INTRODUCTION — Prevention and treatment of overweight and obesity in children in the primary care setting focuses on modifying behaviors that lead to excessive energy intake and insufficient energy expenditure [1-7]. Guidance on cardiovascular health (rather than obesity per se) recommends similar health behaviors, with a slightly different perspective. (See "Pediatric prevention of adult cardiovascular disease: Promoting a healthy lifestyle and identifying at-risk children".)
This topic review will address interventions to prevent and treat childhood obesity in the primary care setting, including an outline of practical approaches to incorporating them into a primary care practice, reflecting the authors' experience. Related content on childhood obesity can be found in the following topic reviews:
●(See "Definition, epidemiology, and etiology of obesity in children and adolescents".)
●(See "Clinical evaluation of the child or adolescent with obesity".)
●(See "Overview of the health consequences of obesity in children and adolescents".)
●(See "Surgical management of severe obesity in adolescents".)
Links to resources related to physical activity and nutrition during prolonged home confinement due to the COVID-19 pandemic are included in a separate topic review. (See "COVID-19: Management in children", section on 'Physical health effects'.)
GENERAL APPROACH TO COUNSELING ABOUT WEIGHT MANAGEMENT
Behavioral strategies — Nutrition and physical activity should be thought of as habitual behaviors, and weight loss counseling should focus on long-term behavior change rather than short-term weight loss. The best-established techniques used for pediatric obesity treatment use a behavioral change model rather than simply providing patients with education on obesity-related health risks, nutrition, and physical activity. Behavioral change counseling includes the following elements [5,8-13]:
●Self-monitoring of target behaviors (logs of food, activity, or other behaviors, recorded by patient or family). This process allows the patient and family to recognize which behaviors may be contributing to weight gain. Clinician feedback throughout the self-monitoring process is essential to behavior change. A patient's food log may also identify other contributors to eating behaviors, such as meal-time environment, boredom, and level of hunger, all of which can be valuable in the evaluation of stimulus control.
●Stimulus control to reduce environmental cues that contribute to unhealthy behaviors. This includes reducing access to unhealthy behaviors (eg, removing some categories of food from the house or removing a television from the bedroom) and also efforts to establish new, healthier daily routines (such as making fruits and vegetables more accessible).
●Goal-setting for healthy behaviors rather than weight goals. Goal-setting is widely used for prompting behavior change. However, the process can be detrimental if goals are not realistic and maintainable. Appropriate goals are identified by the acronym "SMART," where goals should be should Specific, Measurable, Attainable, Realistic, and Timely.
●Contracting for selected nutrition or activity goals. Contracting is the explicit agreement to give a reward for the achievement of a specific goal. This helps children focus on specific behaviors and provides structure and incentives to their goal-setting process.
●Positive reinforcement of target behaviors. Positive reinforcement can be in the form of praise for healthy behaviors or in the form of rewards for achieving specific goals. The reward should be negotiated by the parent and the child, ideally facilitated by the provider to ensure that the rewards are appropriate. Rewards should be small activities or privileges that the child can participate in frequently rather than monetary incentives or toys; food should not be used as a reward.
Patient- and family-centered communication — Effective approaches to behavior change are usually collaborative rather than prescriptive. As an example, the clinician should engage the family in a conversation to select specific behaviors to change, rather than dictate goals to the family [1]. Because the family and patient help to choose goals, they are more likely to be more invested in the process and have confidence in their ability to change the behaviors.
The child should be directly involved in decision-making, as appropriate to his or her age. This process ensures that the family and patient have confidence that they can change a behavior and are invested in the process, which greatly enhances the chance of success. As an example, we teach and model that the child be included in the planning of meals but with proper limits. This might include allowing the child to help choose meals or recipes but within healthy bounds (eg, the child can choose a favorite vegetable or fruit as a side dish but not candy). This process ensures that the child is included in the change process but with reasonable limits and expectations.
Motivational interviewing is a patient-centered counseling technique that is increasingly used for obesity treatment [1,3,5,14-17]. This technique addresses a patient's ambivalence to change and focuses on his or her values as a means to resolve that ambivalence [18]. The clinician employs reflective listening to encourage patients to identify their own reasons for making a behavior change, as well as their own solutions. The tone of motivational interviewing is nonjudgmental, empathetic, and encouraging [14,18]. (See 'Motivational approaches' below.)
Clinicians should help the family focus on specific and achievable behavioral goals, which usually means selecting a few specific behaviors related to weight management and overall health and not goals for weight loss itself. Training in motivational interviewing for childhood obesity is available through "Change Talk," an interactive program developed in collaboration with the American Academy of Pediatrics, which is available free of charge [19].
The efficacy of motivational interviewing in weight management was demonstrated in a randomized trial of more than 600 children with a body mass index (BMI) between the 85th and 97th percentile (two to eight years of age) in 42 primary care practices [20]. At the two-year follow-up, weight status was significantly lower for children who received the combined intervention compared with those treated with usual care. This and six other randomized trials were the focus of a systematic review that found mixed results of individual studies but an overall beneficial effect of motivational interviewing on anthropometric outcomes [21].
Formal assessment of a patient's and family's motivation and self-efficacy has been successfully applied to a variety of health-related behaviors. Several approaches can be used to evaluate a patient's readiness to change (or stage of change) [22], including global assessment through interviewing questions or use of a numerical or visual analog scale (eg, "On a scale of 1 to 10, how ready are you to consider making this change [to diet or exercise]?"). This assessment may help a patient and clinician to recognize ambivalence, which is an important step in changing behaviors.
Family involvement
●Rationale for family involvement – If possible, use family-based behavioral approaches to pediatric obesity treatment, incorporating at least one of the child's primary parents or caregivers [1,17]. Studies have shown that 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 referred child without parental participation [8,9,23-27].
Involvement of the parent(s) or primary caregivers alone as "agents of change" is important in pediatric weight management and is supported by substantial clinical evidence [23,24,28].
●Avoid pressure and criticism – Discuss and shape the parents' strategies to avoid putting inappropriate pressure on the child, particularly in school-aged children. Advise parents to avoid teasing the child about their weight and also to avoid making comments that focus on weight or weight-related appearance ("weight talk"), even if the comments are phrased as compliments or are focused on individuals other than the child, including the parents themselves. Similarly, encourage the family to focus their conversation about food on healthy choices and healthy eating behaviors rather than dieting (ie, caloric restriction with a goal of weight loss).
"Weight talk" by family members has been associated with subsequent weight gain, lower self-esteem, and eating disorders [17,29-31]. By contrast, family conversation that focuses on healthful eating behaviors rather than dieting is not associated with eating disorders [32].
●Role of parenting style – Authoritarian parenting and feeding styles are associated with childhood obesity [33]. In this feeding style, the parent or caregiver exerts high levels of control over the child's eating:
•Exerts inappropriate pressure on the child to eat more of a certain food (typically, foods that are less desired by the child or considered "healthy" by the parent)
•Attempts to restrict the amount or access to other foods (typically, foods that are more desired by the child or considered "unhealthy" by the parent)
•Insists on children finishing all food on their plate, negotiates vegetable intake (must finish for dessert, no second helpings of other foods until vegetables eaten), or strictly limits portion sizes and servings
A few probing questions on how parents handle common mealtime situations and conflicts can identify these patterns and provide opportunities for further discussion and education.
●Economic and cultural considerations – Economic or cultural factors may limit a family's ability or willingness to make changes in diet or physical activity [5]. These obstacles can be addressed by allowing the family to decide when to begin the change process and the intensity with which they are willing to pursue weight management. To initiate the discussion, the following factors should be assessed in selected patients:
•Economic and work schedule challenges – Ask about food insecurity (do you sometimes run out of money for food?); the family's living conditions (whether there is a working stove and/or refrigerator); availability of income assistance such as food stamps; and whether/which caregivers are available to help plan, prepare, and supervise the child's meals.
•Cultural factors – Ask the parents and child what they think of the child's weight. Misperception of the child's weight status, such as a cultural preference for overweight in children, may affect a family's ability to effectively address the problem. Conversely, excessive anxiety about the child's weight status also can interfere with effective management. To address this issue, it is important to explore reasons for the anxiety in the parent or child. Reasons for excessive anxiety may include an overestimate of the child's risk for future obesity or a personal history of disordered eating in the parent.
Strategies for discussing weight — Many families with obesity are sensitive about discussing the issue, reflecting widespread cultural bias including within the medical community [34-36]. Individuals with obesity have often absorbed the bias themselves, leading to self-criticism, low self-esteem, and hopelessness; these feelings are often barriers to behavior change. (See "Overview of the health consequences of obesity in children and adolescents", section on 'Psychosocial'.)
To form a therapeutic alliance and engage the family in addressing weight-related behaviors, the provider must carefully avoid a blaming approach. This might include discussing weight in a "matter of fact" manner but focusing on health rather than weight or appearance. The use of sensitive language demonstrates to the child and family that the clinician's office is a place of support, not judgment, which is essential to engaging them in behavior change [35]. As examples:
●We initiate the discussion of weight management by acknowledging that some individuals gain weight more easily than others, in recognition of the role of genetics and epigenetics. It may be helpful to acknowledge the societal and environmental factors that promote weight gain, such as readily available energy-dense foods and mechanized transportation. These messages avoid blaming a patient or family with obesity, while still strongly encouraging them to invest in lifestyle change.
●We generally use neutral words like "weight" or "body mass index" because these terms are perceived by parents as less stigmatizing and more motivating than the terms "obese" or "fat" [35,37].
●We also choose terms that focus on health and function rather than appearance. For children who already have overweight or obesity, we discuss the goal of "growing into a healthy body weight" and being "strong and healthy." We avoid discussing an "ideal weight" for the child, both because this is a moving target for a growing child but also because choosing a target ideal weight is often unrealistic and leads to discouragement. (See 'Weight goals' below.)
Approaches will vary from child to child and should take into account the child's age, maturity, and overall developmental status. The clinician may choose to discuss the topic initially with the parent, without the child present. This is especially important if the child has experienced weight-related teasing from peers or if there is a concern that the child might misinterpret the discussion. In our practice, for children 8 to 12 years of age, we often talk in general terms with the child about weight and health, linking the discussion to the importance of healthy habits. More frank discussions are typically held with the parent alone to prevent misunderstanding on the side of the child. For adolescents, having separate discussions with similar content with the patient and parent can support the adolescent's desire for autonomy while including the family for support.
EVIDENCE FOR EFFICACY — A preponderance of evidence suggests that routine assessments and counseling interventions are somewhat effective for preventing and treating obesity in children [38-42].
The limited evidence available suggests that the following factors are important for efficacy [38-42]:
●Early intervention
●Assessments for obesity and related comorbidities in primary care practice
●Intensity/frequency of intervention
●Counseling on both diet and physical activity (rather than only one of these)
●Family involvement (see 'Family involvement' above)
The efficacy varies widely among patients, likely depending on readiness/motivation, patient age, and sociocultural and economic barriers, as well as genetic or other fixed factors that contribute to obesity.
Prevention interventions — A meta-analysis reported that prevention interventions resulted in a modest mean reduction in adiposity compared with control groups [38]. As an example, physical activity interventions in children 6 to 12 years of age resulted in a mean difference in body mass index (BMI) of -0.1 kg/m2 (95% CI -0.14 to -0.05). While the effect size is small, this represents a clinically important difference across a population. The best supported strategies were interventions focusing on both diet and physical activity for preschool-aged children and physical activity with or without diet in school-aged children or adolescents. Because the intervention strategies and results varied widely among the included studies, the effect of each intervention component is not clear.
Accordingly, guidelines and policy statements in the United States have advocated for improvements in nutrition quality for children, including:
●Consumption of a diverse, nutrient-dense diet and emphasizing vegetables, fruits, and whole grains
●Quality protein sources and low-fat or nonfat milk and dairy
●Limited intake of sugar-sweetened beverages
●Modest fat content
●Moderate portion sizes [43,44]
Medical societies in the United States and Europe have issued policy statements discouraging access to sugar-sweetened beverages in schools and homes and encouraging clinicians to advocate for these goals [45,46]. In the United States, the nutrition quality of school meals has improved substantially over the past two decades [47]. Sugary beverages are generally restricted, but states may choose whether to offer flavored low-fat milk in addition to low-fat milk in school meals, provided that the meal remains within guidelines for total energy intake [48]. National and international guidelines recommend specific targets for moderate to vigorous physical activity (generally >60 minutes daily for children and adolescents) and limiting sedentary activity behaviors [49-51]. In most countries, activity levels in youth are well below these targets [51].
Worldwide, many regions and countries have addressed childhood obesity through educational interventions, local programs, and/or legislation. An implementation plan with six key areas of action has been outlined in a report from the World Health Organization [52]. Interventions vary widely, based on local and national resources and cultural practices, and it remains unclear which might be associated with the improving trends that have been seen in some populations. (See "Definition, epidemiology, and etiology of obesity in children and adolescents", section on 'Trends'.)
Early intervention — Emerging evidence suggests that intervention during early or mid-childhood can be effective and may be more effective than intervention during adolescence [53-55].
Several studies of children in younger age groups (toddler, preschool, and school-age) have shown improvements in weight status [26,56,57]. In a study from Sweden, a behavioral intervention encouraging healthy food choices and increased physical activity was more successful for young children than for adolescents [58,59]. Moreover, in the United States, low-income preschool-aged children who participated in a comprehensive intervention that included educational enrichment on health and nutrition, family support, health resources, and community outreach services were less likely to have obesity as adults compared with a matched control group (any obesity 43 versus 48 percent, moderate or severe obesity 19 versus 23 percent) [60]. The between-group differences were greater for females or subgroups with additional obesity risk factors including residence in a high-poverty neighborhood.
Programs reporting successful outcomes were typically high intensity or involved more support systems or contact hours than are feasible in a primary medical care setting. Other studies in these younger age groups did not see significant improvements in weight but did so in other obesity-related behaviors (ie, television viewing) [61-63]. There is some evidence that use of motivational interviewing in lower-intensity interventions can have durable beneficial effects [20,64], with up to two years of follow-up [20].
The evidence base in this age group is still small, and the optimal type and timing of intervention remain unclear. Nonetheless, these findings call for further exploration of early interventions to prevent and treat obesity [38,65]. Research has not determined optimal intervention approaches based on child age groups, though it is believed that children should be increasingly included in the counseling dialogue and should be given autonomy in treatment decisions as they mature [3].
Intensity of intervention — Most available data suggest that substantial hours of provider contact are necessary to improve a child's weight status. As an example, systematic reviews concluded that behavioral interventions of moderate or high intensity (defined as 26 to 75 hours or >75 hours of provider contact, respectively) are effective in achieving short-term (up to 12 months) weight improvements in children [16,66,67]. Interventions at this level of intensity are usually impractical for use in a primary care setting, unless ample services from dietitians or other specialized counselors are readily available and funded.
Low-intensity interventions (less than 25 hours of provider contact, typically spread over three to six months) are feasible in a primary care setting, although there is a limited evidence base to support their efficacy. Clinical trials suggest that these low-intensity interventions for treatment of childhood obesity generally have weak or inconsistent effects [39-41,67-69]. However, one randomized study of a guided self-help intervention reported modest but significant benefits on obesity at six months follow-up [70]. The program consisted of a one-hour orientation followed by thirteen 20-minute follow-up sessions (total of 5.3 hours of provider contact) and home use of a self-help manual that included topics such as the traffic light eating plan, stimulus control, physical activities, motivation, social support, and relapse prevention. Compared with a more intensive family-based behavioral treatment program, guided self-help had similar effects on obesity but lower attrition from the program.
It is likely that low-intensity interventions may have important effects on obesity and health behaviors in individual patients, even if they have little or no measurable effect on the study population as a whole. Moreover, meta-analyses suggest that lifestyle interventions to prevent and treat obesity in children are generally effective, even if some of the included studies are too small to show statistically significant changes in weight status [38,71]. (See "Definition, epidemiology, and etiology of obesity in children and adolescents", section on 'Environmental factors'.)
STAGED APPROACH TO WEIGHT MANAGEMENT — We use a staged approach to weight management, as suggested by the American Academy of Pediatrics (algorithm 1) [3]. An overview of care location, providers, and nutrition goals are provided in the table (table 1):
A child's initial stage of treatment is determined by multiple factors, including the child's age, body mass index (BMI) percentile, and previous weight management history in other stages of treatment. Additional intervention to address overweight or obesity is divided into stages representing escalating degrees of supervision, counseling, and intervention. Stages 1 and 2 of weight management are generally implemented or coordinated by the primary care provider and focus on behavior change.
Prevention — Preventing obesity in children should be a focus of preventive health care for all children. Each visit for well-child care should include routine monitoring, brief prevention counseling, and troubleshooting problems (algorithm 1). Key steps are:
Routine monitoring
●Universal measurement of BMI and plotting of results on a BMI chart to track changes over time [72-74]. BMI percentiles can be determined from a standard BMI-for-age growth chart (figure 1A-B) and are used to categorize weight status (table 2).
●Routine assessment of all children for obesity-related risk factors, including:
•Obesity in parents or other family members
•Dietary habits that promote weight gain
•Physical and sedentary activity habits (time spent in sedentary activities, active play, and sports)
•Sleep habits (typical sleep duration and sleep quality)
Counseling — Assessment, goals, and tips for parents [5,75,76]:
●Family eating environment – Establish a healthy feeding relationship for young children; emphasize family-based meals for older children. (See "Introducing solid foods and vitamin and mineral supplementation during infancy", section on 'Feeding environment'.)
●Healthy dietary habits – Encourage a diverse diet and meal-based eating; limit foods with low nutritional value. Identify and address common obstacles to healthy eating, including frequent snacking, picky eating, and poor modeling by other family members (table 3).
●Physical activity – Set limits on screen time and promote unstructured and structured physical activity, as appropriate to the child's age (table 4).
●Sleep – Target recommended sleep time for each age group (table 5) [77,78]. Advice for developing healthy sleep habits is shown in the tables (table 6A-B). Short sleep duration or irregular sleep schedules have been associated with obesity in children and adults; a causal association has been proposed but not established. The evidence linking inadequate sleep to childhood obesity, and strategies for improving sleep, are outlined in separate topic reviews. (See "Definition, epidemiology, and etiology of obesity in children and adolescents", section on 'Sleep' and "Behavioral sleep problems in children".)
Prevention efforts focus on modifiable behaviors associated with weight gain [5,76], although other factors including genetics and gestational factors undoubtedly contribute to the risk for obesity [3]. (See "Definition, epidemiology, and etiology of obesity in children and adolescents", section on 'Genetic factors' and "Definition, epidemiology, and etiology of obesity in children and adolescents", section on 'Metabolic programming'.)
Stage 1: Prevention plus — Children two years and older with excessive weight gain (BMI ≥85th percentile or rising sharply) warrant additional steps to monitor growth and potential obesity-related comorbidities and encourage behavior change, as outlined below (algorithm 1).
Clinical assessment of body mass index and obesity-related risk factors
●BMI
•Measure and plot BMI at each visit on a BMI-for-age growth chart (figure 1A-B) and use the results to categorize weight status (table 2).
•For children and adolescents with severe obesity (defined as BMI >120 percent of the 95th percentile or a BMI ≥35 kg/m2), a specialized growth chart may be useful for monitoring (figure 2A-B) [79,80].
•In addition, note the BMI trend over time. A rapid increase in weight-for-height or BMI warrants increased concern, while a relatively stable or improving BMI trend is reassuring. (See "Definition, epidemiology, and etiology of obesity in children and adolescents", section on 'Definitions'.)
●Parents' weight status – Assess the parents' weight status (eg, by asking whether the parents or other close family members struggle with their weight or by recording their BMI). Obesity in a child's biologic parents is an important predictor of the child's risk of persistent obesity; if both parents have obesity, the child's risk of being obese as an adult is increased 6- to 15-fold as compared with a child whose parents have healthy body weights [81,82]. This is probably primarily due to genetic factors, although shared social and nutritional factors also play a role.
●Assessment of comorbidities – For children with obesity, weight-related comorbidities should be assessed with:
•Focused review of systems (table 7)
•Physical examination including blood pressure (table 8)
•Periodic laboratory monitoring, including measurement of a fasting lipid profile, hemoglobin A1c, or fasting glucose level; aminotransferase levels are suggested, depending on the child's age and risk factors (table 9)
Details of the assessment for weight-related comorbidities are discussed in separate topic reviews. (See "Clinical evaluation of the child or adolescent with obesity" and "Overview of the health consequences of obesity in children and adolescents".)
Education to support healthy eating and activity behaviors — Children with excess weight (BMI ≥85th percentile) generally start with the "prevention plus" stage of weight management (table 1).
●Goal-setting and counseling – In this stage, emphasize long-term changes in behaviors that are related to obesity risk rather than structured diet and exercise prescriptions. The approach is similar to that for obesity prevention, except with more specific goal-setting and more time spent counseling and providing strategies to overcome obstacles.
•Selection of goals – We use a practical, problem-oriented approach, working collaboratively with the patient and family to identify a few specific goals for behavior change, then tracking progress towards those goals during follow-up visits. Examples of goals, supportive evidence, and counseling tips are shown in the tables for eating and nutrition (table 10) and physical activity (table 4). A more detailed assessment of caloric intake and physical activity is often impractical in the primary care setting, has low accuracy, and is not usually necessary to support a brief counseling intervention.
Selection of goals also depends upon the family's finances, available caregivers, and schedules. Identifying who is responsible for shopping and meal preparation, how the child spends time outside of school, who is responsible for supervision, and typical context for meals (location and who is at the table) helps to identify the most appropriate people and practices for focused counseling.
•Commercial programs – Advise families and children to be cautious about commercial or social media-based weight management approaches, which often do not account for children's ages or developmental status. If the family wants to try one of these approaches, review the program with them, discuss whether it is age appropriate and nutritionally sound, and arrange for follow-up, especially to ensure healthy eating patterns.
●Office systems – The following office systems may facilitate a positive experience for families with obesity and efficient counseling:
•Office setup – Whenever possible, practices should have appropriate equipment to provide medical care to patients with obesity. This includes a wide range of blood pressure cuffs (including a "large adult" size) to ensure accurate measurements and high-capacity scales (ideally up to 500 or 1000 lbs). In addition, it is helpful to have office furniture that is appropriate for large patients and their families, including sturdy armless chairs and lower examination tables.
•Educational materials – Having educational materials readily available in the office improves efficiency and communication. In our practice, we have posters with health-related messages on the wall of each clinic room alongside related educational handouts. (See 'Materials and resources for counseling' below.)
•Community resources – To assist families in developing an action plan, the practice can collect and distribute information about resources in the local community, including options for physical activity, active afterschool programs, nutrition counseling services, and sources of healthy food (eg, local sources of fresh produce). Recommendations are most valuable if the provider reviews or becomes familiar with these local resources, such as a gym with adolescent- or child-focused activities or community centers with pediatric- or family-focused weight management classes.
•Training of office staff in sensitive approaches to weighing of patients and how to handle discussions that may arise between children and parents regarding weight.
Follow up — For weight management counseling, the timing of follow-up depends on the clinician's level of concern and the patient's and family's engagement. For this stage, a typical interval between visits is one to three months.
Children ≥6 years with no improvement in BMI trend after three to six months of this intervention should progress to more structured weight management. (See 'Stage 2: Structured weight management' below.)
Stage 2: Structured weight management — For children six years and older with persistent or progressive obesity despite stage 1 management for three to six months, a more structured and intensive weight management approach is generally recommended (table 1 and algorithm 1) [1]. The goals and approach to this stage of counseling are outlined below.
Visit frequency — Approximately monthly visits are suggested, but the frequency also depends upon the level of concern and availability and schedule of the patient, family, and clinician. Greater intensity of counseling (length and frequency of visits) generally improves efficacy. (See 'Intensity of intervention' above.)
Nutrition goals — Work collaboratively with the patient and family to set specific nutritional goals, including a structured plan for meals and snacks, limiting foods with high energy density, and encouraging fruits and vegetables. Examples of goals, supportive evidence, and counseling tips are shown in the table (table 10). These targets are similar to those discussed in stage 1 management, but counseling includes setting and tracking specific goals in each area. When possible, we encourage the entire family to participate in the dietary goals, based on positive long-term results of family-based nutritional interventions [83].
This counseling may be performed by the primary care clinician or a dietitian. Excellent counseling tools designed to support weight management in a pediatric practice are publicly available. (See 'Materials and resources for counseling' below.)
This type of intervention does not predispose to eating disorders, provided that it is implemented in a supportive fashion, with a focus on healthy eating behaviors rather than rigid or highly restrictive dieting [17]. Indeed, there is some evidence that well-conceived interventions help to reduce unhealthy dieting behaviors [84]. Conversely, restrictive approaches to weight management, such as detailed monitoring of caloric intake and exercise, are not recommended, because they rarely produce long-term weight loss and can promote unhealthy eating patterns [17].
For most patients, we avoid more highly structured diets, which include various forms of balanced low-calorie diets, low-fat diets, low-carbohydrate/low-glycemic index diets [85-87], or high-protein diets. These structured diets are reasonably effective in achieving short-term weight loss in a motivated patient and are safe if adequately selected and supervised. However, highly structured diets have poor adherence and success rates over longer periods of time. (See "Obesity in adults: Dietary therapy".)
Physical activity goals — Set more specific and stringent physical activity goals, which typically include (table 4):
●Limit recreational screen time/internet usage – The specific goal(s) should be developed collaboratively with the child and family to ensure that it is specific and achievable. Traditional recommendations are to limit screen time to ≤1 hour/day, with more stringent limits for children <2 years [88,89]. However, these goals may need to be modified because of the proliferation of social media and smartphone use among children. Children and families should first monitor their present amount of media use and then set goals to decrease it. We ask families to set firm and consistent media limits for all family members, including parents.
●Moderate or vigorous physical activity for ≥1 hour/day – Strategies for increasing physical activity are individualized. Clinicians should take into account the developmental stage of the child, family schedule, and personal preferences for types of activity.
For children who are school-aged and older, we generally encourage structured physical activity (ie, participation in team or individual sports or supervised exercise sessions) rather than self-guided activities (eg, unscheduled walking or running). In structured activities, the presence of a coach or leader provides accountability and encourages consistent participation. However, whether a child is willing to engage in structured activities varies, particularly for adolescents. Some adolescents will enjoy engaging in sports or fitness centers, while others may not, due to lack of self-confidence or self-esteem. Directly engaging adolescents in choosing activities to replace sedentary time is helpful.
For preschool-aged children, most physical activity will be unstructured; outdoor play is particularly helpful because it tends to be active and enjoyed by most children [90]. Providers can encourage physical activity in this age group by "prescribing" playground time and providing a list of local resources (playgrounds or other opportunities for active play).
Weight goals — We generally avoid setting specific weight loss goals during discussions with the patient and family and instead emphasize goals for dietary and physical activity behaviors. Weight goals are misleading because they change as the child grows, and patients may feel discouraged if they are do not reach the goal. Throughout the process, the counseling should also emphasize healthy eating patterns and monitor for evidence of disordered eating or distorted body image.
An appropriate pace of weight loss is a function of a patient's age and degree of overweight or obesity [1,3,4]:
●For children and adolescents with mild obesity, the goal of maintaining current body weight is appropriate because this will lead to a decrease in BMI as the child grows taller. If the child is in a phase of rapid linear growth, merely slowing weight gain is more realistic and often improves weight status. For adolescents who have completed linear growth, focus on healthy behaviors and a positive body image, with a long-term goal of gradual weight loss.
●For children and adolescents with more severe obesity (ie, BMI substantially above the 95th percentile), gradual weight loss is safe and appropriate, depending on the child's age and degree of obesity.
•For children between 2 and 11 years old with obesity and comorbidities, a weight loss of up to one pound per month is safe and beneficial but may be difficult to achieve
•For adolescents with obesity and comorbidities, it is safe to lose up to two pounds per week, although a weight loss of one to two pounds per month usually is more realistic
Materials and resources for counseling — Several groups have developed messaging to support this type of brief clinical intervention as outlined above. Materials to support patient education and practice process improvement are available at each of the following websites:
●Let's Go! (MaineHealth) – MaineHealth provides an example of a coordinated intervention that has been implemented in primary care practices across the state of Maine, using common approaches and messaging. The Health Care Tool Kit includes extensive materials for patient education and improvement of practice processes and is available to download free of charge or can be ordered in hard copy from the website. Outcomes analysis suggest substantial increases in clinician support for several obesity-related interventions and improvements in adherence to healthy behaviors as reported by parents, although mean BMI Z-score was not affected [91-93]. The office-based initiative is closely integrated with initiatives in schools, afterschool programs, and communities and is supported by community partners.
●Healthy Care for Healthy Kids Obesity Toolkit (National Institute for Children's Health Quality).
●Eat Smart, Move More, Every Day, Everywhere (North Carolina).
●Institute for Healthy Childhood Weight (American Academy of Pediatrics).
●MyPlate (United States Department of Agriculture).
Motivational approaches — Recommended approaches to weight loss counseling include:
●Tailor the conversation to the family's level of readiness (stage of change).
●The tone of the interview should be nonjudgmental, empathetic, and encouraging [14]. Use preferred terms for weight (most patients prefer terms such as "unhealthy weight" or "weight problem" rather than "obesity").
●Avoid using scare tactics (ie, conversation that emphasizes specific dire, long-term risks or discussion of invasive procedures used to assess comorbid conditions). Scare tactics may garner short-term attention but are rarely effective in achieving long-term change [94]. Although scare tactics are not recommended, health risks can and should be discussed in a balanced and realistic way.
A brief summary of techniques including motivational interviewing is available from the Maine Youth Overweight Collaborative [95]. The intervention should be focused on modifying lifestyle habits of the entire family rather than focused exclusively on the identified child [8,13], consistent with the theoretical principles outlined above. (See 'Behavioral strategies' above and 'Patient- and family-centered communication' above.)
The counseling session can be brief (eg, 5 to 10 minutes) and use preprinted handouts. Additional contact time is valuable if time permits or if an allied health care provider (eg, dietitian or nurse) is available to provide counseling, education, or referral to resources. (See 'Intensity of intervention' above.)
These brief counseling sessions are repeated at each subsequent follow-up visit. To provide continuity and reinforce the message, the provider should review the same concerns at a follow-up session. If progress has been made, the provider should praise the family and encourage additional work; if no progress has been made, the provider should engage in further problem-solving and/or work with the family to identify other goals that seem more achievable.
Stage 3: Comprehensive multidisciplinary intervention — Children ≥6 years with severe or refractory obesity usually require management beyond the capacity of a primary care practice (algorithm 1).
Referrals — For children with severe obesity (BMI ≥120 percent of the 95th percentile or BMI ≥35, whichever is lower) or refractory obesity (progressive increase in BMI percentiles despite stage 2 management), we suggest referral to one or more of these services. The choice depends on the severity of obesity, presence of mental health or other psychosocial challenges, available clinical resources, and affordability.
●Dietitian – For motivated patients/families, referral to a dietitian may be sufficient. Ideally, the dietitian should be experienced with the child's age group and weight management and use motivational techniques similar to those outlined above.
●Mental health – Clinicians should screen for possible mental or emotional health concerns, including bullying/teasing, depression, anxiety, and problems with self-esteem. Children with overweight/obesity have higher degrees of mental health symptomatology, which can impede treatment success [96,97]. We have found the Pediatric Symptom Checklist (PSC-17; available free of charge from Massachusetts General Hospital) to be a useful screening tool to help providers assess possible mental health issues and referral for additional evaluation, such as a psychologist, school counselor, mental health therapist, or social worker.
●Comprehensive weight management program – For most patients, we suggest referral to a comprehensive multidisciplinary weight management program, where available and if this is acceptable to the family (table 1) [1]. These programs typically provide a combination of nutritional and behavioral counseling and have expertise in pharmacotherapy and decisions about weight loss surgery.
●Management of comorbidities – Patients with obesity-related comorbidities such as nonalcoholic fatty liver disease, type 2 diabetes, or obstructive sleep apnea may require referral to an appropriate subspecialist. (See "Overview of the health consequences of obesity in children and adolescents".)
●Weight loss surgery – Adolescents with severe obesity may be candidates for weight loss surgery. In most cases, surgery is undertaken only after sustained efforts to manage obesity through lifestyle and counseling interventions in a multidisciplinary weight management program. (See "Surgical management of severe obesity in adolescents".)
Pharmacotherapy — Pharmacotherapy is occasionally used for adolescents with obesity as an adjunct to diet and physical activity interventions. In most cases, pharmacotherapy is undertaken in the context of a comprehensive multidisciplinary weight management program.
Pharmacotherapy options for adolescents with obesity are limited by low efficacy, tolerability, cost considerations, and lack of information about long-term safety in adolescents [79,98]. For adolescents with severe obesity, the benefit is unlikely to be clinically significant, except for patients with comorbid type 2 diabetes. As a result, surgical management is often the preferred strategy for patients with severe obesity. There may be a role for pharmacotherapy in carefully selected patients and with newer therapeutic agents [99].
Considerations for adolescents include:
●Liraglutide – Liraglutide, a glucagon-like peptide-1 (GLP-1) analog, is associated with weight loss in patients with obesity. In a randomized trial in adolescents, liraglutide resulted in modest weight loss (placebo-adjusted change in BMI -1.58 kg/m2 [95% CI -2.47 to -0.69]; change in weight -4.50 kg [95% CI -7.17 to -1.84]) [100]. Its use is limited by the high frequency of gastrointestinal side effects and need for daily subcutaneous injections [101]. Liraglutide is approved in the United States for weight loss in adolescents 12 years and older with obesity [102]. It is also a second-line treatment for adolescents with type 2 diabetes, using a lower dose than for weight loss. (See "Obesity in adults: Drug therapy", section on 'Liraglutide' and "Management of type 2 diabetes mellitus in children and adolescents", section on 'Pharmacologic agents'.)
●Semaglutide – Semaglutide is a GLP-1 analog designed for once-weekly administration. In a 68-week randomized trial in 201 adolescents with obesity, subcutaneous semaglutide (2.4 mg once weekly, in conjunction with diet and exercise) resulted in substantial weight loss compared with diet and exercise alone (placebo-adjusted change in BMI -6 kg/m2 [95% CI -7.3 to -4.6]; change in weight -17.7 kg [95% CI -21.8 to -13.7]) [103]. The treatment effect is substantially greater than in the trial of liraglutide described above. Gastrointestinal adverse events were common in both semaglutide and placebo-treated groups but were generally mild and rarely led to treatment discontinuation. Subcutaneous semaglutide is licensed in the United States for treatment of obesity and/or type 2 diabetes in adults. (See "Obesity in adults: Drug therapy", section on 'Semaglutide'.)
●Metformin – In adolescents with obesity but without diabetes, randomized trials of metformin with 2 to 24 months follow-up demonstrate only modest reductions in BMI, with range of mean changes -2.70 to +1.30 compared with a placebo -1.12 to +1.90 kg/m2 [104]. Because of these very limited benefits, its use for adolescents without type 2 diabetes is questionable; this is an off-label use. Metformin is generally well tolerated and is a first-line treatment for glycemic control in adolescents with type 2 diabetes. (See "Management of type 2 diabetes mellitus in children and adolescents", section on 'Pharmacologic agents'.)
●Orlistat – Orlistat is approved in the United States for the indication of weight loss in adolescents; it has low efficacy (placebo-subtracted BMI reduction of <1 kg/m2) [105]. Its mechanism is to alter fat digestion by inhibiting pancreatic lipases, which also causes gastrointestinal side effects that limit its acceptability for many patients. (See "Obesity in adults: Drug therapy", section on 'Orlistat'.)
●Phentermine – Phentermine is a norepinephrine reuptake inhibitor that reduces appetite and is approved in the United States for short-term use (12 weeks) in adolescents older than 16 years of age. A longer-term study (six months) showed modest to moderate effect on BMI, with side effects of increased heart rate and blood pressure [106]. (See "Obesity in adults: Drug therapy", section on 'Sympathomimetic drugs'.)
●Phentermine-topiramate – The combination of phentermine and topiramate was evaluated in a 56-week, randomized dose-ranging trial in 223 adolescents [107]. Treatment with phentermine-topiramate resulted in a modest BMI reduction compared with placebo, with slightly greater efficacy for the higher dose (15 mg/92 mg: BMI -5.3 kg/m2, 95% CI -6.4 to -4.3) than mid-dose (7.5 mg/46 mg: BMI -3.7 kg/m2, 95% CI -5.0 to -2.5). Overall outcomes are similar to those seen in larger studies in adults. Phentermine-topiramate is approved in the United States for treatment of obesity in individuals 12 years and older [108]. It is a second- or third-line drug for weight management in adults and is contraindicated in pregnancy. (See "Obesity in adults: Drug therapy", section on 'Phentermine-topiramate'.)
A 2016 systematic review evaluated weight loss medications in 2484 adolescent patients in 29 trials involving various medications, including metformin, sibutramine, orlistat, topiramate, exenatide, and combination metformin-fluoxetine [109]. The review found a mean difference in BMI of -1.3 kg/m2 in medically managed patients (95% CI -1.9 to -0.8), with short or no post-intervention follow-up [98,99,109].
These and other drugs used for medical management of adults with obesity, including drugs in development, are discussed in detail in a separate topic review. (See "Obesity in adults: Drug therapy".)
SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Obesity in children".)
INFORMATION FOR PATIENTS — UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)
●Basics topic (see "Patient education: My child is overweight (The Basics)")
SUMMARY AND RECOMMENDATIONS
●General approach to counseling
•Obesity during childhood is influenced by genetic, epigenetic, behavioral, and environmental factors. Among these, only behavioral and environmental factors are modifiable during childhood, so these are the focus of clinical interventions.
•Counseling about weight and related habits should be supportive rather than blaming, collaborative rather than prescriptive, and focused on the entire family rather than on the child alone. Long-term changes in behaviors that are related to obesity risk should be emphasized rather than diets and exercise prescriptions, which tend to set short-term goals. These approaches help to support an ongoing therapeutic alliance and avoid disordered eating patterns. (See 'General approach to counseling about weight management' above.)
•Counseling regarding childhood obesity can be offered in stages, depending on the child's weight status and response to previous interventions (table 1 and algorithm 1). Preventive care and the first two stages of management are well suited to the primary care setting. (See 'Staged approach to weight management' above.)
●Prevention – For all children, to help prevent obesity, include these steps in routine care (see 'Prevention' above):
•Measure body mass index (BMI) and plot results on a chart to track changes over time (figure 1A-B). The BMI percentile is used to categorize weight status (table 2).
•Provide routine counseling to support a healthy eating environment and diet (table 3), physical activity (table 4), and sleep (table 5). Counseling focuses on these behaviors because they are associated with weight gain, although other factors including genetics and gestational factors also contribute to obesity risk.
●Stage 1: Prevention plus – For children ≥2 years with BMI ≥85th percentile or rising sharply, begin stage 1 counseling (prevention plus). A typical interval between office visits is one to three months. (See 'Stage 1: Prevention plus' above.)
•Assess obesity-related risk factors to allow for early intervention. This includes recording the obesity status (BMI) of the biologic parents and assessing weight-related comorbidities through a focused review of systems (table 7), physical examination (table 8), and laboratory screening (table 11). (See 'Clinical assessment of body mass index and obesity-related risk factors' above.)
•Initiate counseling to improve diet and physical activity habits (table 10 and table 4). The counseling is tailored to the patient and family, addresses the common diet-related problems encountered in children, sets firm limits on television and other media, and encourages daily moderate to vigorous physical activity. (See 'Education to support healthy eating and activity behaviors' above.)
●Stage 2: Structured weight management – For children ≥6 years with persistent or progressive obesity despite stage 1 management for three to six months, we suggest structured weight management (stage 2) rather than general lifestyle guidance (ie, ongoing stage 1 counseling) (Grade 2C). Stage 2 counseling can be given in the primary care setting or in a weight management program, and typical frequency of office visits is monthly. (See 'Stage 2: Structured weight management' above.)
•The counseling is similar to that of stage 1 management but with more specific goals and more frequent follow-up. Typical goals include a structured plan for meals and snacks, limitation of foods with high energy density, and moderate to vigorous physical activity for at least one hour daily (table 10 and table 4). The child and family are asked to log the target behaviors for review in follow-up sessions. Additional contact time is valuable if time permits or if an allied health care provider (eg, dietitian or registered nurse) is available to provide counseling. (See 'Education to support healthy eating and activity behaviors' above and 'Intensity of intervention' above.)
•Educational materials are available from a variety of sources to facilitate counseling. These materials have much in common; it is reasonable for providers to select materials with messaging that is best suited to their community. Options include a Health Care Tool Kit available from MaineHealth. (See 'Materials and resources for counseling' above.)
•Patient and family motivation is an important predictor of success. Motivational interviewing techniques seek to engage the patient and family at their level of readiness; a brief guide to using motivational interviewing for pediatric weight management is available here. (See 'Motivational approaches' above.)
●Stage 3: Comprehensive multidisciplinary intervention – For children ≥6 years with severe obesity (BMI ≥120 percent of the 95th percentile or BMI ≥35, whichever is lower) or refractory obesity (progressive increase in BMI percentiles despite stage 2 management), higher-intensity approaches are needed, which may include referral to a comprehensive pediatric weight management program, pharmacotherapy, and/or weight loss surgery. (See 'Stage 3: Comprehensive multidisciplinary intervention' above.)
For most adolescents who have severe or refractory obesity despite nutritional and behavioral interventions, we suggest referral for weight loss surgery rather than pharmacotherapy (Grade 2C). For most patients, weight loss surgery results in substantial weight loss (50 to 70 percent of excess body weight) and is associated with related improvements in obesity-related comorbidities. By contrast, weight loss drugs that are currently licensed for adolescents are unlikely to achieve clinically significant weight loss and the options are limited by poor tolerability, cost considerations, and lack of data on long-term safety in this age group. However, pharmacotherapy may be reasonable in patients who are reluctant to undergo weight loss surgery and are committed to concomitant efforts to lose weight through changes in diet and exercise. The evidence and outcomes are discussed in detail separately. (See "Surgical management of severe obesity in adolescents" and 'Pharmacotherapy' above and "Obesity in adults: Drug therapy".)
This suggestion and rationale for referral for weight loss surgery also applies to adolescents with type 2 diabetes. For these patients, pharmacotherapy may also be required for glycemic control, as discussed separately. (See "Management of type 2 diabetes mellitus in children and adolescents".)
