3 Nutritional Challenges in Special Conditions and Diseases
Koletzko B, et al. (eds): Pediatric Nutrition in Practice. World Rev Nutr Diet. Basel, Karger, 2015, vol 113, pp 163–167
DOI: 10.1159/000360331
3.5 Management of Child and Adolescent Obesity
Louise A. Baur
Key Words
Obesity · Children · Adolescents · Assessment ·
Management
Key Messages
• The BMI [weight (kg)/height (m)2] should be plotted
routinely on a BMI-for-age chart
• The principles of obesity management include:
management of comorbidities; family involvement;
a developmentally appropriate approach; the use
of a range of behavior change techniques; long-
term dietary change; increased physical activity,
and decreased sedentary behaviors
• Orlistat may be useful as an adjunct to lifestyle
change for more severely obese adolescents, and
metformin for adolescents with clinical insulin re-
sistance
• Bariatric surgery should be considered with severe-
ly obese adolescents
• Coordinated models of care for health service deliv-
ery are needed for the management of pediatric
obesity © 2015 S. Karger AG, Basel
Introduction
Child and adolescent obesity is a prevalent prob-
lem in most westernized and rapidly westernizing
countries and is associated with both immediate
and longer-term complications. Effective treat-
ment of those affected by obesity is vital.
Clinical Assessment
Clinical history should aid in assessing current
and potential future comorbidities as well as
modifiable lifestyle practices (table 1) [1–4]. The
BMI [weight (kg)/height (m)2], a clinically useful
measure of body fatness in those aged >2 years,
should be plotted on nationally recommended
BMI-for-age charts [5], e.g. the WHO Child
Growth Standards. However, the cutoff points
used to define overweight and obesity are some-
3
what arbitrary and may vary between countries.
For example, in the UK the cutoff points for over-
weight and obesity are the 91st and 98th percen-
tiles, respectively, compared with the 85th and
95th in the USA. Hence, local recommendations
should be checked. A waist circumference-to-
height ratio of >0.5 is associated with increased
cardiometabolic risk in school-aged children [6].
Waist circumference-for-age charts are available
for some countries.
Physical examination is used to assess obesity-
associated comorbidities as well as signs of un-
derlying genetic or endocrine disorders (table 2).
The level of investigation is dependent on the pa-
tient’s severity of obesity and age, the clinical
findings and associated familial risk factors.
Baseline investigations may include fasting lipid
screening, glucose, liver function tests and, pos-
sibly, insulin [1–4]. Second-line investigations
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 Table 1. Elements of history-taking in obese children and adolescents

General history Prenatal and birth – history of gestational diabetes and birth weight
Infant feeding – duration of breastfeeding
Current medications – glucocorticoids, some antiepileptics and
antipsychotics
Weight history Onset of obesity and duration of parental and child concerns about
their weight
Previous weight management interventions
Previous and current dieting behaviors
Complications Psychological – bullying, poor self-esteem, depression
history Sleep – snoring, symptoms suggestive of sleep apnea
Exercise tolerance
Specific symptoms related to gastroesophageal reflux, gallstones,
benign intracranial hypertension, orthopedic complications,
enuresis, constipation
Menstrual history (girls)
Family history Ethnicity
Family members with a history of: obesity, type 2 diabetes,
gestational diabetes, cardiovascular disease, dyslipidemia,
obstructive sleep apnea, polycystic ovary syndrome, bariatric
surgery, eating disorders
Lifestyle history Diet and eating behaviors – breakfast consumption, snacking,
fast-food intake, beverage consumption, family routines around
food, binge eating, sneaking food
Sedentary behavior – daily screen time; numbers of televisions,
gaming consoles, computers and smart phones in the bedroom
and home; pattern of screen time
Physical activity – after school and weekend recreation, sports
participation, transport to and from school, family activities
Sleep – duration and routines

may include liver ultrasound, an oral glucose tol-
erance test, more detailed endocrine assessment
and polysomnography.
Treatment Strategies
Systematic reviews of pediatric obesity treatment
show that lifestyle interventions can lead to im-
provements in weight and cardiometabolic out-
comes [7, 8]. While there is no evidence to sup-
port one specific treatment program over anoth-
er, meta-analyses show that family-targeted
behavioral lifestyle interventions can lead to a
mean BMI reduction of 1.25 to 1.30 when com-
pared with no treatment or usual care [8]. The
longer the duration of treatment, the greater the
weight loss observed [8]. Lifestyle interventions
also lead to improvements in low-density lipo-
protein cholesterol, triglycerides, fasting insulin
and blood pressure up to 1 year from baseline [8].
Some of the challenges of treatment are that
‘real-world’ obesity clinics are often more poorly
resourced than in clinical trials, and clinic pa-
tients may be more socially disadvantaged, or
have a broader range of comorbidities, than those
who take part in trials, making treatment adher-
ence more difficult.
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164 Baur
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Koletzko B, et al. (eds): Pediatric Nutrition in Practice. World Rev Nutr Diet. Basel, Karger, 2015, vol 113, pp 163–167
DOI: 10.1159/000360331
Table 2. Physical examination of obese children or adolescents and important physical findings [9, 11]

Organ system Physical findings

Skin/subcutaneous Acanthosis nigricans, skin tags, hirsutism, acne, striae, pseudogynecomastia (males),
tissues intertrigo, xanthelasmas (hypercholesterolemia)
Neurological Papilledema and/or reduced venous pulsations on funduscopy (pseudotumor cerebri)
Head and neck Tonsillar size, obstructed breathing
Cardiovascular Hypertension, heart rate (cardiorespiratory fitness)
Respiratory Exercise intolerance, wheeze (asthma)
Gastrointestinal Hepatomegaly and hepatic tenderness (nonalcoholic fatty liver disease), abdominal
tenderness (secondary to gallstones or gastroesophageal reflux)
Musculoskeletal Pes planus, groin pain, and painful or waddling gait (slipped capital femoral epiphysis),
tibia vara (Blount disease), lower-limb arthralgia and restriction of joint movement
Endocrine Goiter, extensive striae, hypertension, dorsocervical fat pad, pubertal staging, reduced
growth velocity
Psychosocial Flat affect and low mood, poor self-esteem, social isolation
Other – evidence of Short stature, disproportion, dysmorphism, developmental delay
a possible underlying
genetic syndrome

However, the broad principles of management A Developmentally Appropriate Approach

are well recognized [1–4, 7, 8]: management of
obesity-associated comorbidities; family involve-
ment; a developmentally appropriate approach;
long-term behavior modification; dietary change;
increased physical activity; decreased sedentary
behaviors; a plan for longer-term weight mainte-
nance strategies; and consideration of the use of
pharmacotherapy and other nonconventional
therapies.
For preadolescent children, weight outcomes
may be improved with a parent-focused interven-
tion, without direct engagement of the child [9].
There are more limited data on the treatment of
3
adolescent obesity than on younger children, and
especially on interventions that would be sustain-
able in most health care settings. Generally, pro-
vision of at least some separate therapist session
time with the adolescent seems appropriate.

Elements of Treatment
Family Focus
Many clinical trials show that family-based inter-
ventions can lead to long-term relative weight
loss, i.e. from 2 to 10 years. Parental involvement
when managing obese preadolescent children ap-
pears vital, although there are more limited data
on management of adolescents.
Behavior Modification
Weight outcomes are improved with the use of a
broader range of behavior change techniques [1–
4]. One such technique, goal-setting, can include
performance goals (such as changing eating or ac-
tivity behaviors) or outcome goals (such as spe-
cific weight loss). Examples of the former include
not buying cookies, or reducing television time to
3 h per day. Another technique, stimulus control,
refers to modifying or restricting environmental
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Management of Child and Adolescent Obesity 165

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Koletzko B, et al. (eds): Pediatric Nutrition in Practice. World Rev Nutr Diet. Basel, Karger, 2015, vol 113, pp 163–167
DOI: 10.1159/000360331
influences in order to aid weight control, with ex-
amples including not eating in front of the televi-
sion, or using smaller plates and bowls within the
home. A third commonly used technique, self-
monitoring, involves the recording of a specific
behavior or outcome, such as the use of a food di-
ary, daily pedometer measurement of physical ac-
tivity, or weekly weighing.
Dietary Change and Eating Behaviors
Treatment programs incorporating a dietary
component can be effective in achieving relative
weight loss in children and adolescents, although
no one dietary prescription appears superior to
another [8]. However, dietary interventions are
usually part of a broader lifestyle change pro-
gram, and are rarely evaluated on their own. The
two most commonly reported diets are: (a) the
modified stop/traffic light approach, where foods
are color-coded on the basis of nutritional value
and energy content to indicate those to be eaten
freely (green) or more cautiously (amber, red),
and (b) a calorie restriction/hypocaloric diet ap-
proach. Both diets can lead to sustained weight
loss across different settings and age groups [8].
The role of dietary macronutrient modification in
the management of obese children and adoles-
cents remains unclear.
In general, dietary interventions should follow
national nutritional guidelines and have an em-
phasis on the following [1–3]:
• Regular meals
• Eating together as a family
• Choosing nutrient-rich foods which are lower
in energy and glycemic index
• Increased vegetable and fruit intake
• Healthier snack food options
• Decreased portion sizes
• Drinking water as the main beverage
• Reduction in sugary drink intake
• Involvement of the entire family in making
sustainable dietary changes
In advising patients and families on dietary chang-
es, is there a risk of an eating disorder developing?
166
Koletzko B, et al. (eds): Pediatric Nutrition in Practice. World Rev Nutr Diet. Basel, Karger, 2015, vol 113, pp 163–167
While most people with obesity do not have a
binge eating disorder, the latter is more common
in people with severe obesity. Further, overweight
adolescents are more likely to binge-eat, and child-
hood obesity is a risk factor for later bulimia. How-
ever, professionally run pediatric obesity programs
do not increase the risk of disordered eating and
may improve psychological wellbeing [10].
Physical Activity and Sedentary Behaviors
In clinical practice, increased physical activity
may best result from a change in incidental, or un-
planned, activity, such as by walking or cycling
for transport, undertaking household chores and
playing. Organized exercise programs have a role,
with children and adolescents being encouraged
to choose activities that they enjoy and which are
sustainable. Limiting television and other small-
screen recreation to less than 2 h per day is par-
ticularly strategic, but may be challenging [11].
Parental involvement is vital and may include
monitoring and limiting television use, role-mod-
eling of healthy behaviors, and providing access to
recreation areas or recreational equipment.
Long-Term Weight Maintenance
In those who undergo an initial weight manage-
ment intervention, a period of further therapeutic
contact appears to slow weight regain [12]. At
present, there is limited evidence to guide the na-
ture and type of long-term weight maintenance
interventions.
Nonconventional Therapies
There is relatively limited evidence to guide the
use of less orthodox treatment approaches such as
very-low-energy diets, pharmacological therapy
or bariatric surgery in treating severe pediatric
obesity. Such therapies should occur on the back-
ground of a behavioral weight management pro-
gram and be restricted to specialist centers with
expertise in managing severe obesity.
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DOI: 10.1159/000360331
 Existing recommendations on management of
pediatric obesity suggest that drug therapy (large-
ly orlistat, a gastrointestinal and pancreatic lipase
inhibitor) can be used in the treatment of severely
obese adolescents, in the context of a tertiary care
protocol provided by a multidisciplinary care
team and incorporating continued diet and activ-
ity counseling [1–4]. For obese, insulin-resistant
adolescents there may be a role for the use of met-
formin, an insulin-sensitizing agent [13].
The few consensus guidelines for bariatric sur-
gery in adolescents have highlighted its use in se-
verely obese adolescents, with consideration of the
adolescent’s decisional capacity and attainment of
physical maturity, as well as the presence of a sup-
portive family environment [1, 3, 4, 14, 15]. The
need for management in centers with multidisci-
plinary weight management teams, for the surgery
to be performed in tertiary institutions experi-
enced in bariatric surgery and for long-term mul-
tidisciplinary follow-up has been emphasized.
Health Service Delivery Issues
Given the high prevalence and chronicity of pedi-
atric obesity, there is a need for coordinated mod-
els of care for health service delivery. One poten-
tial approach, the chronic disease care model, is
based upon a tiered level of service delivery relat-
ing to disease severity [16]. Thus, while most peo-
ple affected by the problem of obesity can be man-
aged via self-care or family-based care, with sup-
port from primary care or community-based
health service providers, there is a need for treat-
ment by multidisciplinary care teams, and possi-
bly tertiary care clinics, for those who are more
severely affected. Individual clinicians should be
aware of the presence of other services within
their geographic region, and the capacity of these
to take referrals or to comanage patients.

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Koletzko B, et al. (eds): Pediatric Nutrition in Practice. World Rev Nutr Diet. Basel, Karger, 2015, vol 113, pp 163–167
DOI: 10.1159/000360331