Dietary glycaemic index has also been implicated in weight reduction.¹²³  Two small,  short-term studies of obese adolescents reported increased weight loss on a diet with reduced glycaemic load, but the numbers were small and long-term effects are unknown.^124,125

Strategies to change dietary habits to a more calorie-reduced intake are based on behavioural principles,  of which Bandura’s social cognitive model¹²⁶  is the most widely used. The model is based on the notion that lifestyle changes succeed through cognitively driven,  intentional behaviours such as self-monitoring,  goal setting,  and rewarding   of   successful   change.  A   widely   adopted approach in children uses the trafic light system, which was developed by Epstein and colleagues.¹²⁷ Motivational interviewing has been advocated as an especially useful technique for patients who might not feel ready for change.¹²⁸  It is a so-called empathetic way of being, including reffective listening,  shared decision making, and   agenda   setting.¹²⁹  American   Heart   Association guidelines   recommend   motivational   interviewing   for paediatric weight management.¹³⁰ However, the effectiveness of this approach versus other behavioural approaches is not known.

Most weight reduction programmes are provided by outpatient clinics.  In one study,  investigators examined an inpatient intervention and showed some evidence of effectiveness.^131,132  Although the school setting has not been regarded as a site for treatment of childhood obesity (as opposed to prevention),  promising results from a randomised trial of classroom-based weight reduction in obese   Mexican-American   children   suggest   that   this venue needs further examination.¹³³ Residential summer camps   for   obese   adolescents   have   short-term effectiveness,¹³⁴  but long-term effects remain unknown.

Internet intervention for obese adolescents has been examined, without promising results.¹³⁵

Better research into non-pharmacological treatment is urgently needed, especially into extent of caloric restriction and effectiveness of increasing energy expenditure.

Consensus   guidelines   for   age-appropriate   safety monitoring of weight-reducing regimens are also needed to ensure appropriate height growth and biological and social development. Since randomised clinical trials are costly,  multicentre collaborative research with common protocols   might   be   the   most   cost-effective   and generalisable approach.  In view of ageing populations worldwide and increasing use of technology-intensive medical treatments,  allocation of increasingly scarce medical resources will demand more evidence-based information for treatment of childhood obesity. Questions such as how often an obese child should have dietary counselling will not be readily answered unless improved evidence is made available.

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Joan C Han, Debbie A Lawlor, Sue Y S Kimm

Lancet 2010; 375 - 1737-48
Published Online May 6, 2010 DOI - 10.1016/ S0140- 6736(10)60171-7

Unit on Growth and Obesity, Program on Developmental Endocrinology and Genetics, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, DHHS, Bethesda, MD, USA (J C Han MD); MRC Centre for Causal Analyses in Translational Epidemiology, Department of Social Medicine, University of Bristol, Bristol, UK (Prof D A Lawlor PhD); and Department of Internal Medicine/Epidemiology, University of New Mexico School of Medicine, Albuquerque, NM, USA (S Y S Kimm MD)

Correspondence to - Dr Sue Y S Kimm, University of New Mexico Health Sciences Center, Department of Internal Medicine/Epidemiology, University of New Mexico, MSC 10 5550 Albuquerque, NM 87131-0001, USA .(JavaScript must be enabled to view this email address)

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