Nutrition Diet and Weight Issues among Children and Adolescents - Intervention And Treatment Of Overweight And Obesity

In the absence of acute medical necessity, such as children who are dangerously obese, most health professionals concur that drastic caloric restriction is an inappropriate weight-loss strategy for children who are still growing. Instead they advise efforts to stabilize body weight with a healthy, balanced diet, increased physical activity, and education about nutrition, food choices, and preparation. This approach is especially effective for children who are just slightly overweight, since maintaining body weight often allows them to "outgrow" overweight and become normal-weight adults.

When active weight loss is indicated, it is generally for children with BMI greater than the 95th percentile or those experiencing complications of overweight or obesity. Among children aged two to seven, gradual weight loss of about one pound per month is advised. Older children who are severely overweight (BMI greater than 35), with serious health risks, may be advised to lose between one and two pounds per week. Figure 4.11 is a diagram displaying the criteria—age, BMI, and medical complications of overweight (hypertension, elevated lipids, sleep apnea)—health professionals use to determine whether weight maintenance or weight loss is recommended.

Many studies confirm that dietary interventions with children and teens are as ineffective long-term as they are with adults. In "Treatment of Pediatric and Adolescent Obesity" (Journal of the American Medical Association, vol. 289, no. 14, April 2003), National Institutes of Health investigators Jack and Susan Yanovski observed that studies found that long-term weight reductions were maintained FIGURE 4.11
Recommendations for weight management for children and adolescents 2–20 years old in only about half of children and adolescents treated with intensive behavioral-modification therapy. Further, they characterized effective behavior-modification programs lacking widespread applicability because they are labor-intensive, not easily conducted by primary care physicians (pediatricians and family medicine physicians), and require intensive involvement from parents. Many practitioners believe that behavior modification alone is insufficient for severely obese children and adolescents. For this population, researchers and practitioners have had success with pharmacotherapy—drug treatment with medications known as "anorexiants," which reduce appetite by blocking the reuptake of the neurotransmitters norepinephrine and serotonin. The most serious adverse effects of these medications are increases in blood pressure and pulse rate sufficient to warrant reducing the drug dose or discontinuing it altogether. Like many other researchers and clinicians, the Yanovskis concluded that it "remains exceedingly difficult for overweight children and adolescents to lose weight, and even more difficult for them to sustain that weight loss long term. The ultimate goal must be prevention of the development of overweight in children and adolescents."

Robert Berkowitz and his colleagues at the Department of Psychiatry, Weight and Eating Disorders Program and the Children's Hospital, University of Pennsylvania School of Medicine, Philadelphia, compared the efficacy of family-based behavioral treatment alone to a combined regimen of family-based behavioral therapy and weight-loss medication among adolescents. The researchers reported the results of their study in "Behavior Therapy and Sibutramine for the Treatment of Adolescent Obesity: A Randomized Controlled Trial" (Journal of the American Medical Association, vol. 289, no. 14, April 2003). For the first six months of the study, the eighty-two participants aged thirteen to seventeen with BMIs ranging from 32 to 44 received behavior therapy and sibutramine (an anorexiant medication marketed under the brand name Meridia) or behavior therapy and a placebo (an inactive compound). During the second six months all participants received behavioral treatment and sibutramine.

During the first phase, behavioral treatment called for participants to attend thirteen weekly group sessions followed up by six biweekly group sessions. In phase 2, the group sessions were conducted biweekly from months seven to nine and monthly from months ten to twelve. Parents met in separate group sessions held on the same schedule as the adolescents' meetings. Dietitians, psychologists, or psychiatrists conducted the groups. Participants in both treatment groups were instructed to consume a 1,200 to 1,500 calorie diet of conventional foods, with approximately 30 percent of their calories derived from fat, 15 percent from protein, and the remainder from carbohydrates. They were advised to incrementally increase their physical activity with the goal of walking or participating in aerobic activity for 120 minutes per week or more. Participants kept daily eating and activity logs that they submitted at each session.

At the end of the first six months, participants in the behavioral treatment and sibutramine group lost a mean of 7.8 kg (17.2 lbs) and had an 8.5 percent reduction in BMI, which was significantly more than weight loss of 3.2 kg (7.05 lbs) and reduction in BMI of 4 percent in the behavioral treatment and placebo group. Participants who received behavioral treatment and sibutramine also reported significantly less hunger. From months seven to twelve, participants initially treated with sibutramine maintained their weight loss with continued use of the medication, while those who switched from placebo to sibutramine lost an additional 1.3 kg (2.87 lbs). The researchers explained behavioral treatment and sibutramine participants' failure to lose further weight during the second phase of the study as consistent with the observation that weight loss tends to plateau in obese adults after six months of treatment with behavior therapy or pharmacotherapy.

The researchers concluded that weight-loss medication may be of benefit to adolescents. However, they cautioned that their use must be carefully monitored in adolescents, as in adults, to control increases in blood pressure and pulse rate. Absent the numerous large-scale studies necessary to confirm the safety and effectiveness of pharmacological treatment of obesity in adolescents, the researchers advised that "weight-loss medications should be used only on an experimental basis for adolescents."

Since adherence—sticking with any nutrition, diet, or exercise program—is an issue for adults and children, researchers Marsha Mackenzie and her colleagues reported about the successful implementation of a fun, family-centered nutrition and exercise program in "Effect of a Kids N Fitness© Weight Management Program on Obesity and Other Pediatric Health Factors" (Diabetes, vol. 49, supplement 1, May 2000). The weight-control program consisted of eight weekly, ninety-minute sessions with nutrition, education, and exercise components. Nutrition activities involved critical food label reading, dining-out strategies, supermarket shopping, snack preparation, and holiday eating tips. Each session also included a half hour of exercise such as hip-hop dancing, aerobics, volleyball, or calisthenics. Families were educated to promote eating changes at home and to encourage attainment of individual exercise goals. The investigators reported decreasing weight gain per month and increasing exercise as well as significant positive changes in knowledge, physical function, children's health behaviors, children's physical and mental health, and self-esteem. They hypothesized that incorporating fun activities in a nonthreatening environment with peer and professional support was responsible for the favorable outcomes of the program.

Educating Parents

Researchers agree that primary prevention is the strategy with the greatest potential for reversing the alarming rise in overweight and obesity among children and teens. Public health educators recommend counseling parents and caregivers about healthy eating habits for children. They advise offering children a variety of healthy foods, in reasonable quantities, to assist children to make wise food choices. Children should be encouraged, but not forced, to sample new foods and should not be pressured to clean their plates. No foods or food groups should be entirely off-limits, or children may become fixated on obtaining the forbidden foods.

Though it is difficult to impress children with the future health risks associated with excess weight, parents should be informed that obese children are more likely to suffer from diabetes, heart, and joint diseases such as osteoarthritis, as well as breast and colon cancer. Adults should model healthy habits, consuming no more that 30 percent of calories from fat, exercising regularly, and limiting time spent in front of the television. Health educators are especially eager to reduce children's television viewing, with its destructive blend of junk-food advertising and enforced inactivity. Finally, health professionals caution that food should not be used to punish or reward behavior nor as a way to comfort or console children. The undivided attention of a parent or caregiver or an expression of sympathy, reassurance, or encouragement may satisfy a child's need better than an ice cream cone or an order of French fries.