Recommendations for treatment of child and adolescent overweight and obesity

In this article, we review evidence about the treatment of obesity that may have applications in primary care, community, and tertiary care settings. We examine current information about eating behaviors, physical activity behaviors, and sedentary behaviors that may affect weight in children and adolescents. We also review studies of multidisciplinary behavior-based obesity treatment programs and information about more aggressive forms of treatment. The writing group has drawn from the available evidence to propose a comprehensive 4-step or staged-care approach for weight management that includes the following stages: (1) Prevention Plus; (2) structured weight management; (3) comprehensive multidisciplinary intervention; and (4) tertiary care intervention. We suggest that providers encourage healthy behaviors while using techniques to motivate patients and families, and interventions should be tailored to the individual child and family. Although more intense treatment stages will generally occur outside the typical office setting, offices can implement less intense intervention strategies. We not ony address specific patient behavior goals but also encourage practices to modify office systems to streamline office-based care and to prepare to coordinate with professionals and programs outside the office for more intensive interventions.     

Assessment of child and adolescent overweight and obesity

Accurate appropriate assessment of overweight and obesity in children and adolescents is a critical aspect of contemporary medical care. However, physicians and other health care professionals may find this a somewhat thorny field to enter. The BMI has become the standard as a reliable indicator of overweight and obesity. The BMI is incomplete, however, without consideration of the complex behavioral factors that influence obesity. Because of limited time and resources, clinicians need to have quick, evidence-based interventions that can help patients and their families recognize the importance of reducing overweight and obesity and take action. In an era of fast food, computers, and DVDs, it is not easy to persuade patients to modify their diets and to become more physically active. Because research concerning effective assessment of childhood obesity contains many gaps, this report is intended to provide a comprehensive approach to assessment and to present the evidence available to support key aspects of assessment. The discussion and recommendations are based on >300 studies published since 1995, which examined an array of assessment tools. With this information, clinicians should find themselves better equipped to face the challenges of assessing childhood overweight and obesity accurately.     

An assessment of adolescent overweight and obesity in Xi'an City, China.

OBJECTIVES: To assess the magnitude of overweight and obesity, and its associated socio-demographic factors in adolescents in Xi'an city, China. METHODS: A total of 1804 adolescents attending junior high schools in Xi'an City (age: 11-17 years) were included in this cross-sectional study. Body mass index using IOTF cut-offs defined overweight and obesity. Socio-demographic information was collected from the parents of the survey participants using self-administered, structured and pre-coded questionnaires. RESULTS: Overall, 16.3% of adolescents were overweight or obese, but there was a marked gender difference in the prevalence with 19.4% (95% CI: 15.6% - 23.7%) of boys versus 13.2% (95% CI: 10.0% - 16.4%) ofthe girls being overweight or obese. In a multivariate model, age, residence, household wealth, and parents' body mass index were significantly associated with being overweight/obese (p < 0.05). After adjusting for age and gender, the odds of an adolescent being overweight or obese was 2.7 times (95% CI: 1.8 - 4.0) higher in urban areas compared to rural areas; and 1.6 times (95% CI: 1.04 - 2.5) higher for adolescents from rich compared to poor families. An adolescent with one or both parents being overweight was 1.8 times (95% CI: 1.3 - 2.5) more likely to be overweight themselves compared to those with normal weight parents. CONCLUSIONS: 1) Overweight and obesity is a major public health problem in adolescents in Xi'an City and is likely to increase rapidly in the near future; 2) Overweight and obesity is more prevalent in younger boys from richer families living in urban districts and whose parents were either overweight or obese.     

Treatment of adolescent overweight and obesity

Adolescence is a vulnerable period for the development of obesity, and adolescent weight tracks strongly into adulthood. Previous reviews of treatment strategies have failed to discriminate between adolescents and children, thereby, disregarding the uniqueness of this population. Hence, this review aims to summarise the evidence for treatment approaches for adolescent obesity. Pubmed, OVID, EBSCOhost and Google Scholar were searched for randomised controlled trials, meta-analyses and systematic reviews testing treatments for overweight/obese adolescents (aged 12–19 years), published from 1982–2006 in English. Eligible studies had to assess either weight, percentage overweight, body mass index (BMI) or body fat. Thirty-four randomised controlled trials were eligible. The results of this review indicate that the safety and efficacy of surgical and pharmacotherapy treatments for adolescent obesity is uncertain. Diet and physical activity approaches may improve obese status in the short term. However, obesity interventions appear more effective when strategies are combined, rather than when used in isolation. Psychological interventions, such as behavioural and cognitive behavioural therapy, show promise in achieving the necessary lifestyle changes for obesity reduction; however, long-term follow-up studies are needed. There were multiple limitations in appraising the literature. Inconsistent definitions of overweight/obesity make comparisons between studies difficult. Many studies have not used direct adiposity measures, have failed to assess pubertal status or have not used an exclusive adolescent sample. We conclude that, despite these limitations, current evidence indicates that behavioural and cognitive behavioural strategies combined with diet and physical activity approaches may assist in reducing adolescent obesity,although long-term follow-up studies are needed. Electronic supplementary material The online version of this article (doi:) contains supplementary material, which is available to authorized users.     

Quality assessment of clinical practice guidelines for the prevention and treatment of childhood overweight and obesity

Background  The prevalence of childhood overweight and obesity is increasing at dramatic rates in children and adolescents worldwide. Clinical practice guidelines (CPGs) are “systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances.” Their objective is to provide explicit recommendations for clinical practice based on current evidence for best practice in the management of diseases. Materials and methods  The aim of this study was to identify and assess the quality of CPGs for the prevention and treatment of obesity and overweight in childhood. We developed a search to identify CPGs published between January 1998 and August 2007. We considered for inclusion documents that provided recommendations for clinical practice referring to children and adolescents. Three independent appraisers assessed the quality of the1 CPGs using the AGREE (Appraisal of Guidelines Research and Evaluation) instrument. We identified 376 references and selected 22 for further assessment. Results  The overall agreement among reviewers using the intraclass correlation coefficient was 0.856 (95% confidence interval [CI] 0.731–0.932). Six of the 22 initial guidelines were recommended and a further eight were recommended with conditions or provisos. We concluded that the number of documents with recommendations on the prevention and treatment of childhood obesity published during the 10-year study period was considerable, but only a few of them could be considered as high quality. CPGs were deficient in areas such as applicability, editorial independence and rigor in development. Conclusion  Due to the increasing burden of obesity among children and the potential for long-term comorbidities, clinicians need to be critical in assessing the rigor of how these are developed and their appropriateness for use in the clinician’s own practice. There is a need to improve the methodology and the quality of CPGs on childhood obesity to help clinicians and other decision-makers to tackle this disease. This project was funded with a grant (AE08_015) from CIBER de Epidemiología y Salud Pública (CIBERESP), Spain.     

Obesity prevention, screening, and treatment: practices of pediatric providers since the 2007 expert committee recommendations

This study surveyed pediatric primary care providers at a major academic center regarding their attitudes and practices of obesity screening, prevention, and treatment. The authors compared the care providers' reported practices to the 2007 American Medical Association and Centers for Disease Control and Prevention Expert Committee Recommendations to evaluate their adherence to the guidelines and differences based on level of training and specialty. Of 96 providers surveyed, less than half used the currently recommended criteria for identifying children who are overweight (24.7%) and obese (34.4%), with attendings more likely to use the correct criteria than residents (P < .05). Although most providers felt comfortable counseling patients and families about the prevention of overweight and obesity, the majority felt their counseling was not effective. There was considerable variability in reported practices of lab screening and referral patterns of overweight and obese children. More efforts are needed to standardize providers' approach to overweight and obese children.     

Parental overweight/obesity,social factors,and child overweight/obesity at 7 years of age

Background: This study used gender‐based analyses to examine whether child overweight/obesity is related to parental overweight/obesity and sociodemographic factors, in a representative population‐based cohort of 7‐year‐old children. Methods: Data from the Québec Longitudinal Study of Child Development 1998–2010 was used. Children (n= 1336) were randomly selected from each public health region of Québec. The study was based on face‐to‐face interviews and a set of questionnaires addressed to mothers and fathers. Results: Compared to children with no overweight/obese parent, the adjusted odds ratio (OR) of being overweight/obese with two overweight/obese parents was 5 for boys (95% confidence interval [CI]: 2.31–10.85) and 5.87 for girls (95%CI: 2.63–13.12). Gender differences appeared when one parent was overweight/obese. For girls, having either an overweight/obese mother (OR, 3.10; 95%CI: 1.14–8.38) or father (OR, 3.64; 95%CI: 1.68–7.91) significantly increased the odds of being overweight/obese at 7 years. For boys, however, having only an overweight/obese father (OR, 2.05; 95%CI: 1.01–4.16) was related to overweight/obesity, but having only an overweight/obese mother was not related to overweight/obesity at 7 years for boys. In girls, but not in boys, having an immigrant mother also significantly related to overweight/obesity (OR, 2.71; 95%CI: 1.28–5.75) at 7 years, after controlling for other social factors. Conclusions: Gender differences in socialization may explain why at 7 years of age, girls' bodyweight is influenced by having even one overweight/obese parent (mother or father), while boys' bodyweight appears to be influenced only by father's overweight/obesity when only one parent is overweight/obese.     

Psychosocial aspects of child and adolescent obesity

In addition to counselling families about regular physical activity and healthy nutrition, clinicians need to identify and help them to address the psychosocial factors that may be contributing to their child’s or adolescent’s obesity. Affected individuals may suffer from depression, low self-esteem, bullying, and weight bias, experiences that can make achieving desired health outcomes more difficult. Clinicians should try to identify these underlying stressors and ensure that appropriate counselling is implemented.     

Delineating mechanisms of change in child and adolescent therapy: methodological issues and research recommendations

BACKGROUND: Mechanisms of therapeutic change are rarely studied in child and adolescent therapy. Our central thesis is that the study of mechanisms of treatment is an excellent investment for improving clinical practice and patient care. Indeed, extending treatment trials to clinical settings, without complementary research that studies why and how treatment works, could have great limitations. METHOD: In this article, we discuss the importance of studying mechanisms, the logical and methodological requirements, and why almost no studies to date provide evidence for why or how treatment works. Standard statistical practices (tests of mediation) and designs (randomized controlled clinical trials) contribute greatly to outcome research but have little to say about mechanisms given the way they are commonly used. CONCLUSIONS: The article ends with recommendations to guide research on mechanisms of therapeutic change.     

Early causes of child obesity and implications for prevention

Child obesity is becoming a serious public health concern, and major research effort is being devoted both to understand its aetiology and to improve the effectiveness of prevention strategies. Early growth patterns, both prenatally and postnatally, are emerging as important markers of later obesity risk, with rapid neonatal weight gain a clear risk factor for later obesity and metabolic syndrome. Thus, in two distinct senses child obesity is a growing problem. The paper summarises current evidence on growth pattern and obesity, relating it to infant feeding practice and appetite regulation, and highlights the areas in which public health interventions are feasible. Of the conclusions drawn, one involves a futuristic solution to child obesity where neonates are given an infusion of the hormone leptin to reset their appetite regulation.     

Parent-focused child maltreatment prevention: improving assessment, intervention, and dissemination with technology

The goal of this article is to examine how technology has been and can be utilized to enhance parent-focused child maltreatment (CM) prevention efforts. The authors begin with a brief discussion of the current state of the CM prevention field. In the sections that follow, they review studies that have examined the use of technology across three facets of prevention: identification of CM, administration/augmentation of CM prevention programs, and broad dissemination and implementation of evidenced-based CM prevention programs. They conclude with a discussion of limitations and problems related to the use of technology as a tool to enhance CM prevention and future directions.     

Regional, socioeconomic and urban-rural disparities in child and adolescent obesity in China: a multilevel analysis

Aim: To study socio‐demographic patterns of obesity in Chinese children and adolescents. Methods: Data came from the 2005 cycle of the Chinese National Survey on Student’s Constitution and Health. In all, 231 326 subjects aged 7–18 years, distributed across 622 schools and 30 provinces, were analysed. Multilevel modelling was used to estimate variations at individual, school area and province levels. Results: The prevalence of obesity varied enormously across different areas. Young people living in high socioeconomic and urban areas had higher body mass index (BMI) and higher odds of overweight and obesity than those living in lower socioeconomic and rural areas. Subjects living in provinces with a higher standard of living, as indicated by less perinatal mortality, lower Engel coefficient, and higher personal expenditure on health had higher BMI and higher odds of overweight and obesity than those living in less affluent provinces. An interaction between gender and urbanicity revealed that boys in urban areas were especially prone to obesity. Conclusion: In contrast to most present‐day high income countries, obesity among young people in China is associated with affluence and urban residence. Intervention and strategy for obesity prevention should be targeting high socioeconomic families in urban areas, perhaps with particular focus on boys.