Obesity and Weight ManagementManual of Clinical Nutrition Management III- 83 Copyright © 2013 Compass Group, Inc.
achieve weight goals depends on the patient’s age, baseline BMI percentile, and the presence of medical
complications (9).
The Expert Committee recommends that the first step in the assessment of an overweight child includes
evaluation for underlying syndromes, including genetic causes (eg, Prader-Willi syndrome) and
endocrinologic causes (eg, hypothyroidism and Cushing syndrome). In addition, a complete medical and
psychosocial history should be gathered, and a physical exam should be performed to identify complications.
These complications include sleep apnea, pseudotumor cerebri, orthopedic complications, and acanthosis
nigricans (the coarse, hyperpigmented areas in the neck folds or axilla that are associated with insulin
resistance and type 2 diabetes). Children with eating disorders or symptoms of depression require
psychological treatment and should not participate in a weight-control program without the concurrence of a
therapist or specialist (9).
Approaches
Children and Adolescents
The primary goal of a program to manage uncomplicated obesity in children and adolescents is healthy eating
and activity, not achievement of ideal body weight (9). For children with a secondary complication of obesity
(eg, hypertension or dyslipidemia), improvement or resolution of the complication is an important medical
goal. The first step in weight control for all overweight children (85th to 94th percentile) older than 2 years is
the maintenance of baseline weight. Prolonged weight maintenance, which allows a gradual decline in BMI as
children grow in height, is a sufficient goal for many children (9). Weight maintenance is also the goal for
children aged 2 to 7 years who have a BMI greater than the 95th percentile and no complications (9). However,
if complications (eg, hypertension, dyslipidemia, or insulin resistance) are identified, weight loss is indicated
in this group. For children 7 years and older who are overweight (85th to 94th percentile), weight
maintenance is the goal if no complications are present, and weight loss is indicated if complications are
present (9). Weight loss is indicated independent of complications for children aged 7 years and older who
are at or above the 95th percentile (9).
Weight loss achieved by lifestyle approaches, including a low-energy diet and increased physical activity, is
recommended (Grade I) (12). Energy intake levels need to be individualized to meet the patient’s growth and
development needs. Approaches to weight loss should be based on family readiness and involvement (9). The
dietary goals for patients and families should include well-balanced, healthy meals and a healthy approach to
eating. A low-energy diet (900 to 1,200 kcal/day) as part of a clinically supervised, multicomponent weight
loss program is associated with both short-term and longer-term reductions in adiposity among children ages
6 to 12 years (Grade I) (12). A reduced energy diet < 1,200 kcal/day) in the acute treatment phase of adolescent
overweight is generally effective for short-term improvement in weight status. However, without continuing
intervention weight is regained (Grade I) (12). Counting calories can be tedious and inaccurate (9). As an
alternative, targeting high-energy and high-fat foods and beverages in the existing diet and focusing on one or
two small dietary changes at a time is suggested (9). Behavior modification approaches, such as the traffic
light diet, are very effective (Grade I) (9,12). Children and adolescents must receive adequate vitamins, minerals,
protein, and energy to maintain healthy growth. Linear growth may slow during weight loss (9). However,
most overweight children are tall and impact on adult stature appears to be minimal (13). Although
pharmacological means of treatment are being investigated (9), the only treatment option currently available
is for adolescents (12 years or older) who may be treated with Orlistat for up to one year. See Weight Contol
Information Network information at http://www.win.niddk.nih.gov. Bariatric surgery (eg, laparoscopic
adjustable gastric band (LAGB) and Roux-en-Y gastric bypass (RYGB)) may be a treatment option for children
and adolescents who are obese (> 95th percentile) for weight based on age in specialized centers when a
severe comorbidity is present (refer to discussion on Surgery in this section).
Like adults, children and adolescents who are obese have an increased risk for vascular disease (9,10). The
characteristic pattern consists of elevated serum low-density lipoprotein cholesterol and triglycerides levels
and lowered high-density lipoprotein cholesterol levels (14). The American Heart Association (AHA) dietary
guidelines for primary prevention of atherosclerotic heart disease recommend that children older than 2
years gradually begin to adopt a diet that contains no more than 30% of energy from fat. A diet low in fat
(<30% of total energy, but no less than 20% of total energy), saturated fat (<10% of energy per day),
cholesterol (less than 300 mg/day), and low in trans fatty acids is encouraged (15,16). Similar to adult
guidelines, the AHA suggests daily consumption of five or more servings of fruits and vegetables and six to
eleven servings of whole grain foods. In addition, low-fat dairy products, fish, legumes, poultry, and lean