Managment and Treatment
Some treatments involving children and adolescents have produced substantial short-term improvements in percent overweight, blood pressure, and lipid profiles. However, longer-term effects of treatment generally have been disappointing. The most successful interventions have been family based and behaviorally oriented. Such treatments include parents in the treatment process, usually as a target of treatment along with the child; a diet program that promotes adherence and provides sufficient nutrition for growth; modification of the child’s food environment at home and in school; a physical activity program emphasizing life-style activities instead of a specific exercise regimen; specific strategies to reduce sedentary time; behavior modification techniques, including self-monitoring of diet and activity behaviors; identification of potential barriers and problem-solving; cognitive restructuring techniques to help the child cope with difficult situations, stressful times, and dietary lapses; parental skills training and role modeling; and a contracting and reward system emphasizing positive reinforcement for both proximal and distal goals.
State-of-the-art programs incorporating these elements in research settings have produced 10-year success in up to about one-third of participating children. These are much better results than those from adult treatment programs.
Perhaps the most important factor in weight control treatment is the readiness of the child and the family. Although the clinician participates in treatment, the family has the primary role. A clinician can provide the requisite knowledge and methods, but until a family is ready to change, the necessary changes will not occur. Therefore, when there is a lack of agreement between parent and child, or between two parents, it is appropriate to defer treatment until a consensus is reached. In some cases, participation of a family therapist may facilitate treatment. Although family therapy-based interventions for obesity have yet to be proven effective, a child’s weight problem is often a focus of family conflict within treatment-seeking families. Consequently, changes made as part of a treatment program may substantially alter family dynamics.
In children without complications of obesity that require immediate weight reduction, the initial goal of treatment should be to maintain weight or to slow the rate of gain. Once weight maintenance is achieved, progression to a weight loss goal of about 1 pound per month is appropriate for most children and adolescents. This strategy allows children to “grow into” their weight over time without risking adverse health effects from more rapid weight loss. In such cases, a combination of increased activity levels and moderate calorie restriction can be effective. Reductions in total dietary fat content and calorically dense foods, through substitutions and eliminations alone, can produce a sufficient caloric deficit without changing the general pattern of food consumption for the child or family. Diets that are low in calories and fats and high in complex carbohydrates and fiber are not associated with complications in older children and adolescents, and such diets lead to loss of body fat without significantly compromising growth in height. However, frequent monitoring of growth and intermittent assessment by a nutritionist is recommended to ensure that the diet is nutritionally adequate.
Sedentary behavior, and television viewing in particular, has received much attention as an etiologic factor for obesity. Recent experimental studies suggest that reducing television viewing, and videotape and video game use, may be an effective strategy for primary prevention of obesity and for weight control among obese children. When obese children are heavy television viewers, reduced viewing time may result in increased activity levels, decreased eating in front of the TV, and decreased exposure to high-fat, high-calorie food advertising.
Children with more severe obesity or significant associated complications (eg, pickwickian syndrome, imminent slipped capital femoral epiphysis, noninsulin-dependent diabetes mellitus, pseudotumor cerebri) demand more restrictive dietary interventions because of the immediacy of their problems. For these patients, very-low-calorie diets, also known as protein-modified fasts, may be indicated. The goal of the protein-modified fast is to maximize loss of fat while minimizing loss of protein. These diets generally provide from 800 to 1000 Kcal/d of energy and from 2.0 to 2.5 g of protein per kg ideal body weight per day. Such patients require vitamin and mineral supplements, particularly potassium and calcium, and sufficient fluids. These diets tend to produce mean weight losses of approximately 3.0 kg during the first week and 1.0 kg per week thereafter, with broad variation. They should not be recommended for patients with renal, hepatic, or cardiac disease. Inadequately supervised, commercially available, very-low-calorie diets have been associated with cardiac arrhythmias, cardiac arrests, and death, and they are not recommended for children or adolescents. Even when properly supervised, very-low-calorie diets have been associated with hair loss, thinning of the skin, cold intolerance, orthostatic hypotension, and arrhythmias. Patients treated with such diets require close, frequent follow-up by physicians thoroughly trained in clinical nutrition and experienced in the use of these therapies. Therefore, most clinicians will refer such patients to a specialized childhood obesity treatment program.
Current pharmacologic therapies should be reserved for use in children or adolescents who have failed behavioral and nutritional treatments and who are participating in monitored clinical trials. The results of pharmacologic treatment studies in obese adults suggest that weight gain generally returns after medication use is discontinued. This suggests that pharmacologic treatments may eventually need to be used for long-term treatment. As a result, long-term safety and efficacy should be established before they are routinely used in children and adolescents. Similarly, surgical treatments, gastroplasty and gastric bypass, are occasionally being used in the adolescent age group as an extension of their use in adults, although clinical trials are needed to assess the safety and efficacy of these approaches in adolescents.
Revision date: June 21, 2011
Last revised: by Andrew G. Epstein, M.D.