9
Treatment options

https://doi.org/10.1016/j.beem.2005.04.010Get rights and content

The prevalence of child and adolescent overweight and obesity is rapidly increasing and is associated with morbidity, both medical and psychosocial. Obesity is unlikely to resolve spontaneously. It is important that health professionals can assess obesity and initiate an action plan. The evidence base for what works best in the management of child and adolescent overweight and obesity is limited. It is uncertain whether protocols from clinical research trials can be translated into primary care. Dietary change, with an emphasis on lower fat intake and smaller portion size, should be commenced. There should be an increase in physical activity and a decrease in sedentary behaviours, combined with behavioural change and parental involvement. These are the elements of a lifestyle intervention. In the severely obese adolescent with obesity-related co-morbidity, the use of very low-energy diets and anti-obesity agents could be considered. Bariatric surgery may be indicated in carefully selected, older, severely obese adolescents.

Section snippets

The extent of the problem necessitates an active approach

In the last decade or so the prevalence of child and adolescent overweight and obesity has increased dramatically in Western countries, together with countries in economic transition to Westernised lifestyles.1 The increase in prevalence has occurred against a background of increased knowledge and research publications about obesity2 and increasing exposure of the topic in the lay press. In the enthusiasm to prevent the condition, it is important not to neglect those children and adolescents in

Why treat childhood obesity?

There are a number of compelling reasons to intervene in child and adolescent overweight and obesity.

  • An overweight child or adolescent is likely to become an obese adult unless there is active intervention. Tracking studies are in general agreement that body weight tracks from childhood through to adulthood; what varies between studies is how strongly weight tracks and from what age prediction is accurate.4, 5 The predictive power of body weight increases with age, so that over 50% of obese

Who should be treated?

All children and adolescents who are overweight ideally should have a weight management plan. Clinically, overweight and obesity are defined by body mass index (BMI) percentiles because of the changing relationship between height and weight in the growing child. Using the Centers for Disease Control (CDC) growth charts10 >85th centile is defined as overweight and >95th centile is defined as obese. These BMI centile cutpoints are arbitrary, as they are not related to morbidity. There are no

How strong is the evidence that treatment of overweight and obesity works?

A recent Cochrane review states that: “Although 18 research studies were found, most of these were very small studies and so evidence from them is limited. In conclusion, there is a limited amount of quality data on the effects of programmes to treat childhood obesity, and as such no conclusions can be drawn with confidence”.11 An earlier study by Glenny et al also identified that childhood obesity management studies were limited by number of subjects, study design, lack of control group data

Dietary change

There is no direct evidence as to what dietary intervention works best in children and adolescents, but the aim is to reduce the overall kilocalorie content using foods of high nutritional value (Table 2). Most standard dietary interventions involve low-fat ad-libitum intake of food. Such a diet will provide about 25% of energy as fat. This target level is met by only 10% of children in national surveys.17 Reducing fat in practice targets snacks, take-away and processed foods, and altering

Adolescents: the forgotten group

Adolescence has been termed a ‘critical period’ for the development of adult obesity42, with obese adolescents having a high risk of becoming obese adults.5 Intervention in this age group may be vital for both future health and the ability to sustain long-term weight control. Adolescence is a period of dramatic physical and cognitive change. Changes in eating habits, physical activity and other aspects of lifestyle are likely to be maintained into adulthood.43, 44

Adolescents are one of the most

Where should obesity intervention take place?

Given the prevalence of the condition, community or primary health care is the logical site for intervention. However, almost all the clinical research studies on childhood obesity management have taken place in university or tertiary care centres. It is not certain that the protocols could be translated into the broader community. There is some evidence that weight-loss outcomes are similar whether treatment is carried out in hospital, doctor's office, school setting or camps.49 In a study of

What is known about outcomes?

Most studies on the management of overweight and obesity in children and adolescents are relatively short-term. It is therefore, important that future research has a sufficiently long follow-up. Epstein's group showed that over 10 years children were able to maintain a relative loss of 5% of their overweight, whereas their parents had lost and then regained significantly more than baseline at 10 years.8 Nuutinen and Knip have published data over 5 years and showed children were able to maintain

Obesity treatment goals

The primary outcome of treatment is a change in weight and body composition. In children and younger adolescents who have significant growth potential and who do not have severe obesity with co-morbidity, weight maintenance is the management goal. This allows normal height growth to be used therapeutically, and means that the lifestyle changes need not be too rigorous. To accomplish weight maintenance in practice the family needs to weigh their child regularly, be non-judgmental about the

More intensive options

When lifestyle interventions are unsuccessful, or if obesity is severe, more intensive interventions may be considered.

Pharmacotherapy

In this review only orlistat and sibutramine therapy will be considered, as these have some limited quality data on use in this age group. Orlistat is a unique anti-obesity agent in that its absorption is negligible, and as a pancreatic lipase inhibitor it reduces the amount of fat available for intestinal absorption. Because of its effect on fat absorption, there is a theoretical risk of fat-soluble vitamin deficiency in particular. In a 3-month open-label pilot study in adolescents by

Barriers to intervention

There are early barriers to successful obesity intervention. Parents may not identify their children as overweight73, thereby not seeking help. It may be difficult for health professionals to raise the need for intervention, but it will be easier if co-morbidity is apparent. There may be a belief that obesity will resolve spontaneously in puberty; this is not supported by the tracking data. There may be concerns that dietary restriction will interfere with normal growth. Normal growth requires

Special cases

In the severely obese child or adolescent, both physician and parents may be concerned that there is a secondary cause for the obesity, such as Cushing's syndrome, Prader-Willi, hypothyroidism, or hypothalamic lesions. Affected individuals are invariably short with evidence of significant growth impairment. If a child looks normal, is an appropriate height for parental height, is growing normally and is of normal intelligence, then intensive investigation is not required. Six single gene

Summary

Active intervention in childhood and adolescent overweight and obesity is necessary, as spontaneous resolution is unlikely. Children and adolescents also have obesity-related co-morbidity which can be improved by weight loss. For most children and younger adolescents, weight maintenance may be all that is required, with normal height growth allowing a better match in height and weight over time. There is limited evidence for what interventions are effective, and it is likely that research

References (75)

  • W.H. Dietz et al.

    Optimal dietary therapy for obese adolescents: comparison of protein plus glucose and protein plus fat

    Journal of Pediatrics

    (1982)
  • M.R. Brown et al.

    A high protein, low calorie liquid diet in the treatment of very obese adolescents: long-term effect on lean body mass

    The American Journal of Clinical Nutrition

    (1983)
  • V.A. Stallings et al.

    One year follow up of weight, total body potassium and total nitrogen in obese adolescents treated with the protein-sparing modified fast

    The American Journal of Clinical Nutrition

    (1988)
  • T. Lobstein et al.

    Obesity in children and young people: a crisis in public health. Report of the International Obesity TaskForce Childhood Obesity Working Group

    Obesity Reviews

    (2004)
  • K. Steinbeck

    Conventional treatment for childhood and adolescent obesity

  • B.A. Teachman et al.

    Implicit anti-fat bias among health professionals: is anyone immune

    International Journal of Obesity

    (2001)
  • S.S. Guo et al.

    Body mass index during childhood, adolescence and young adulthood in relation to adult overweight and adiposity: the fels longitudinal study

    International Journal of Obesity and Related Metabolic Disorders

    (2000)
  • R.C. Whitaker et al.

    Predicting obesity in young adulthood from childhood and parental obesity

    The New England Journal of Medicine

    (1997)
  • A. Must et al.

    Long term morbidity and mortality of overweight adolescents. A follow-up of the Harvard Growth Study

    The New England Journal of Medicine

    (1992)
  • F.J. Nieto et al.

    Childhood weight and growth rate as predictors of adult mortality

    American Journal of Epidemiology

    (1992)
  • L.H. Epstein et al.

    Do children lose and maintain weight easier than adults: a comparison of child and parent weight changes from six months to ten years

    Obesity Research

    (1995)
  • CDC (Centers for Disease Control and Prevention). Growth charts: United States. Advance data number 314; December 4...
  • Summerbell CD, Ashton V, Campbell KJ, et al. Interventions for treating obesity in children. Cochrane review library....
  • A.-M. Glenny et al.

    The treatment and prevention of obesity: a systematic review of the literature

    International Journal of Obesity

    (1997)
  • US National Institutes of Health

    Clinical guidelines on the identification, evaulation and treatment of overweight and obesity in adults: executive summary. Expert panel on the identification, evaluation and treatment of overweight in adults

    The American Journal of Clinical Nutrition

    (1998)
  • L.H. Epstein

    Family based behavioural intervention for obese children

    International Journal of Obesity and Related Metabolic Disorders

    (1996)
  • Obesity. Preventing and managing the global epidemic. Report of a WHO Consultation on Obesity....
  • A.M. Magarey et al.

    Reducing the fat content of children's diet: nutritional implications and practical considerations

    Australian Journal of Nutrition and Dietetics

    (1993)
  • L.H. Epstein et al.

    Decreasing fruit and vegetable intake and decreasing fat and sugar intake in families at risk of childhood obesity

    Obesity Research

    (2001)
  • S.J. Nielson et al.

    Patterns and trends in food portion sizes 1977–1998

    Journal of the American Medical Association

    (2003)
  • C.B. Ebbeling et al.

    A reduced-glycemic load diet in the treatment of adolescent obesity

    Archives of Pediatrics and Adolescent Medicine

    (2003)
  • J. Parizkova et al.

    Management through activity

  • J. Schwingshandl et al.

    Effect of an individualised training programme during weight reduction on body composition: a randomised trial

    Archives of Disease in Childhood

    (1999)
  • C. Maffeis et al.

    Energy expenditure during walking and running in obese and non-obese pre-pubertal children

    Journal of Pediatrics

    (1993)
  • E.M. Haymes et al.

    Buskirk Heat tolerance of exercising lean and obese prepubertal boys

    Journal of Applied Physiology

    (1975)
  • C. Riddoch et al.

    Long term health implications of fitness and physical activity patterns

    Archives of Disease in Childhood

    (1991)
  • O.T. Raitakari et al.

    Patterns of intense physical activity among 15–30-year old Finns. The cardiovascular risk in young Finns study

    Scandinavian Journal of Medicine and Science in Sports

    (1996)
  • Cited by (37)

    • Pediatric obesity: Current concepts

      2018, Disease-a-Month
      Citation Excerpt :

      The best long-term data on childhood obesity treatment is noted with the research results of LH Epstein and associates in their classic paper on diet and exercise published in 1985.152 Leading experts (i.e., The World Obesity Federation (previously called the International Obesity Task Force [IOTF]) have called for longitudinal clinical trials to test the validity of Epstein’s work and alert the world to the growing health crisis caused by soaring levels of obesity.151–153 Research seeks to utilize controlled trials of dietary measures and physical exercise with strong parental involvement to reduce the percentage of overweight children by at least 20%.151

    View all citing articles on Scopus
    View full text