Treatment

A national expert committee on the evaluation and treatment of childhood overweight was convened to develop recommendations for health professionals who deal with this health problem. The resulting guidelines have been published (Barlow 1998) and form the basis for recommended weight management programs for youth.

Weight for height status should be assessed by calculating BMI and comparing it to age- and gender-appropriate percentiles.

A protocol for screening and referring overweight youth is shown in Fig.1. Among children who have BMI values >85th percentile, an assessment of potential medical or psychosocial complications is needed.

A medical assessment which includes family history of obesity and chronic disease risk factors, measurements of blood pressure, blood sugar and blood lipids, a weight history, screening for depression, and a physical exam to rule out exogenous causes of overweight should be performed on all overweight youth.

When a child or adolescent has been diagnosed as at risk for overweight or overweight, an assessment of environmental factors known to contribute to obesity is recommended.

This usually starts with a nutrition assessment which should include a review of all medical and laboratory findings and an estimate of usual dietary intake. A dietary assessment should include:

• the number of eating occasions in a usual day
• preferred or disliked foods
• frequency of eating purchased foods (takeout, deli and restaurant foods)
• any dietary restrictions or alterations that have been implemented to date
• portions sizes of food served and eaten
• frequency of consumption of foods high in fat and sugar as well as foods that are of low nutrient density

A 24-hour recall combined with a food frequency or food record can assist in collecting such data. Parental attitudes toward eating and parental food-related practices must also be assessed.

Bright Futures in Practice: Nutrition http://www.brightfutures.org/training/index.html#Nutrition contains age-appropriate nutrition assessment tools that can assist dietitians and other health professionals in collecting appropriate eating and food-related data (see resources).

Physical activity level should be determined by the frequency and duration of moderate-to-strenuous physical activity as well as daily activities, such as walking to school.

Current recommendations are to participate in moderate activity on all or most days of the week and moderate to strenuous activity at least 3 days per week.

A separate assessment of the frequency and duration of sedentary activities is also required. Age-appropriate physical activity assessment forms are available (see resources). http://www.brightfutures.org/training/index.html#PA

If abuse, neglect or other psychosocial issues are suspected, a referral should be made to a mental health professional for an in-depth assessment. A mental health professional can also assess the child or adolescent for signs of depression, dysthymia, or eating disorders.

The type of treatment program recommended for overweight youth varies according to the needs of the individual as determined by physical and environmental assessments.

Figure 2 illustrates the recommended treatment goals based on a child's BMI and age. Weight loss should not be attempted until the family has shown that they can maintain the child's weight. For severely obese children, as well as those with significant medical complications, rapid weight loss may be required. Several pediatric obesity treatment centers have health professionals experienced in the management of severe obesity with complications. Staff at these centers can assist health professionals in the treatment of such youth when necessary. The Weight-control Information Network (WIN) http://www.niddk.nih.gov/health/nutrit/win.htm can help health professionals locate specialized programs when required (see resources).

Figure 2. Recommended Goals for Weight Management by Age and BMI

Adapted from: Barlow SE, Dietz WH. Obesity Evaluation and Treatment: Expert Committee Recommendations. Pediatrics. 1998;102(3). URL: http://www.pediatrics.org/cgi/content/full/102/3/e29.

The first step in the treatment of overweight among children is an assessment of readiness of the family to make behavior changes. This is done by asking members of the family about their concern regarding the child's weight, if they believe it is possible for the child to maintain or lose weight, and what behaviors they think need to be changed to facilitate weight management.

It is important to include all members of the family in weight management programs since the entire family must modify eating and activity patterns if weight loss or maintenance is to be achieved.

Parents who believe that their child is destined to be overweight or who are hesitant to adopt new behaviors to assist youth in weight management may benefit from counseling to motivate them to make behavior changes before a treatment program is started. A treatment program undertaken reluctantly by family members not ready to make behavior changes is very likely to result in failure to meet program goals.

Unsuccessful attempts at weight management may lower self-esteem in overweight children and frustrate family members. A general approach to therapy based on recommendations of the expert committee is listed in table 4.

1. Early intervention is recommended, preferably before the child reaches the 95th percentile for BMI.
2. Parents should be informed of medical complications associated with childhood overweight and all youth should be assessed for medical complications.
3. All family members and caregivers should be involved in the weight management program.
4. All family members should be assessed to determine their readiness to make behavior changes and treatment should not begin until all family members are ready to adopt behavior changes.
5. Weight management programs should emphasize goals of improving eating and physical activity patterns as opposed to specific weight goals.
6. Programs should be skill based ® families should be taught to identify problem behaviors, monitor such behaviors, utilize behavior modification principles to address problem behaviors, and to utilize problem-solving skills when dealing with obstacles to behavior change.
7. Families should be involved in assessing current eating and activity patterns, determining which behaviors need to be modified, setting goals for behavior changes, and determining how success of reaching these goals will be determined.
8. New behavior changes should not be instituted until previous changes have been accomplished and maintained.
9. Routine follow-up visits should be scheduled to monitor progress and prevent relapse to former eating and activity patterns.

Adapted from: Barlow SE, Dietz WH. Obesity Evaluation and Treatment: Expert Committee Recommendations. Pediatrics. 1998;102(3). URL: http://www.pediatrics.org/cgi/content/full/102/3/e29.

It should be stressed to the child and family that the primary goal of a weight management program is to adopt healthier eating and activity habits, not to reach a specific weight. To accomplish this, weight management programs should emphasize the development of new skills by family members, including:

• training on how to become more aware of current eating, activity and parenting patterns that contribute to overweight
• assistance in identifying problem behaviors such as the consumption of specific foods or barriers to physical activity
• behavior modification training so that families can make gradual, permanent changes in eating and activity patterns
• problem solving skills so that families learn to deal with new barriers or issues that arise as the child continues to develop socially, mentally and physically.

Families should not be asked to make more than 2-3 behavior changes during the initial treatment visit. Goals should be set cooperatively by the family and health professional(s) and the family should be involved in determining how success will be measured. Additional changes should be negotiated and instituted only after the family has demonstrated success in achieving the initial changes.

It is imperative that the family be involved in determining what behavior changes will be made. This allows the health professional to teach skills in identifying problem behaviors, increases the family member's awareness of their own habits, and provides an opportunity for the health professional to teach behavior modification skills. It also provides a sense of ownership in the program on the part of family member, which may result in increased compliance.

There are no standard physical activity or dietary regimens recommended for pediatric weight management programs. Reducing the intake of foods such as savory snacks or high-sugar beverages is often the first dietary change recommended. Calorie counting or counting fat grams is not recommended. Replacing high-fat or high-sugar foods with healthier alternatives and teaching portion control are tactics better accepted by families and are more likely to result in longer-term behavior changes. Replacing sedentary activities with more strenuous activities is a relatively easy first goal for changes in physical activity. Referrals to community centers, local parks and recreation programs, and community education programs can also be beneficial. However, it is up to the family to decide what changes they feel are achievable at any point in the treatment program.

Bi-weekly or weekly reviews of changes in dietary intake and physical activity as well as measurements of weight should occur, at the clinic or at home, to help the family members review treatment goals and assess their progress. Health professionals should learn to place the greatest emphasis on success experienced in making behavior changes and less emphasis on successful weight maintenance or loss.

It is important that the family maintain a regular schedule of visits with health professionals involved in weight management until a satisfactory weight for height has been achieved and all medical complications have been resolved. Follow-up visits at six-month intervals are recommended after the completion of a weight management program to monitor growth and development and to reinforce the newly adopted behaviors within the family setting.