less than with more-intensive clinic-based and inpatient interventions.¹¹⁴ Approaches using Internet-based treatment offer some evidence that, even when delivered in this nontraditional format, behavioral treatment is more efficacious than dietary and physical activity education alone.²³¹

Several researchers have addressed a key question, namely, who should be the target for change. Including parents as agents of change seems critical for children's success, particularly for younger children. Several studies by Epstein et al^118,123,232 of children 8 to 12 years of age demonstrated that targeting and reinforcing behavioral changes in parents as well as their children was more effective than targeting children alone. Another study of obese adolescents 12 to 16 years of age produced similar findings.²³³ Studies conducted in Israel with children 6 to 11 years of age suggested that targeting exclusively parents for change was superior to targeting only children for change.^234,235 Israel et al²³⁶ found that providing training in parenting skills sustained improved child weight status at 1-year follow-up assessments. Although parents need to be active in helping their children make healthy diet and physical activity choices,²³⁷ the evidence suggests that targeting parents to lose weight improves their child's outcomes, particularly for children <12 years of age.²³⁴ The evidence on the amount and type of parental involvement in adolescents' weight control is far more inconsistent.

Evidence for Efficacy of Behavioral Therapy Components

The most effective treatments for childhood obesity include both dietary and physical activity interventions; however, simply providing education about needed changes is inadequate.^238–241 A number of behavioral therapy techniques, including environmental control approaches (such as parental modeling of healthful eating and physical activity), as well as monitoring, goal-setting, and contingency management, can facilitate recommended changes in children's diet and physical activity.²²⁵ A nonrandomized trial conducted in Israel by Eliakim et al²⁴² demonstrated that children and adolescents who completed a 12-week program that included behavioral therapy sessions with a psychologist reduced their BMI more than did untreated control subjects. An early study of children 5 to 8 years of age by Epstein et al²³⁹ demonstrated that family-based behavioral therapy, including praise, modeling, and contracting, produced greater benefits than did diet and exercise education without behavioral therapy. Similarly, in their study of children 10 to 11 years of age, Flodmark et al¹⁰⁸ found that the addition of family therapy to dietary counseling and medical visits was effective.

Published descriptions of various weight management interventions and programs indicate that self-monitoring or parental monitoring is a nearly universal component, even in pharmacologic intervention trials. Monitoring usually consists of written documentation of foods eaten (or categories of foods, on the basis of the prescribed dietary plan) and/or physical activity performed. Goal-setting and contingency management are commonly reported behavioral tools, but interventions differ in their dietary and activity targets and in whether specific weight change is a rewarded goal. Environmental control is a less common behavioral strategy, but more than one half of the studies reviewed described specifically how caregivers were encouraged to make obesity-discouraging changes in the home and other environments.

Several factors complicate efforts to determine the relative efficacy of individual behavioral strategies. A major obstacle is that strategies included in interventions often are not described completely. Another obstacle, with only a few exceptions,²⁴³ is the limited number of dismantling trials that test the efficacy of single strategies in isolation. Furthermore, most intervention programs teach and encourage the use of many behavioral strategies to help children change their diet and/or physical activity levels; however, few report on whether participants use these strategies and whether their level of use, individually or collectively, is associated with observed changes in weight. Some evidence supports their collective effectiveness and, to a lesser degree, their individual impact. In one study, Epstein et al¹¹⁸ found that children's reports of seeking low-energy snacks, graphing their weight, and eating fewer items classified as “red foods” (on the traffic light diet) were related to weight outcomes and an association with weight loss did exist. Others have reported that more-frequent and more-accurate self-monitoring is related to better outcomes in children.^244–246 Still others have found that positive parental modeling of healthy choices and parental praise of such choices are related to better outcomes.²⁴⁷ It is noteworthy that children whose parents mastered various behavioral strategies had better treatment outcomes than did children whose parents did not master the strategies.²⁴⁸

Many interventions encourage children and caregivers to use additional behavioral techniques that can be classified as problem-solving approaches, including strategies such as preplanning and relapse prevention. The addition of structured or formal problem-solving training to a family-based, behavioral, weight loss program was found to be more effective in one trial²⁴⁹ but not in another.²⁴⁸ Cognitive strategies, such as cognitive restructuring, have been used to augment behavioral strategies, but cognitive strategies alone seem less effective than behavioral strategies alone,²⁴⁹ and addition of cognitive strategies fails to improve the efficacy of behavioral strategies alone.²⁵⁰

Behavioral strategies seem efficacious in changing both dietary and physical activity behaviors. Several trials by Epstein et al^144,243 have examined how behavioral approaches can be used to affect activity levels. Using environmental control and providing reinforcement to reduce sedentary behaviors were reported to be effective in improving weight status. A study by Faith et al²⁵¹ of obese children 8 to 12 years of age demonstrated that simply placing an exercise bike in front of the television was not effective but making viewing contingent on pedaling reduced viewing and increased physical activity.

Overall, systematic training and parental adoption of various behavioral skills for helping change children's dietary and physical activity behaviors are core and seemingly necessary components of pediatric obesity treatment. However, it is unclear whether all skills are necessary for all families or whether tailoring can be used to optimize outcomes while minimizing intervention resources.

Potential Psychological Complications of Behavior-Based Treatment

Only one study, a 10-year follow-up study of children who completed behavioral interventions for obesity, reported on potential complications of treatment. Epstein et al¹²³ found increased rates of psychiatric disorders such as depression, substance abuse, and eating disorders, but it was unclear whether these conditions were a result of treatment or simply comorbid conditions associated with obesity. Other trials showed improvements in children's psychological functioning and did not find higher rates of eating disorders among children treated with a family-based, behavioral, weight management intervention.²⁵¹

Weight Loss Medications in the Treatment of Pediatric Obesity

The use of weight loss medications in obesity treatment has a complicated history. Many medications used to treat obesity were eventually withdrawn from the market or their use restricted after documentation of dangerous side effects.^252–255 The most-recent examples are the withdrawal of the prescription medication fenfluramine, which was banned in the United States in 1997, because of associated cardiac valve abnormalities^254–255 and the removal of ephedra from the herbal market²⁵⁶ and phenylpropanolamine from the over-the-counter market because of cardiovascular concerns.^254–255 These experiences underscore the need to use weight loss medications conservatively for all obese patients. Particular care must be taken when the use of weight loss medications is considered for children, because the long-term effects of these substances on growth and development have not been studied.

Pharmacotherapy alone has not proved to be an effective obesity treatment.^252,254,255 Medication used as part of a structured lifestyle modification produces an average weight loss of 5% to 10%, which typically plateaus at 4 to 6 months of therapy, after which weight regain may occur. Weight regain is common if the drug is withdrawn.^252,254,255 Despite these limitations, pharmacologic agents may be helpful in the treatment of obesity for carefully selected patients, as part of a multimodal therapy²⁵⁷ that includes diet, exercise, and behavior modification.

Few guidelines are available regarding the use of weight loss medications in the pediatric population. Weight loss through lifestyle changes is optimal. However, when clear health risks are present and lifestyle changes alone have not been effective, medications may be used as adjunctive therapy. Freedman et al²⁵⁷ used cross-sectional (N = 10099) and longitudinal (N = 2392) analyses to assess risk factors associated with excess adiposity in very overweight children and adolescents between 1973 and 1996. They concluded that the 99th percentile of BMI for age may be an appropriate threshold for identifying children and adolescents who are at very high risk for biochemical abnormalities and severe adult obesity and thus may be candidates for more-aggressive treatment such as pharmacotherapy.²⁵⁷ Obese pediatric patients who seem to be candidates for drug therapy should be referred to a tertiary care center for evaluation and treatment. Presently, the Food and Drug Administration (FDA) approves 6 drugs specifically for obesity treatment,²⁵⁴ only 2 of which, orlistat and sibutramine, have been approved for limited use among pediatric patients. Some research suggests that drugs developed and approved for the treatment of insulin resistance also may improve weight control. Preliminary research suggests that metformin may improve weight control, but this has not been tested in children and the drug is not approved for this indication.

Medications Approved by the FDA for Limited Use in the Treatment of Pediatric Obesity

Sibutramine, an appetite suppressant, is a nonselective reuptake inhibitor. It is most effective against serotonin and norepinephrine but also blocks dopamine reuptake.²⁵⁸ Sibutramine is currently licensed in the United States for use for persons ≥16 years of age. The FDA has extended the period of treatment to 2 years.²⁵⁹ Tolerability and side effects of sibutramine are similar for adults and adolescents.²⁵⁹ The major undesirable side effect of sibutramine is vasoconstriction, leading to increased heart rate and blood pressure. This effect persists even after significant weight loss,²⁵⁹ limiting the usefulness of this drug for obese individuals with concomitant hypertension.

A 1-year, multicenter study of 498 adolescents 12 to 16 years of age found that those who received sibutramine plus behavioral therapy lost significantly more weight than did those who received a placebo and behavioral therapy.²⁶⁰ Patients in the sibutramine group lost an average of 6.35 kg during the study, whereas those in the placebo group gained 1.8 kg. The adolescents in the sibutramine group also exhibited significant decreases in insulin and triglyceride levels. The main adverse reaction was tachycardia, which was twice as common in the sibutramine group (12.5%) as in the placebo group (6.2%).²⁶⁰ A previous but much smaller (N = 82) randomized, control study at the same medical center found that sibutramine used in combination with behavioral therapy increased weight loss by 4.6 kg, compared with placebo.²⁴⁴ However, weight loss in the sibutramine group plateaued after 6 months of therapy, and serious side effects such as hypertension and tachycardia were observed for 19 of 44 patients. A second group of researchers who studied the safety and efficacy of sibutramine in a double-blind control study involving 60 obese adolescents reported an average weight loss of 8.1 kg at 6 months in the sibutramine group but did not observe any significant changes in blood pressure.²⁶¹ All investigators concluded that more research is required to determine the long-term safety and efficacy of sibutramine in adolescents.^244,260,261

Orlistat is a reversible lipase inhibitor. It binds lipase in the lumen of the stomach and intestine, making it unavailable to hydrolyze dietary fat (triglycerides) and cholesterol to free fatty acids and glycerol. Intact triglycerides and cholesterol cannot be absorbed; they pass through the intestine and are excreted in the feces. Through this mechanism, orlistat reduces fatty acid absorption by ∼30% (16 g/day) in persons consuming a 30% fat diet. The side effects of orlistat are consistent with its method of action on intestinal lipase.^253,262 The drug's most common side effects are abdominal cramping and flatus. The most troubling side effects are oily bowel movements, flatus with discharge, and oily spotting on underwear caused by unabsorbed fat in the feces.²⁶² In a tolerability study with 20 adolescent patients, 3 patients dropped out and those who completed the study reported taking 80% of their prescribed medication. Side effects were usually mild to moderate and generally decreased in frequency with continued treatment.^263,264 The observed decrease may be attributable to improved compliance with the recommended dietary changes (no more than 30% of energy from fat), reinforced by unpleasant side effects. Orlistat does not inhibit other intestinal enzymes. It is minimally absorbed and exerts no effect on systemic lipases.²⁶² Because it can interfere with the absorption of fat-soluble vitamins, patients taking the drug must also take a daily supplement.

In a 54-week, double-blind, randomized, control trial of 539 obese adolescents 12 to 16 years of age, those taking orlistat reduced their BMI (−0.55 kg/m²), whereas those taking a placebo showed a slight increase in BMI (+0.31 kg/m²). This difference was significant (P < .001). Changes in waist circumference followed a similar pattern. Waist circumference decreased in the orlistat group (−1.33 cm) but increased in the placebo group (+0.12 cm; P < .05). No significant between-group differences in blood glucose and lipid levels were observed, however, which suggests that the weight loss was too small to change metabolic risk factors. Up to 50% of participants reported moderate side effects.²⁶³ The 17 adolescents who completed the tolerability study lost an average of 5.4 kg (BMI change: −2.0 kg/m²) at 6 months.²⁶² In adult studies, the drug improved weight loss among people on a weight-reducing diet and helped them maintain weight loss for up to 2 years.²⁵² One disadvantage of using orlistat in the pediatric population is that it must be taken with each meal, which may reduce its usefulness for children who typically eat lunch at school. In 2006, the FDA recommended that orlistat be approved for over-the-counter use.²⁶⁵

Choosing the Right Medication

More than 120 potential drugs for treatment of obesity are currently in various stages of research, but presently no agent that treats obesity effectively as a single therapy is available. Weight management medications should be prescribed only for patients who have significant weight-related health risks, who have not reduced their weight successfully with a structured diet and lifestyle modifications, and who understand the limitations of available pharmacotherapy, including the need for concomitant lifestyle changes and the fact that the effectiveness of currently approved medications decreases after 6 months of treatment. Obese pediatric patients who may benefit from pharmacotherapy should be referred to a tertiary care center for evaluation and treatment. The choice of pharmacotherapy should be made on an individual basis, taking into account the patient's weight-related health risks, the mechanism of action and adverse effects associated with various medications, patient/family preferences, and, if known, the cause of obesity. Medication should be used only as part of a multimodal weight loss therapy that includes diet, physical activity, and behavior modification.

Discontinuing Medications

It is not possible to provide uniform guidelines regarding the duration of pharmacotherapy. Physicians must recognize that weight regain is common after drugs are withdrawn. Patients should participate in an intensive lifestyle-modification program while using medications, so that they will be better able to manage their weight on their own. Lifestyle-management techniques may need to be intensified when medication is discontinued.

Bariatric Surgery

Severe obesity has proved difficult to treat through diet and lifestyle changes, even with the addition of weight management medications. The increased use of bariatric surgery to treat morbid obesity and associated comorbidities in adults has generated interest in using this therapy for adolescents. There is limited research on the safety, efficacy, and long-term outcomes of bariatric surgery for adolescents; therefore, data from adult studies must be considered as surrogate evidence.

Bariatric Surgical Procedures

Bariatric weight loss procedures can be divided into 3 main categories, that is, malabsorptive, restrictive, and combination. Combination procedures, such as the Roux-en-Y gastric bypass, restrict food intake and limit the amounts of energy and nutrients the body absorbs. Gastric bypass procedures are the only form of bariatric surgery currently approved by the FDA for use in adolescents, because they are the most extensively studied.²⁶⁶ European and Australian researchers have reported success with a restrictive procedure known as a laparoscopic adjustable-gastric band procedure.²⁶⁷ The least-invasive bariatric procedure, it has the added advantages of being totally reversible and having the least potential for adverse nutritional consequences. However, the laparoscopic adjustable gastric band has not been approved by the FDA for use in people <18 years of age, because of a lack of both short-term and long-term safety and efficacy data for adolescent patients. Currently, a multicenter clinical trial of the laparoscopic adjustable gastric band is being conducted with adolescents.

Case Series

Two retrospective case series on bariatric surgery in adolescents, totaling ∼40 patients who underwent gastric bypass procedures, reported significant weight loss for most patients, with resolution of most comorbid conditions. Complications included nutritional deficiencies, including iron and folate deficiencies. Perioperative complications included pulmonary embolism, wound infection, and dehydration, with later complications such as small bowel obstruction, incisional hernias, and weight regain in up to 15% of cases.^268,269 Apovian et al²⁷⁰ reviewed 8 retrospective case-series studies of weight loss surgery in children and adolescents between 1980 and 2004. They found that bariatric surgery in adolescents could promote durable weight loss for most patients; however, there seemed to be significant complication and mortality rates. Appropriately designed trials are needed to determine whether other bariatric surgical procedures are acceptable for use in adolescents.^266,271

Recommendations and Controversies

An expert panel of pediatricians and pediatric surgeons made recommendations about selection criteria for bariatric surgery in minors.²⁶⁶ The panel recommended that patients be physically mature, have a BMI of ≥50 kg/m² or ≥40 kg/m² with significant comorbidities, have experienced failure of a formal, 6-month, weight loss program, and be capable of adhering to the long-term lifestyle changes required after surgery. In addition, centers should offer this procedure only if surgeons are experienced in bariatric surgery and a team of specialists is capable of long-term follow-up care of the metabolic and psychosocial needs of the patient and family. In response to these recommendations, others have proposed a lower BMI cutoff point, similar to adult recommendations, citing greater success with earlier intervention and lower operative risks when patients are at lower weights.²⁷² Freedman et al,²⁵⁷ using cross-sectional (N = 10099) and longitudinal (N = 2392) analyses to assess risk factors associated with excess adiposity in very overweight children and adolescents, concluded that the 99th percentile of BMI for age may be an appropriate threshold for identifying candidates for more-aggressive treatment, including bariatric surgery. Attainment of physical maturity can be assessed through Tanner stage and bone age. Generally, girls should be ≥13 years of age and boys ≥15 years of age. Assessing the patient's psychological readiness for bariatric surgery is often more difficult than determining physical readiness.²⁶⁶ Patients must be capable of and willing to adhere to nutritional guidelines postoperatively, must demonstrate decisional capacity, and must provide informed assent for surgical treatment.

After the procedure, meticulous, lifelong, medical supervision of patients who undergo bariatric procedures during adolescence is essential to ensure optimal postoperative weight loss, eventual weight maintenance, and overall health. This is particularly important for adolescents, because the long-term effects of bariatric surgery in younger, reproductively active populations have not been well characterized.^266,270,271 Given the limited quantity and scope of data on the risks and benefits of adolescent bariatric surgery, a conservative approach is needed.

Stages of Treatment

On the basis of the evidence in this report, a step or staged approach for weight management in the pediatric population is recommended. Evidence supports the components of these stages, but the staged approach itself has not been evaluated. We suggest this approach as a practical way to address childhood obesity. The staged care process is divided into 4 stages, that is, (1) Prevention Plus (healthy lifestyle changes), (2) structured weight management, (3) comprehensive multidisciplinary intervention, and (4) tertiary care intervention. Each stage and its appropriate application are described. Two primers have been developed to help primary care providers and other practitioners assess the ability of commercial weight loss programs and bariatric surgery centers to treat pediatric obesity patients.

The purpose of this article is to offer practical guidance to providers by providing recommendations, including those that lack the best possible evidence. When evidence of an effect of obesity treatment was not available, the writing group considered the literature, clinical experience, the likelihood of other health benefits, the possible harm, and the feasibility of implementing a particular strategy before including it. Although a thorough, evidence-based review was beyond the scope of this project, the writing group provided a broad rating of the evidence, so that readers can appreciate the limitations of these recommendations and watch for new studies that will refine them. The rating categories were as follows: (1) recommends with consistent evidence (CE), that is, multiple studies generally show a consistent association between the recommended behavior and either obesity risk or energy balance; (2) recommends with mixed evidence (ME), that is, some studies demonstrated evidence for weight or energy balance benefit but others did not show significant associations, or studies were few in number or small in sample size; (3) suggests, that is, studies have not examined the association of the recommendation with weight or energy balance, or studies are few, small in number, and/or without clear findings; however, the expert committee thinks that these recommendations could support the achievement of healthy weight and, if future studies disprove such an effect, then these recommendations are likely to have other benefits and are unlikely to cause harm. The rating categories for the treatment recommendations may differ from those for the prevention recommendations because of limited research in certain areas of treatment of childhood obesity.

Table 1 is designed to acquaint providers with the dietary, physical activity, and behavioral interventions that correspond to each of the 4 stages of the staged weight management process. Table 1 also identifies the appropriate setting, caregivers, and frequency of follow-up evaluation corresponding to each stage of treatment. It should be noted that patients who require stages 3 and 4 may benefit from referral to a community-based program or a pediatric weight management center for additional evaluation and treatment, to access a multidisciplinary health care team.

Table 2 provides a treatment algorithm to help physicians determine the appropriate weight management stage for each patient, on the basis of his or her age, BMI percentile, and, if applicable, weight-related disease status and former obesity treatment history. Age-appropriate, BMI-dependent, weight goals are also provided for treatment stages 1 to 3. Figures 1, 2, and 3 present this information in a flow algorithm. New data indicate that extreme obesity in children is increasing in prevalence, and these children are at high risk for multiple cardiovascular disease risk factors.²⁵⁷ Because of this, the expert committee proposes recognition of the 99th percentile BMI. The marked increase in risk factor prevalence at this percentile provides clinical justification for this additional cutoff point. Although more research is needed, the committee recommends that providers use this BMI cutoff point in providing treatment with the staged approach. Table 3 provides 99th percentile cutoff points according to age and gender.

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FIGURE 1

Suggested staged treatment for 2- to 5-year-old children. The order of the stages and the time in each stage should be tailored to the child's physical and emotional development and the readiness of the child and family to change. SWM indicates structured weight management; CMI, comprehensive multidisciplinary intervention.

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FIGURE 2

Staged treatment for 6- to 11-year-old youth. The order of the stages and the time in each stage should be tailored to the child's physical and emotional development and the readiness of the child and family to change. SWM indicates structured weight management; Cont, continue; CMI, comprehensive multidisciplinary intervention; TCI, tertiary care intervention.

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FIGURE 3

Staged treatment for 12- to 18-year-old youths. The order of the stages and the time in each stage should be tailored to the child's physical and emotional development and the readiness of the child and family to change. SWM indicates structured weight management; Cont, continue; CMI, comprehensive multidisciplinary intervention; TCI, tertiary care intervention.

Choosing and Advancing Treatment Intensity

The Prevention Plus stage may be an appropriate initial treatment intervention for all overweight and obese children 2 to 18 years of age. Obese children and adolescents with significant comorbidities and those with severe obesity may be immediately enrolled in a more-advanced stage of treatment if such services are readily available and if the child demonstrates appropriate motivation and readiness to change. It may take 3 to 6 months for the lifestyle changes to produce a notable decrease in BMI. In most circumstances, the general goal for all ages is for BMI to deflect downward until it is <85th percentile. Although long-term monitoring of BMI is ideal, short-term (<3-month) weight changes may be easier to measure. However, children may be advanced to a more-intensive level of treatment at any time if, in the judgment of the health care provider, they are not making adequate progress, their BMI has increased, comorbidities have developed or worsened, or children who are candidates for more-aggressive treatment show appropriate readiness to change.

Stage 1: Prevention Plus

To foster development of a healthful lifestyle, all children 2 to 18 years of age with a BMI percentile in the normal range (5th to 84th percentile) should follow the recommendations for food consumption, activity, and screen time, as described in the accompanying prevention report. Children with BMIs in the 50th to 85th percentile may become overweight during adolescence, underscoring the need for providers to address weight management and lifestyle issues with all patients regardless of their presenting weight.

For children 2 to 18 years of age with BMI of >85th percentile, it is recommended that the Prevention Plus stage be introduced. This differs from the prevention stage in that providers need to spend more time and intensity on the recommendations and provide closer follow-up monitoring (3–6 months). However, children in this stage who have BMI values between the 85th and 95th percentiles, whose BMI values have tracked in the same percentile over time, and who have no medical risks may have a low risk for excess body fat. Clinicians may continue obesity prevention strategies and not advance the treatment stage. These recommendations can be implemented by primary care physicians or allied health care providers who have some training in pediatric weight management or behavioral counseling.

Stage 1 interventions should be based on the family's readiness to change and include the following (level of evidence is identified in parentheses): (1) consumption of ≥5 servings of fruits and vegetables per day (ME), (2) minimization or elimination of sugar-sweetened beverages (ME), (3) limits of ≤2 hours of screen time per day, no television in the room where the child sleeps, and no television viewing if the child is <2 years of age (CE), and (4) ≥1 hour of physical activity per day (ME). Physical activity can be increased gradually for sedentary children. Children may be unable to achieve 1 hour of activity per day initially but can gradually increase activity to reach ≥1 hour/day. If musculoskeletal pain prevents patients from engaging in activity, then referral to a physical therapist may be warranted.

Patients and family members should be counseled to facilitate the following eating behaviors: (1) eating breakfast daily (ME); (2) limiting meals outside the home, including at fast food venues and other restaurants (ME); (3) eating family meals at least 5 or 6 times per week (ME); and (4) allowing the child to self-regulate his or her meals and avoiding overly restrictive behaviors (CE for children <12 years of age and suggested for those >12 years of age). Providers should acknowledge cultural differences and help families adapt recommendations to address these differences (suggest).

Within this category, the goal should be weight maintenance with growth that results in decreasing BMI as age increases. Monthly follow-up assessments should be performed. If no improvement in BMI/weight status has been noted after 3 to 6 months, then advancement to stage 2 is indicated, on the basis of patient/family readiness to change. Prevention Plus can be implemented by primary care providers or allied health professionals (registered nurses or registered dietitians) with additional training in pediatric weight management.

Stage 2: Structured Weight Management

This stage targets the same behaviors as the Prevention Plus stage (food consumption, activity, and screen time) and offers additional support and structure to help the child achieve healthy behaviors. This stage requires additional training in behavioral counseling for primary care providers or other providers. It is characterized by closer follow-up monitoring, more structure, and inclusion of monitoring activities. Eating and activity goals specific to this stage of treatment are described below.

Stage 2 recommendations include the following (level of evidence is identified in parentheses): (1) development of a plan for use of a balanced-macronutrient diet, emphasizing small amounts of energy-dense foods (suggest); (2) provision of structured daily meals and snacks (breakfast, lunch, dinner, and 1 or 2 snacks per day) (suggest); (3) ≥60 minutes of supervised active play per day, to ensure activity (ME); (4) ≤1 hour of screen time per day (suggest; CE for ≤2 hours); (5) increased behavioral monitoring (eg, screen time, physical activity, dietary intake, and restaurant logs) by provider, patient, and/or family (CE); and (6) reinforcement for achieving targeted behavior goals (not weight goals) (suggest).

Within this category, the goal should be weight maintenance that results in decreasing BMI as age and height increase; however, weight loss should not exceed 1 lb/month for children 2 to 11 years of age or an average of 2 lb/week for older overweight/obese children and adolescents. If no improvement in BMI/weight status is observed after 3 to 6 months, then the patient should be advanced to stage 3.

Ideally, a dietitian with expertise in childhood obesity could provide the nutrition and physical activity counseling in conjunction with the primary care provider. Additional training in motivational interviewing/behavioral counseling, monitoring and reinforcement, family conflict resolution, meal planning, and physical activity counseling could help primary care providers implement treatment.

Parents should be involved in behavioral modification for children <12 years of age, with gradual decreases in parental involvement as the child ages. Referral to a physical activity program may be necessary to help some families develop an active lifestyle. Monthly follow-up assessment is recommended for most patients in this stage of treatment.

Stage 3: Comprehensive Multidisciplinary Intervention

The eating and activity goals associated with this stage of treatment are generally the same as those of the preceding treatment stage, that is, structured weight management. The distinguishing characteristics of comprehensive multidisciplinary intervention are increased intensity of behavioral change strategies, greater frequency of patient-provider contact, and the specialists involved in the treatment. At this level of intervention, ideally the patient should be referred to a multidisciplinary obesity care team. The need for formalized behavioral therapy and a multidisciplinary treatment team exceeds the capacity of the services most primary care providers can supply. An individual provider, or several providers, can coordinate and supervise a multidisciplinary care program.

For stage 3, the eating and activity goals are the same as in stage 2 (level of evidence is identified in parentheses). Activities within this category should also include the following: (1) planned negative energy balance achieved through structured diet and physical activity (ME); (2) structured behavioral modification program, including food and activity monitoring and development of short-term diet and physical activity goals (CE); (3) involvement of primary caregivers/families for behavioral modification for children <12 years of age (CE); (4) provision of training for all families to improve the home environment (suggest); and (5) frequent office visits. Weekly visits for a minimum of 8 to 12 weeks seem to be most efficacious (CE), and subsequent monthly visits help maintain new behaviors. Group visits may be more cost-effective and have therapeutic benefit (ME).

Systematic evaluation of body measurements, dietary intake, and physical activity should be conducted at baseline and at specific intervals throughout the program. Within this category, the goal should be weight maintenance or gradual weight loss until BMI is <85th percentile. Weight loss should not exceed 1 lb/month for children 2 to 5 years of age or 2 lb/week for older obese children and adolescents.

For implementation of the comprehensive multidisciplinary intervention, comprehensive treatment should be provided by a multidisciplinary obesity care team, including a behavioral counselor (for example, social worker, psychologist, other mental health care provider, or trained nurse practitioner), registered dietitian, and exercise specialist (physical activity specialist or other team member with training or a community program prepared to assist obese children). The primary care provider should continue to monitor medical issues and maintain a supportive alliance with the family. Referral to a commercial weight loss program that meets the criteria outlined in primer 1 should be considered.

Stage 4: Tertiary Care Intervention

The intensive interventions in this category have been used to only a limited extent in the pediatric population but may be appropriate for some severely obese youths who have been unable to improve their degree of adiposity and morbidity risks through lifestyle interventions. Candidates should have attempted weight loss at the level of stage 3 (comprehensive multidisciplinary intervention), should have the maturity to understand possible risks associated with stage 4 interventions, and should be willing to maintain physical activity, to follow a prescribed diet, and to participate in behavior monitoring. Lack of success with stage 3 treatment is not by itself a qualification for stage 4 treatment. It is recommended that programs that provide these intensive treatments operate under established protocols to evaluate patients, to implement the program, and to monitor patients.

The components of stage 4 include referral to a pediatric tertiary weight management center that has access to a multidisciplinary team with expertise in childhood obesity and that operates with a designed protocol. This protocol should include continued diet and activity counseling and consideration of additions such as meal replacement, a very-low-energy diet, medication, and surgery (suggest).

There are few reports on the use of highly restrictive diets for children or adolescents. A restrictive diet has been used as the first step in a childhood weight management program, followed by a mildly restrictive diet.

Two medications have been approved by the FDA for use in adolescents, that is, sibutramine, a serotonin reuptake inhibitor that increases weight loss by decreasing appetite, and orlistat, which causes fat malabsorption through inhibition of enteric lipase. To be effective, these medications must be used in conjunction with diet and exercise. The FDA has approved sibutramine for patients ≥16 years of age and orlistat for patients ≥12 years of age.

Generally, gastric bypass has been used to treat severely obese adolescents who have not improved their weight or health with behavioral interventions. Inge et al²⁶⁶ proposed stringent patient selection and facility qualification criteria, that is, BMI of ≥40 kg/m² with a medical condition or ≥50 kg/m², physical maturity (generally 13 years of age for girls and ≥15 years for boys), emotional and cognitive maturity, and ≥6 months of participation in a behavior-based treatment program. Surgery should be performed only by experienced surgeons associated with a pediatric obesity center. Adolescents who undergo this procedure require careful medical, psychological, and emotional evaluation before surgery and prolonged nutritional and psychological support after surgery; many youths who might otherwise qualify live too far from an adolescent bariatric center.

For implementation of stage 4, the multidisciplinary team should have expertise in childhood obesity and its comorbidities, with patient care being provided by a physician, nurse practitioner, a registered dietitian, a behavioral counselor, and an exercise specialist. Standard clinical protocols for patient selection should evaluate patient age, degree of obesity, motivation and emotional readiness, previous efforts to control weight, and family support. Standardized clinical protocols for evaluation before, during, and after the intervention should be followed. These evaluations should focus on the physical and emotional effects of the treatment. These protocols should be established by physicians, dietitians, physical activity specialists, and behaviorists familiar with weight management and pediatric care.

Weight Loss Goals

In most circumstances, the general goal for all ages is for BMI to deflect downward until it is <85th percentile. With the realization that some children are healthy with BMI values between the 85th and 95th percentiles, however, clinical judgment plays a critical role in weight recommendations. Although long-term monitoring of BMI is ideal, short-term (<3-month) weight changes may be easier to measure. Resolution of comorbidities is also a goal.

The expert committee recommends that the weight loss recommendations indicated in Table 4 be considered when the staged treatment plan is implemented. The recommendations are based on clinical recommendations and judgment because of the limited amount of evidence. Children whose BMI is between the 85th and 94th percentiles, whose BMI has tracked in the same percentile over time, and who have no medical risks may have a low risk for excess body fat. Clinicians can continue obesity prevention strategies and not advance to the next treatment stage.

Because the Youth Risk Behavior Surveillance Survey indicates that 15% of teens practice some unhealthy eating behaviors, all teens should be evaluated for these symptoms. If the average weight loss is >2 lb/week in any age group, then it is important to evaluate for excessive energy restrictions by the parent or the child/teen or unhealthy forms of weight loss, such as meal skipping, purging, fasting, excessive exercise, and/or use of laxatives, diet pills, or weight loss supplements.

Primers

Future Directions

With the realization that conventional treatment programs are not available to a large number of children in the United States, an emerging area of intervention involves the use of outreach clinics, distance education/counseling, or telemedicine. The University of Iowa hospitals and clinics outreach program confirmed the success of this approach by expanding the availability of tertiary care. The university established a network of outreach clinics throughout the state, and >75% of its tertiary care patients receive treatment outside the city and county where the university's main hospital is located.²⁷³ Use of telemedicine and other electronic communication techniques can extend the reach of specialty care experts associated with tertiary care centers and allow them to partner with primary care providers in the management of very obese patients. Two research studies, with a combined enrollment of 289 adult subjects, demonstrated that patients participating in weight management programs who received counseling via e-mail or telephone lost as much weight as those who attended in-person counseling sessions.^274,275 Little information is available on the use of remote weight loss counseling in the pediatric population. However, one small study by Saelens et al¹¹⁴ developed a weight management intervention that provided computer-based diet and activity education along with physician visits and counseling via telephone and mail. Adolescents who used this program lost slightly more weight than did those who received typical care, and they reported a higher level of satisfaction with the intervention.

A hospital-based, regional obesity center in South Dakota currently is studying how it can help primary care providers and adult patients living in remote rural communities participate in a medically monitored, multidisciplinary, weight management program. Primary care physicians received 3 hours of computer-based training in obesity assessment techniques and the medical monitoring procedures required to ensure the safety and efficacy of patients following an ∼1000 kcal (4032 kJ)/day, full meal replacement diet regimen. Patients participated in a weekly group behavioral modification program via telephone or video conference. A therapist associated with the tertiary care center facilitated all behavioral change sessions. Patient medical records were reviewed weekly by a nurse practitioner and the supervising physician associated with the tertiary care center. Preliminary results indicate that weight loss, improvement in comorbid conditions, and patient satisfaction are comparable to those of patients participating in the same treatment at the tertiary care center. In addition to promoting preventive strategies, the public health system can support national weight management goals by providing community-based programs that meet some of the multidisciplinary treatment needs of patients enrolled in structured weight management programs (V. Mermel, PhD, unpublished data, 2006).

Larger-scale research programs are needed to validate the use of electronic counseling as a behavior management training tool for pediatric patients. In addition, investments in information technology infrastructure are required to enhance delivery of health care services, including obesity treatment, to rural areas.

Improving the Availability of Obesity Treatment

In 2006, the Institute of Medicine released a progress report on nationwide efforts to prevent childhood obesity.²⁷⁶ It concluded that obesity prevention requires the coordinated efforts of government agencies (federal, state, and local), industry representatives (involved in the manufacture and marketing of foods, beverages, leisure, and recreational products), communities, schools, and families. While acknowledging some progress, the Institute of Medicine described current efforts to increase activity and to promote healthful eating as “generally fragmented.”²⁷⁶

Special attention must be paid to ensuring that members of ethnic minorities and groups of low socioeconomic status have equal access to obesity prevention and treatment programs and to healthier foods and recreational opportunities within their communities. Black and Hispanic children and adolescents have higher rates of obesity, and such weight-driven diseases as type 2 diabetes and hypertension, than do their white peers, but they receive less care for these conditions.²⁷⁷ Fewer recreational facilities,¹⁵⁵ fewer full-service grocery stores,²⁷⁸ and the relatively high cost of foods low in energy density²⁷⁹ have been identified as possible causes of the increased incidence of obesity in minority and low-socioeconomic status groups. A comprehensive policy is needed to address economic and cultural barriers to a more-healthful lifestyle.²⁷⁹ Health care professionals of different ethnic backgrounds must be involved in the development and implementation of culturally appropriate, weight management programs for children and adolescents with diverse ethnic, racial, and cultural backgrounds.²⁸⁰

Developing a coordinated approach to the treatment of obesity is no less complex. Few primary care providers have the time²⁸¹ or training^280,282 needed to implement fully basic obesity treatment such as that described for the structured weight management stage. In addition, the number of tertiary care centers specializing in pediatric weight management is limited, and currently there is no registry of centers or programs. In fact, obesity treatment, even when available and medically necessary, is rarely reimbursed.^280,283 Given the large number of obese children and adolescents in need of intensive intervention and the limited availability of specialty care, some experts suggest that the role of primary care providers must change.²⁸² For pediatric providers to take on this role, pediatric primary care would need to be revised, because currently the system is geared toward treatment of acute conditions and not management of chronic diseases such as obesity.

Most primary care practitioners lack the training and time to assess, to modify, and to monitor obese patients' diet, physical activity, and behavioral habits properly. A survey of >900 health care professionals (physicians, dietitians, and nurse practitioners) involved in pediatric care identified behavioral modification strategies, guidance in parenting techniques, and addressing of family conflicts as the 3 treatment techniques in which they felt least competent. Dietitians alone reported feeling confident in their ability to assess and to modify diets and activity.²⁸² The American Medical Association is working with federal agencies, public health organizations, and medical societies to ensure that more physicians currently in practice, as well as those presently in medical school, are trained in the management of obesity in children and adults.²⁸⁴ In addition, the American Medical Association is encouraging primary care providers to identify community resources and referral services that can help them care for obese patients. Similar training must be made available to nurse practitioners, dietitians, behaviorists, and exercise specialists, because it is these health care professionals, together with physicians, who form the multidisciplinary treatment team required for tertiary obesity care. The American Dietetic Association has provided postgraduate certification in adult and childhood obesity management for several years. More dietitians must be encouraged to pursue this training, because their expertise is required in the early stages of obesity management. Training in obesity treatment for health care professionals also is limited. Recently, the American Dietetic Association sponsored a continuing education program to teach its members how to use Internet-based tools in pediatric weight management counseling. No formal research is available to validate the utility of these Internet-based resources for pediatric patients. However, clinical experience with the use of these resources has been positive.

Coaching patients in the process of behavioral change lengthens patient/provider encounters. The time constraints of the current primary care system represent a barrier to providing this aspect of treatment.²⁸² Lack of reimbursement for weight management services is an additional obstacle. Generally, third-party payers do not reimburse physicians who provide such services themselves or who employ multidisciplinary teams within their practices to provide the services.^280,283 Some efforts are being made to increase the number of physicians qualified to treat obesity and to improve reimbursement for those services. Because the National Institutes of Health and other health organizations recognize obesity as a disease, pressure is growing for third-party payers to reimburse health care providers for preventive counseling and management. Many organizations are lobbying actively for insurance coverage of obesity treatment. State and federal policymakers are evaluating which obesity treatments are effective and thus may qualify for Medicaid and Medicare reimbursement.²⁸¹ More research is needed to identify successful weight management interventions and to secure reimbursement for obesity treatment from all third-party payers.

Increasing the number of health care practitioners with expertise in obesity treatment and securing reimbursement for a staged approach to obesity treatment services are necessary and eventually should foster development of additional tertiary care centers. Such centers cannot be developed soon enough to meet current and projected treatment needs, however, and, even when new tertiary care centers are created, people in rural areas are unlikely to have access to one. Some researchers have proposed that obesity treatment centers be regionalized in the way that pediatric cancer treatment centers are. Other approaches, such as development of satellite/outreach tertiary care clinics, use of telemedicine, and involvement of public health services, must also be explored. Obesity is a chronic condition. Therefore, individuals will need follow-up care after successful weight loss. Ultimately, a broad range of strategies must be developed to support maintenance of a healthy weight.