MANAGEMENT AND TREATMENT OF OBESITY IN CHILDREN AND ADOLESCENTS

Management of obesity in children and adolescents requires family-centered communication and family-based interventions rather than those focused on the patient (child or adolescent) alone. Targeting a parent as an important agent of behavior change, either with or without the child, is more effective for long-term weight management than targeting only the child without parental participation. Any therapeutic intervention without the understanding, approval, and active participation of family members is unlikely to succeed (Skelton, 2021; Schwarz, 2020).

Effective approaches should be collaborative rather than prescriptive, with the clinician engaging the family in selecting specific behaviors to change. The child should be directly involved in decision-making as appropriate for his or her age. Any intervention is likely to fail if it does not involve active participation and support of family members. Because the child may be one of many family members who have obesity, successful treatment often requires a change in the entire family’s approach to eating. In some cases, family therapy may be advised. An intensive group therapy approach has been found to be superior to standard, family-based therapy in achieving lifestyle changes and reducing the BMI of overweight adolescents.

A team approach to management includes nurse educators, nutritionists, exercise physiologists, and counselors, as well consultations with pulmonary medicine specialists, orthopedists, and/or gastroenterologists as appropriate. In addition, any acute or chronic complications of obesity are managed and psychiatric assistance obtained for eating disorders or severe depression (Schwarz, 2020).

The Staged Approach

The staged approach to addressing obesity is determined by multiple factors, including age, BMI, and previous weight-management history. Management to address overweight or obesity is divided into stages that represent degrees of supervision, counseling, and intervention. The American Academy of Pediatrics recommends a four-stage approach to treatment of childhood obesity:

Stage 1 (Prevention-Plus Protocol) can be implemented in primary care for children ≥2 years old with BMI ≥85th percentile, with recommendations for improving the diet, increasing physical activity, modifying family behaviors or environments, monthly follow-ups, and advancement to stage 2 if BMI does not improve in 3 to 6 months.
Stage 2 (Structured Weight Management Protocol) for children ≥6 years old consists of more structure and supervision in a primary care office and includes stage 1 guidelines plus increased structure and education, follow-up as often as needed, and advancement to stage 3 if BMI does not improve in 3 to 6 months.
Stage 3 (Comprehensive Multidisciplinary Intervention) for children ≥6 years old with severe obesity (BMI ≥35) can be implemented in a primary care office and includes stage 2 guidelines, increased structured dietary program, plus a multidisciplinary team and outside facilities, such as a pediatric obesity treatment clinic for structured physical activity.
Stage 4 (Tertiary Care Intervention) is implemented if a patient has a BMI ≥95th percentile, significant comorbidities, and has not responded to stages 1 through 3, or has a BMI 99th percentile and has shown no improvement in stage 3. This is carried out in a pediatric weight management center with a multidisciplinary team with expertise in pediatric obesity, and includes stage 3 recommendations, medications, extremely structured dietary regimens, or bariatric surgery.
(Skelton, 2021; Johnson, 2021)

Lifestyle Interventions for Children and Adolescents

Research has indicated that lifestyle interventions incorporating a dietary component along with an exercise and/or behavioral therapy component are effective in treating childhood and adolescent obesity. Lifestyle modification therapy is essential for pediatric obesity treatment and should be used as the first-line therapeutic option. Many treatment programs apply strategies such as dietary modification, increasing physical activity, and behavioral changes, including self-monitoring, stimulus control, positive reinforcement, social support, and cognitive behavior therapy.

Successful pediatric obesity management requires consideration of both the patient and family’s readiness. Setting a combination of short-term attainable goals and realistic long-term goals can help with participant motivation. Identifying what internally drives patient/family motivation for behavior change is an important element in making lifestyle changes (Sease et al., 2021; Chung & Rhie, 2021).

WEIGHT-LOSS GOALS

Weight-loss goals are based on the child’s age and degree of overweight or obesity. For children and adolescents who are overweight or mildly obese, the goal of maintaining current body weight is appropriate, as this will lead to a decrease in BMI as the child grows taller. If a child is in a phase of rapid linear growth, simply slowing weight gain is more realistic and often improves weight status. For adolescents who have completed linear growth, healthy behaviors, positive body image, and a long-term goal of gradual weight reduction should be the focus.

At high degrees of obesity, however, gradual weight loss is safe and appropriate depending on the child’s age and degree of obesity. For children between 2 and 11 years with obesity as well as comorbidities, a weight loss of one pound per month is safe and of benefit, but may be difficult to achieve. For obese adolescents with comorbidities, it is considered safe to lose up to two pounds per week, although a weight loss of one to two pounds per month is usually a more realistic goal. Because is it difficult to achieve and sustain a dramatic reduction in BMI, realistic goals should emphasize gradual weight loss and maintenance rather than a rapid fall to an ideal body weight (Skelton, 2021).

DIET

There is limited evaluation and clinical evidence to support structured dietary interventions for children with obesity. These are reasonably effective in achieving short-term weight loss in a motivated patient and are safe if adequately selected and supervised. However, they have poor adherence and success rates over a longer period of time.

Rather than focusing on a specific structured diet, goals are more apt to be achieved if eating behaviors are the focus. Programs that modify family patterns of eating are most likely to be successful.

A semi-structured dietary approach aimed at encouraging children and families to select food groups of lower energy-density and decreasing portion size are best used for weight loss in children. Such an approach may include:

Intake of five or more servings of fruits and vegetables daily
Decreased intake of calorie-dense foods such as saturated fats, salty snacks, and high-glycemic foods such as candy
Minimized intake of sugar-containing beverages
Minimized eating outside the home and eating fast food in particular
Family meals at least five times a week
Self-regulation of food
Eating breakfast daily
Discouraging dieting
Avoiding skipping meals
(Mayo Clinic, 2020b; Skelton, 2021)

It is important to note that the long-term effects remain poorly understood of a very controlled-energy diet on adolescent growth and development and subsequent reproductive function, musculoskeletal development, and intermediary metabolism. In light of these factors and problems inherent in adhering to and maintaining severe caloric restriction, very controlled-energy diets are not recommended for the great majority of children and adolescents with obesity.

In circumstances where rapid weight loss is recommended, a protein-sparing modified fast can achieve rapid weight loss in an inpatient or outpatient setting and has been successfully used in children and adolescents with obesity. A high-protein diet, however, does not reduce obese children’s desire to eat, and ratings of desire to eat significantly increase over the duration of the intervention (Schwarz, 2020).

Weight loss tools—such as ChooseMyPlate, MyPlate, and HealthyPlate—use effective visual cues to teach healthy dietary patterns, including major food groups, portion sizes, and the goal of including more fruits and vegetables.

ChooseMyPlate graphic showing food groups and portion sizes for healthy eating

Healthy food selection and relative portion recommendations for avoiding obesity. (Source: USDA.)

PHYSICAL ACTIVITY

Increasing child and family levels of physical activity is a key focus in obesity treatment. It has been demonstrated that lifestyle exercise programs, in connection with dietary restrictions, provide long-term weight control in children and adolescents. It is recommended that children and adolescents participate in 60 minutes or more of physical activity each day (Schwarz, 2020).

Providers can recommend a variety of options for consideration. Structured physical activity (such as sports or performance arts) may be team-based or individual, competitive or noncompetitive. Noncompetitive activities may be more appealing to some children, particularly those with more severe obesity. Less-structured activities can include recreational sports with peers or family, or self-directed physical training.

For preschool-aged children, physical activity for the most part will be unstructured, and outdoor play is particularly helpful. Providers can encourage physical activity in this age group by prescribing playground time and providing a list of local resources (such as playground locations) in addition to discouraging sedentary time. Parents can be encouraged to consider physical activity levels when making choices for daycare and after-school programs.

For older children, structured physical activity is encouraged whenever possible, such as team or individual sports, or supervised exercise sessions. Children are more likely to participate consistently in such activities since they are accountable to a coach or a leader.

Directly engaging adolescents in choosing activities to replace sedentary time is helpful, as some will enjoy engaging in sports or fitness centers, while others may not (Schwarz, 2020; Skelton, 2021).

The following are recommendations for physical activity in the management of obesity and overweight in children and adolescents:

Limit screen time. Decrease sedentary behavior such as watching television, surfing the internet, using a tablet or smartphone, and playing video games to no more than two hours per day for children older than 2 years. Children younger than 2 should have no screen time at all.
Emphasize activity, not exercise. Children should be moderately to vigorously active for at least an hour a day doing activities they enjoy.
(Mayo Clinic, 2020b)

DOG OWNERSHIP AND PHYSICAL ACTIVITY

Dog ownership is associated with a number of physical, mental, and emotional health benefits. Owning and caring for a dog has shown promise in increasing children’s outdoor physical activity. Among a growing body of research on the physical activity benefits of dog ownership, studies have been conducted in children that show those from dog-owning families accumulate more physical activity and are more likely to meet physical activity recommendations (Ng et al., 2021).

THE ROLE OF PHYSICAL THERAPY WITH CHILDHOOD OBESITY

The American Physical Therapy Association (2021) recommends that primary care providers involve physical therapists in the management of childhood and adolescent obesity. Physical therapists can assess a child’s risk factors for injury during exercise and evaluate and monitor a child’s increasing level of activity. Recommendations include:

Do not rely on BMI alone. Use BMI charts that reflect demographics and tools for measuring whole-body fat mass such as waist circumference or skin-fold thickness before beginning treatment. Ideally, it is recommended that body composition be analyzed by cross-sectional imaging.
Be aware that a child with type 2 diabetes who is receiving insulin treatment can experience hypoglycemia during exercise.
Evaluate the child’s psychosocial barriers, which may include low self-esteem, anxiety, negative body image, or other psychological issues that can influence how a child will adhere to the plan of care.
Measure exercise endurance capacity and muscle strength. This can be accomplished by using the 20-meter shuttle run test for endurance and the handgrip strength test and standing broad jump test for muscle strength.
Promote weight loss by encouraging endurance exercises, whole-body exercises being the best option.
For children over the age of 5 years, to avoid injury when there is muscle weakness, strength training is recommended under the supervision of a physical therapist to ensure the proper execution of the exercises.

Physical therapists can be very important in helping a child develop a sense of self-efficacy that can motivate them to continue exercising.

CASE

Jaime, Age 9

Jaime is a 9-year-old boy who was referred to physical therapy for help in establishing a personal fitness plan after being identified as obese during a routine BMI screening at his school. Jaime is a pleasant child who enjoys reading and playing video games during his free time. His dad drives him to and from school, and Jaime spends most of the day in the classroom. At recess, he likes to read on a bench while the other kids play. He attends gym class one day a week.

The physical therapist, Monica, conducted an initial evaluation that included Jaime’s overall health status, history of his current presenting complaint, and screening for medical red flags, as well as evaluation of pain, joint range-of-motion, manual muscle testing, bony and soft-tissue palpation, orthopedic special tests, sensation testing, postural evaluation, gait biomechanics, and static and dynamic balance testing.

Monica next met with Jaime and his parents about an appropriate long-term fitness routine that would include cardiovascular exercise, strength training, flexibility, and functionality work. Jaime looked worried at the mention of exercise. “You won’t make me play basketball, will you?” he whispered. She assured Jaime that there are plenty of exercises he can do that don’t require throwing or catching. Monica helped Jaime and his family plan an activity program designed to gradually increase his activity level to at least 60 minutes/day. His father purchased a stationary bike and a set of free weights for them to use together. Monica reviewed safe weight-lifting technique and set parameters for the appropriate amount of weight for Jaime to be lifting.

Two weeks later, Jaime reported logging 60 minutes of activity on three of seven days and at least 30 minutes on three of the remaining days. His parents also bought him new sneakers and started a daily “family workout night” after dinner, beginning with specific stretches and core strengthening exercises learned at physical therapy, followed by riding the stationary bike or swimming at the community pool. Jaime’s dad started walking to school with him instead of driving. They now log each day’s activities in order to track their progress.

After six weeks, Jaime has made the following progress toward his long-term physical fitness goals:

A reduced BMI and an absence of weight gain since program initiation
Reading for half of recess and playing actively with his peers during the other half
60 minutes of physical activity attained on 85% of days since the start of the program

Due to the consistent support of Jaime’s parents and his rapid progress toward his physical therapy goals, it is decided that Jaime need not follow up with physical therapy until one month later, at which time he may be discharged to an independent home fitness program.

Behavioral Therapy

One of the most up-to-date approaches to managing pediatric obesity is cognitive behavioral therapy (CBT). It has been suggested that CBT can be very effective for mental health problems such as depression, impulsivity, and body image distortion that may coexist with pediatric obesity. Evidence is strong for the recommendation of family-based multicomponent behavioral interventions to treat obesity in children ages 2 to 18 years old.

Common components of pediatric obesity CBT include a behavioral approach aimed at changing eating habits and physical activity through self-monitoring, and a cognitive approach aimed at changing distorted body image and help with emotion regulation.

The cognitive approach includes thinking about emotions and negative automatic thoughts related to eating habits, helping to regulate emotions, promoting problem solving to cope with high-risk situations where food control is difficult, changing self-esteem and body image, and applying cognitive strategies to prevent relapse (Weir, 2019).

MENTAL HEALTH ISSUES

Obese children endure physical complications but also experience mental health problems such as depression, attention deficit hyperactivity disorder, and eating disorders, as well as psychosocial impairments related to school adjustment, bullying, and low self-esteem.

Depression and anxiety not only decrease treatment compliance, but also negatively impact growth and development. A recent 20-year cohort study reported that childhood overweight and obesity may increase the risk for mood disorder in adulthood, making early intervention a prime consideration (Kang & Kwack, 2020).

CASE

Motivational Interviewing

Cynthia, Age 15

Cynthia is a 15-year-old African American girl who is 5 feet, 3 inches tall and weighs 180 pounds, with a BMI of 31.9. She has been referred to the local health clinic by the school nurse at Winston Senior High School because of recent weight gain. The clinic’s nurse practitioner employs Motivational Interviewing to assist adolescent patients and their families in weight-loss efforts. During the first session with the family, the nurse found both parents to be very supportive and eager to help Cynthia meet the goals agreed on with the clinic’s weight loss team.

Today is Cynthia and her parents’ second visit to the clinic, and the nurse practitioner utilizes MI in her meeting with the family.

Nurse: “Hello, Cynthia. Hello, Mr. and Mrs. Rockland. It’s good to see you all again. Tell me, how have things been going for you this past week?” (Asking an open-ended question)

Cynthia: “Oh, so, so. Mom and Dad have been after me to follow the plan, and I’m trying, but not very well, I’m afraid.” (Responding with elaboration)

Nurse: “You haven’t been completely successful sticking with the plan.” (Rephrasing)

Mom: “She’s trying, but not has hard as we think she could.”

Nurse: “You think she is not trying hard enough.” (Restating)

Mom: “Well …”

Cynthia (interrupting): “I really am trying hard, but there’s so many things that happen and get in the way!” (Emotional elaboration)

Nurse: “You sound a bit upset!” (Mirroring)

Cynthia: “I am! It’s really hard when you sit in the cafeteria and everyone else is eating the good stuff, and your lunch is a salad with a dinky piece of chicken in it!” (Elaboration)

Nurse: “It sounds like it’s hard to sit and watch others enjoying the foods you like but aren’t supposed to eat.” (Reflecting)

Dad: “I know just how she feels. I’ve been heavy all my life, and it’s very hard to give up those things you’ve always enjoyed.” (Empathizing)

Nurse: “I can certainly understand how you both feel.” (Empathizing)

Cynthia: “You know, it’s really hard. I didn’t gain any weight last summer but started gaining again when I went back to school this fall.” (Elaborating)

Nurse: “It sounds like you were successful in sticking to your diet last summer.” (Affirming)

Cynthia: “Yes, but when I went back to school, everyone around me was eating all the good things I like and can’t have.” (Elaborating)

Nurse: “You want to stick to your diet and lose weight, but you still want to enjoy the foods you like. That sounds like a dilemma to me.” (Summarizing)

Cynthia: “Yeah, that’s exactly it! But I really do want to be thinner like the other girls. I don’t want to be a fatty! I know I can do it, but sometimes it’s just so hard.” (Using “change talk”)

Nurse: “Well, let’s see. You say you want to be thin like the other girls, and at the same time, you’re saying that eating the foods you shouldn’t eat is very important to you.” (Developing and examining discrepancy)

Cynthia: “Yes, I don’t like to look the way I do, and I really want to try harder. I really do.” (Using change talk)

Nurse: “You really are strongly motivated to change and believe you can do it.” (Supporting self-efficacy)

Cynthia: “Yes, and I know Mom and Dad are really trying to help me.” (Using change talk)

Nurse: “I see. So, tell me what the three of you might do to make this wish happen.” (Finding out what the patient and family already knows)

Cynthia: “I don’t know what else I can do. I miss Taco Bell!”

Dad: “You and me both.”

Mom: “Well, I think I have a suggestion. Maybe we could all try to be more creative with the meals we make. Maybe we could explore some new recipes so your lunch is more exciting. We could start to cook together. How does that sound?” (Collaborating)

Dad: “That’s sounds like fun to me. When should we start?” (Encouraging)

Cynthia: “That does sound like fun. We’ve never cooked anything together before. Could we really do that?” (Collaborating and negotiating)

Nurse: “Would you be interested in meeting with the dietitian again to get some ideas about the foods you could make and some basic recipes?” (Asking permission, collaborating, negotiating a plan, empowering)

Cynthia: “Shall we do that, Mom and Dad? Yeah, let’s do that!” (Collaborative response)

Mom: “I would love to spend time with you in the kitchen.” (Agreeing on action plan)

Dad: “You know I like to cook, and Mom and I can share meal planning and cooking with you on alternate days of the week.” (Agreeing on action plan)

Pharmacology

The role of pharmacological therapy in the treatment of obesity in children and adolescents is limited. Although there have been some positive findings, anorectic drugs should never routinely be used for the prevention or treatment of obesity in childhood or adolescence. These agents must not be prescribed for prepubertal children until clinical studies have been performed to assess safety and efficacy. The use of medication for childhood obesity is also limited by side effects, costs, and uncertainty about their long-term safety.

Medication might be prescribed for some adolescents, but only after the patient has failed to respond to vigorous attempts to modify behavior as part of an overall weight-loss plan. However, the risks of taking prescription medications over the long term are unknown, and the medication effects on weight loss and weight maintenance for adolescents are also unknown.

Orlistat is approved by the Food and Drug Administration for the treatment of obesity in adolescents (ages ≥12 years). All adolescents who are prescribed anorectic agents should receive concurrent nutritional and family counseling and should implement a plan of regular exercise and physical activity.

Liraglutide is also approved for use in adolescents ages 12 years and older. However, its use is limited by the high frequency of gastrointestinal side effects and need for daily subcutaneous injections.

Phentermine is approved in the United States for short-term use (12 weeks) in adolescents older than age 16. Long-term study over 6 months showed modest to moderate effect on BMI, with side effects of increased heart rate and blood pressure.

Setmelanotide (Imcivree) has recently been approved for patients ages 6 years and older for weight control caused by rare genetic conditions.

Metformin, an oral diabetic medication, is helpful in children with impaired glucose tolerance or polycystic ovary syndrome, and often promotes weight loss. This medicine can usually be used in children as young as 6 years. Unfortunately, any weight loss is usually regained after stopping the medication (Skelton, 2021; Schwarz, 2020).

Surgical Procedures for Adolescents

Current data shows that bariatric surgery in adolescents is as safe and effective as bariatric surgery in adults. Bariatric surgery is effective in selected adolescents with severe obesity who fit the criteria endorsed by policy statement from the American Academy of Pediatrics. These candidate requirements include:

Has attained final or near final adult height
Has BMI of >40 or >35 with significant comorbidities
Has been compliant with other treatment modalities, including lifestyle modifications and possibly pharmacotherapy
Has a sound psychological evaluation as well as competent family support to ensure success with postsurgical changes
Demonstrates ability to follow healthy dietary guidelines
Has access to experienced surgeon/pediatric bariatric surgery center for long-term follow-up

Follow-up should last at least several years and include transition to an adult bariatric team over time (ASMBS, 2022a).

Contraindications include:

Medically correctable cause of obesity
An ongoing substance abuse problem (within the preceding year)
Medical, psychiatric, psychosocial, or cognitive condition that prevents adherence to postoperative dietary and medication regimens or impairs decision-making capacity
Current or planned pregnancy within 12 to 18 months of the surgery
Concomitant eating disorders

The Roux-en-Y gastric bypass, laparoscopic adjustable gastric band, and sleeve gastrectomy are the most widely used procedures in pediatric obesity. Their use, however, is associated with subsequent nutritional deficiencies (ASMBS, 2022a).

Laparoscopic sleeve gastrectomy is the preferred technique due to is technical ease and good results. Sleeve gastrectomy has demonstrated excess weight loss and is technically less complex, with less malabsorption of specific nutrients.

The gastric bypass and laparoscopic sleeve gastrectomy both result in slightly more than a 25% weight loss over three years. Children treated with bariatric surgery also show remission of type 2 diabetes, prediabetes, abnormal kidney function, elevated blood pressure, and dyslipidemia after three years (Calcaterra et al., 2021; ASMBS, 2022a).