10. Overweight and Obesity
This section of the Guidelines provides recommendations to pediatric care providers
on management of overweight and obesity in their patients. The section begins with
background information on the current prevalence of overweight and obesity in childhood
and the association between childhood overweight and obesity and cardiovascular
(CV) risk factors. This is followed by a subsection addressing the identification
of overweight and obesity and then individual subsections on the prevention and
treatment of overweight and obesity in childhood, with the Expert Panel's summaries
of the evidence reviews in each of these areas. The evidence review and the development
process for the Guidelines are outlined in Section I. Introduction and are described
in detail in the Appendix. Methodology. This evidence review combines a systematic
review with an Expert Panel consensus process that incorporates and grades the quality
of all relevant data based on preidentified criteria. Because of the large volume
of included studies and the diverse nature of the evidence, the Expert Panel also
provides a critical overview of the studies reviewed for each risk factor, highlighting
those that in its judgment provide the most important information. Detailed information
from each study has been extracted into the evidence tables, which will be available
Each subsection ends with the conclusions of the review, grading of the evidence,
and age-specific recommendations for the evaluation, prevention, and treatment of
overweight and obesity in pediatric practice. Where evidence is inadequate, recommendations
are a consensus of the Expert Panel. References are listed sequentially at the end
of the section, with references from the evidence review identified by unique PubMed
identifiers (PMID) in bold text. Additional references do not include the PMID number.
Dramatic increases in childhood overweight and obesity in the United States since
1980 are an important public health focus. Despite efforts over the past decade
to prevent and control overweight and obesity, recent reports from the National
Health and Nutrition Examination Survey (NHANES) show sustained high prevalence,
with 17 percent of children and adolescents with a body mass index (BMI) above the
95th percentile for age and gender. Section 2. State of the Science:
Cardiovascular Risk Factors and the Development of Atherosclerosis in Childhood
reviews in detail the evidence that atherosclerosis in childhood and adolescence
is associated with the presence and extent of individual risk factors, including
obesity. To summarize, two major post mortem studies have demonstrated that the
presence of obesity in childhood and adolescence is associated with increased evidence
of atherosclerosis at autopsy, especially in males.,,,
Because of the strong association with elevated blood pressure, dyslipidemia, and
insulin resistance (IR), obesity is even more powerfully correlated with atherosclerosis;
this association has been shown for each of these risk factors in all of the major
pediatric epidemiologic studies.,,,,,,
Longitudinal studies have demonstrated tracking
of elevated BMI and increased adiposity in childhood to the presence of obesity
Improvement in weight status and decrease in body fatness have been shown to be
associated with decreases in systolic and diastolic blood pressures (BPS),,,,
total cholesterol (TC), low-density lipoprotein cholesterol (LDLC) and/or
and inflammatory markers.,
Subclinical vascular changes indicative of atherosclerosis have been demonstrated
in overweight and obese children;,,,
exercise and weight loss have been shown to result in significant improvement in
Finally, epidemiologic studies have demonstrated that measures of
obesity in childhood (greater skinfold thickness, higher BMI percentile) correlated
significantly with greater evidence of arterial vascular abnormalities in adulthood,
even after adjustment for adult contemporaneous risk factor status.,,,,
Using childhood BMI z-scores and national death registry data, an epidemiologic
study of 10,235 men and 4,318 women enrolled between 1930 and 1976 and followed
up after age 25 years demonstrated that for each one unit increase in BMI z-score
from ages 713 years in males and ages 1013 years in girls, there was
a significant increase in risk for a coronary heart disease event.
Using an established computer-simulation, state-transition model of coronary heart
disease (CHD in U.S. citizens older than age 35 years) and NHANES data for adolescents
above the 95th percentile for weight in 2000, an analysis estimated that adolescent
obesity will likely increase adult CHD by 516 percent over the next 25 years,
with more than 100,000 excess cases of CHD attributable to obesity in childhood.
IDENTIFICATION OF OVERWEIGHT AND OBESITY IN CHILDREN AND ADOLESCENTS
To identify overweight and obesity in children living in the United States, BMI
percentile distributions relative to gender and age on the Centers for Disease Control
and Prevention (CDC) 2000 growth charts are now the preferred reference. The
CDC growth charts were not developed as a health-related standard. Instead, the
growth charts present percentiles of the BMI distribution derived from measurements
taken during several NHANES surveys as points of reference. Although the charts
were published in 2000, they include selected data from the 1963 to 1980 surveys
and thus are not representative of the U.S. population in 2000. These BMI percentile
growth charts provide the best reference data available for describing normal growth
in U.S. children. They are, however, a screening tool and not an instrument for
the diagnosis of overweight and obesity.
An expert committee jointly convened by the American Medical Association (AMA),
the CDC, and the Maternal and Child Health Bureau (MCHB) of the Health Resources
and Services Administration, U.S. Department of Health and Human Services (HHS),
recently recommended that BMI be used to assess weight-for-height relationships
This conclusion was reached because BMI can be easily calculated from height and
weight, correlates strongly with direct measures of body fat (especially at higher
BMI values), associates only weakly with height, and identifies individuals with
the highest body fat correctly with acceptable accuracy, particularly above the
85th BMI percentile.
Pediatric care providers need a feasible standard for identifying overweight and
obesity in their patients, since parents recognize a child's overweight status in
less than half of cases.
The AMA/CDC/MCHB Expert Committee defined a BMI at or greater than the 95th percentile
as obese and a BMI between the 85th and 94th percentiles as overweight; children
in the latter BMI category have a great deal of variation with respect to prediction
of future risk. The Expert Panel for these Guidelines concluded that BMI is a sufficient
measure for screening children and adolescents to identify those who need evaluation
for CV risk factors associated with body adiposity and that the scientific evidence
linking elevated BMI to CV risk factors and morbidity is strong and well-supported.
The Expert Panel recommends that children and adolescents ages 218 years with
a BMI at or greater than the 95th percentile be described as "obese" and identified
as needing assessment for CV risk factors. For children with a BMI that falls between
the 85th and 95th percentiles, the term "overweight" should be used, and the position
of the child's BMI on the growth chart should be used to express concern regarding
weight-for-height disproportion. It is very important to follow the pattern of growth
over time, using these cut points to identify children who require more frequent
followup and further assessment rather than to assign a diagnosis. Some may feel
that "obese" is an unacceptable term for children and parents, so as with all health
conditions, the practitioner is encouraged to use descriptive terminology that is
appropriate for each child and family, with a thorough explanation and discussion.
Each patient and family should be considered on an individual basis in deciding
how best to convey the seriousness of this issue and to develop management plans.
OVERVIEW OF THE EVIDENCE ON PREVENTION OF OVERWEIGHT AND OBESITY: ROLE OF
DIET OR COMBINED DIET AND PHYSICAL ACTIVITY INTERVENTIONS
Dietary recommendations for children and adolescents focus on promoting optimal
health by including all foods and beverages necessary to provide required macronutrients
and micronutrients and calories, consistent with HHS and U.S. Department of Agriculture
2010 Dietary Guidelines for Americans (2010 DGA).
Prevention of overweight and obesity throughout childhood is a primary goal for
the recommendations of these Guidelines and represents an important health objective
for all children. The evidence review and the recommendations for nutrition and
diet in all children are presented in Section 5. Nutrition and Diet. In this section,
the focus of the evidence review is on studies that specifically addressed prevention
of overweight and obesity in children and adolescents using primarily lifestyle
interventions. Given the major overlap between the two dietary goals for childrenpromotion
of CV health and prevention of obesitythe majority of the obesity prevention
recommendations are the same as those developed for the promotion of CV health in
The Expert Panel's evidence review for overweight and obesity included a large number
of studies: 30 systematic reviews, 12 meta-analyses, 121 randomized controlled
trials (RCTs), and 47 observational studies. There were five systematic reviews
of intervention studies to prevent obesity, four of which were published between
2004 and 2006. The most recent was a rigorous review that selected only RCTs that
included a control group and that directly addressed prevention of overweight and
obesity in a normal population, with followup of at least 12 months and with obesity-specific
The review included a total of 24 studies, and of these, all but 2 were school-based.
The intervention was described for the 10 most recent studies and involved a combined
dietary and physical activity intervention in 8 and a pure dietary intervention
in 2; each of these is described below. The evidence review concluded that overall,
the interventions described significantly reduced obesity measures, with 41 percent
of studies reporting positive results.
The RCTs in the Expert Panel's evidence review for overweight and obesity were reviewed
to identify a total of 17 studies that specifically addressed dietary intake in
normal children within the context of overweight and obesity prevention. Many of
these studies evaluated dietary interventions designed to address the prevention
of overweight and obesity by lowering fat intake and increasing fruit and vegetable
intake to meet the published nutritional goal of five servings per day of fruits
and vegetables. Most were school-based and often were part of multicomponent programs
designed to simultaneously change dietary intake and increase physical activity
The age groups addressed ranged from preschoolers to teenagers, and the study sizes
from 213 to over 5,000 subjects. Measures of overweight and obesity varied and included
weight, BMI, BMI percentile, and BMI z-score. Dietary intake was assessed by a variety
of methods, including parental report, self-report, diet records, and direct observation
of meals. Most studies were minimally successful in improving dietary quality, with
small decreases in fat intake, small increases in fruit and vegetable intake, and
small increases in physical activity; however, measures of obesity were rarely changed.
As an example of this kind of study, a 2-year school-based health behavior intervention
in children in grades 68 used sessions taught by classroom teachers focused
on decreasing the consumption of high-fat foods, increasing fruit and vegetable
intake, decreasing TV viewing, and increasing moderate and vigorous physical activity.
There was no attempt to change caloric intake. Obesity was defined as a composite
indicator based on BMI and triceps skinfold thickness greater than or equal to age-
and gender-specific 85th percentiles. After 2 years, fruit and vegetable consumption
increased, and TV viewing time decreased in boys and girls. There was no change
in time spent in moderate and vigorous physical activity, the primary outcome of
the trial. Prevalence of obesity decreased among girls but not boys.
Another example is the Child and Adolescent Trial for Cardiovascular Health (CATCH),
the largest school-based study ever funded in the United States, taking place in
This multicomponent school CV health promotion intervention for middle-school children
resulted in improvement in children's diets, with significantly lower saturated
fat intakes and significantly more vigorous physical activity by children in the
intervention schools, findings that were sustained for 3 years after the end of
CATCH intervention goals were not focused on obesity, and there were no differences
in BMI during the original study or at late followup. The Pathways school RCT in
American Indian schoolchildren used similar approaches to CATCH in changing the
school diet and physical activity environments, in addition to teaching lifestyle
approaches through curricula. The Pathways trial focused on obesity prevention;
however, there were no significant differences in obesity measures between the randomized
groups, although measures of diet and physical activity did improve.
An example of a primary dietary intervention study is the Special Turku Coronary
Risk Factor Intervention Project (STRIP), which randomized 1,062 Finnish infants
to a conventional diet or a low-saturated fat diet at age 7 months.
The intervention families received individualized counseling biannually by a dietitian
who focused on lowering saturated fat in the diet and a physician who consistently
recommended increased physical activity with no specific activity intervention.
Since the study began in 1990, the children have been evaluated at least annually.
Review of growth data indicates that there have been consistently fewer overweight
girls in the intervention group beginning at age 2 years. At age 10 years, 10.2
percent of girls in the intervention group were overweight (defined as 20 percent
above weight for height of average Finnish children) compared with 18.8 percent
of controls (P = 0.04); there was no difference in overweight prevalence between
groups among boys. There was no significant difference between intervention and
control groups in weight for height or obesity (40 percent above average weight
for height) at any single age. At 9-year followup, both male and female children
in the intervention group reported consuming less total fat and saturated fat and
had higher insulin sensitivity than did controls.,
A detailed evaluation of macronutrient and micronutrient intakes, linear growth,
and neurologic status has identified no adverse effects from the intervention.
To evaluate the relationship between calcium intake and body fat in the prevention
of obesity, an RCT of calcium supplementation and physical activity was conducted
in preschool children. Analysis of body composition and calcium intake showed no
association for the entire group. Among children in the lowest tertile of calcium
intake, fat mass gain was lower in the calcium group, but this was not correlated
with total calcium intake.
Observational studies described in detail in Section 5. Nutrition and Diet have
linked increased consumption of sugar-sweetened beverages with the development of
overweight and obesity. One RCT assigned adolescents with a BMI above the 25th percentile
for age and gender who regularly consumed at least one sugar-sweetened beverage/day
to an intervention in which noncaloric beverages were delivered to the home free
of charge for 25 weeks.
Consumption of sugar-sweetened beverages was reduced dramatically, by 82 percent
in the intervention group, with no change in controls. BMI increased in both groups;
although the increase was less in the intervention group than in the control group,
the difference between groups was not significant. However, among subjects in the
highest tertile for BMI at baseline (above the 75th percentile), reduction of sugar-sweetened
beverages was accompanied by a significant decrease in BMI compared with an increase
in BMI in controls. This pilot study suggests that reducing sugar-sweetened beverage
intake may have a beneficial effect on body weight in overweight and obese adolescents.
Another study was a cluster RCT testing the reduced intake of carbonated drinks
on obesity in six primary schools in England; carbonated drinks were reduced by
a 0.7 net servings/day along with a modest decrease in overweight/obese children.
Innovative methods for teaching nutrition and changing diet to prevent overweight
and obesity have been explored. A computer game-based intervention with overweight
and obesity as a secondary outcome was associated with improved nutritional knowledge
and better food choices than a conventional curriculum among students in the last
three grades of primary school.
A 10-session multimedia game designed to increase preference for fruits and vegetables
was successful among fourth-grade students in increasing their fruit and vegetable
consumption over a 5-week intervention.
CONCLUSIONS OF THE EVIDENCE REVIEW ON PREVENTION OF OVERWEIGHT AND OBESITY WITH
DIET OR COMBINED DIET AND PHYSICAL ACTIVITY INTERVENTIONS
The Expert Panel concluded that there is good evidence that the dietary behavior
of children can be safely improved with interventions that result in lower saturated
fat intake, reduced intake of sugar-sweetened beverages, and increased consumption
of fruits and vegetables. None of these studies included any intervention to change
calorie intake. In a small number of studies, the changes described are associated
with significantly lower BMI or BMI percentile on followup. Most studies also had
specific interventions aimed at changing physical activity behaviors, so it is difficult
to separate benefits related to diet change alone. Although calorie balance is generally
seen as a key issue for weight control, intervention studies addressing both diet
and physical activity had mixed results, perhaps because most offered relatively
weak interventions at the community level rather than targeting individual, at-risk
youths. No evidence was identified that diets that address lowering saturated fat
intake, reducing intake of sugar-sweetened beverages, and increasing consumption
of fruits and vegetables are harmful.
For pediatric patients with a BMI below the 85th percentile for age and gender,
the recommendations in these Guidelines for nutrition and diet for reducing CV risk
for all children, which build on the 2010 DGA for the general public (CHILD
1, Section V. Nutrition and Diet), specifically address optimizing the diet in each
of these areas, as well as increasing intake of whole grains and matching energy
intake to growth and energy expenditure with monitoring of BMI and dietary intake
over time.40 No additional dietary recommendations to prevent obesity
are indicated based on this evidence review. As described above, it is very important
to follow the pattern of growth over time to identify children who require more
frequent followup, further assessment, and intervention.
OVERVIEW OF THE EVIDENCE ON PREVENTION OF OVERWEIGHT AND OBESITY: ROLE OF
There is strong evidence for the beneficial effects of physical activity and limiting
sedentary time on the overall health of children and adolescents. 
Section 6. Physical Activity reviewed the evidence on the benefits of physical activity
and limited sedentary time on overall CV health, including a decrease in BMI, especially
if subjects are overweight or obese. The recommendations for activity for all children
in these Guidelines address both the limitation of sedentary activity and the prescription
of daily physical activity. A recent evidence-based review of physical activity
included 850 studies in children and recommended at least 60 minutes of moderate
to vigorous physical activity daily to achieve beneficial effects on health,61 The authors concluded that such a
program would have little influence on BMI in normal-weight children.
From the evidence review for these Guidelines, studies were identified that addressed
obesity prevention through a pure physical activity intervention to increase physical
activity and/or decrease sedentary time. These are not common, with one systematic
review and eight RCTs identified in which a physical activity intervention was tested
to prevent obesity. A systematic review by The Cochrane Collaboration addressed
prevention of overweight and obesity and selected 22 studies published between 1990
and 2005 for inclusion.
Two of 10 long-term studies lasting at least 12 months and 4 of 12 short-term studies
focused on physical activity alone, and each is included in the RCT review below.
Overall, the Cochrane reviewers concluded that physical activity "interventions
employed to date have, largely, not impacted weight status of children to any degree."
The Cochrane reviewers noted that, as a group, the studies have been underpowered
and/or poorly designed, with interventions often set for short-term impact.
From the RCTs in the evidence review for these Guidelines, a 6-month, classroom-based
trial in third- and fourth-grade students was effective in decreasing sedentary
activity (TV and video use), with associated significant relative decreases in BMI,
triceps skin folds, waist circumference, and waist-to-hip ratio in the intervention
group compared with the control group. A school-based trial in fourth-grade
students compared three groups: three 30-minute physical activity classes/week
taught by an exercise specialist, three classes taught by a teacher, and no activity
After 3 school years, there was no significant improvement in BMI or body fat measures,
but interpretation of results was complicated by differences between the groups
at baseline. In a small group of nonobese sedentary adolescent males, a 5-week prospective
trial of endurance training was associated with decreased thigh fat but no change
in BMI or intra-abdominal fat.
In nonobese African American girls, a 12-week pilot intervention with an afterschool
dance class and education to reduce sedentary activity at home was associated with
a significant decrease in home TV use and fewer meals in front of the TV, increased
physical activity, decreased BMI, and decreased waist circumference; the latter
results were not significant, but the study was not powered for these outcomes.
A year-long enhanced physical activity program in nursery schools in Scotland had
no effect on BMI or measures of physical activity and sedentary behavior at 6 and
Gender differences in response to interventions were reported in two school-based
trials. After an intervention that combined education and activity for inner-city
high school students, health knowledge was improved in males and females, but eating
habits and fitness and cholesterol levels were significantly improved only in females,
with no change in males; neither males nor females had any change in BMI.
Among second-grade American Indian children enrolled in a physical activity intervention,
boys were seen to be more active at baseline and followup. Activity levels
were increased among children in the intervention schools compared with controls,
but there was no difference in BMI or percentage of body fat.
CONCLUSIONS OF THE EVIDENCE REVIEW ON PREVENTION OF OVERWEIGHT AND OBESITY WITH
The RCTs described above have evaluated the effect of interventions that addressed
only physical activity and/or sedentary behavior on prevention of overweight and
obesity. In a small number of these, the intervention was effective. Notably, these
successful interventions often addressed reduction in sedentary behavior rather
than attempts to increase physical activity. In the majority of studies, there was
no significant difference in any measure of body size, including BMI, BMI percentile,
or percentage of body fat. Sample sizes were often small, and followup was often
short, frequently less than 6 months. The results of one study suggested that gender-specific
programs may be more successful in changing physical activity behavior. Overall,
the Expert Panel concluded that, based on the evidence review, increasing physical
activity in isolation is of little benefit in preventing obesity. By contrast, the
review suggests that reducing sedentary behavior may be beneficial in preventing
the development of obesity. The physical activity recommendations in these Guidelines
specifically address the CV health benefits of limiting sedentary behavior and increasing
physical activity in all children (Section VI. Physical Activity). No additional
specific recommendations addressing activity in preventing obesity beyond those
developed for all children are indicated based on this evidence review.
OVERVIEW OF THE EVIDENCE ON CHILDREN AT INCREASED RISK FOR OVERWEIGHT AND OBESITY
Certain populations of children who are of normal weight are at risk for developing
overweight and obesity as they grow older. Observational studies have identified
risk factors that put these children at greater risk; however, research is lacking
regarding an appropriate intervention. Despite that fact, epidemiologic associations
suggest that primary care providers should be alert to increasing BMI trends and
excessive weight gain beyond what is anticipated for height increase or pubertal
change when dealing with these children and should consider intervention before
the child becomes overweight.
From the evidence review for these Guidelines, observational studies have identified
sample populations that are at special risk for obesity as follows:
- Children with BMI between the 85th and 95th percentiles.,,,,
- Children in whom there is a positive family history of obesity in one or both parents.,,,,,,
- Early onset of increasing weight beyond that appropriate for increase in height.
This can be identified early, beginning in the first year of life.,
- Excessive increase in weight during adolescence, particularly in Black girls.,
- Children who previously had been very active and become inactive or adolescents
who are inactive in general (e.g., a child who has previously participated in organized
sports and has stopped, particularly in adolescence).
No RCTs that specifically address these populations were identified. Despite this
absence of RCT evidence, the Expert Panel believes that lifestyle recommendations
addressing energy balancediet and physical activitywith a goal of prevention
of excess weight gain are needed for normal-weight children with characteristics
consistent with these special risks for the development of overweight and obesity.
The diet and activity recommendations proposed for all children in these Guidelines
should be vigorously reinforced in these children. In any child, the development
of a BMI between the 85th and 95th percentiles should be taken as a sign that increased
attention to diet and activity, as well as BMI-specific followup, is indicated.
OVERVIEW OF THE EVIDENCE ON TREATMENT OF OBESITY
In children who are already obese, the primary goal of obesity treatment is to improve
weight-for-height disproportion through weight loss in older children or through
weight maintenance during linear growth through adoption of a healthier lifestyle
in younger children. From this evidence review, many studies measuring intermediate
variables have shown a significant decrease in CV risk factors with an improvement
in weight and/or decrease in body fatness: decreases in systolic and diastolic
decreases in TC, LDLC, and/or TG,,,,
decrease in IR;,,,,,
decrease in inflammatory markers; and improvement in subclinical measures
If weight improvements are sustained, these studies suggest that the improved weight
profile should be associated with improved overall health and CV risk, reduced incidence
of type 2 diabetes mellitus (T2DM), and other problems known to be associated with
obesity in childhood.
The evidence review for overweight and obesity for these Guidelines identified 5
systematic reviews, 2 meta-analyses, and 69 RCTs addressing the treatment of obesity.
Of these, a major systematic review from the U.S. Preventive Services Task Force
(USPSTF) in 2005 considered all treatment intervention trials applicable to primary
care settings published since 1985 in Western industrialized nations. Of
23 identified studies, the majority involved short-term, behavioral counseling interventions
in small numbers of primarily White school-aged children. At followup, mean BMI
percentiles decreased from above the 95th percentile at baseline to between the
90th and 95th percentiles at 1-year followup; no long-term followup results were
available. Six studies in the USPSTF review involved adolescents, as did an additional
review of 17 studies confined to adolescents. Only half of the interventions
were associated with any mean change in BMI at short-term followup. No long-term
followup results were available. In all adolescent studies, high dropout rates,
as high as 45 percent, complicate the interpretation of results. No adverse effects
on eating behaviors, eating disorder symptoms, or weight dissatisfaction were reported,
but these results often were not specifically provided. Both published reviews concluded
that the evidence that behavioral counseling interventions are effective treatment
for obese children and adolescents is fair to poor because of small, short-term
studies with limited generalizability.
By contrast, a 2008 systematic review from the Agency for Healthcare Research and
Quality evaluated RCTs of weight interventions in obese and overweight children
and adolescents released between 2005 and 2007; the review concluded that medium-
to high-intensity (defined as meeting for at least 25 hours over 6 months) behavioral
management programs were effective in achieving small to moderate weight loss that
was sustained for up to 12 months after the end of treatment. The majority of studies
took place in specialized centers for obesity research, with only rare studies in
clinical practice settings.
A 2007 meta-analysis quantitatively evaluated the efficacy of RCTs that used lifestyle
interventionsdefined as any combination of diet, physical activity, and/or
behavioral treatmentpublished before August 2005. Lifestyle interventions
were compared with no-treatment control groups or information/education-only controls.
Effect sizes were calculated from the means and standard deviations of the change
scores of the weight loss measure (percentage overweight, BMI z-score, BMI, or weight)
from the beginning of treatment to the end of treatment and/or followup; only one
weight measure was included for each study. Compared with both kinds of controls,
there was a significant effect size at the end of treatment and at followup.
A majority of RCTs in the evidence review for these Guidelines tested a hypocaloric
diet and an increase in physical activity with behavior change counseling to support
these changes. Twenty-one RCTs described this type of combined intervention, and
obesity measures included percentage overweight, weight, relative weight, BMI percentile,
BMI z-score, body fat percentile, and/or waist circumference. Thirteen of 21 trials
reported a significant decrease in at least one of these measures on short-term
followup, when intervention and control groups were compared.,,,,,,,,,,,,
Two of these studies were initiated in primary care settings, and the remainder
occurred in research clinics. Of note, in obese adolescents, inclusion of peers
in a cognitive-behavioral diet and activity intervention was successful in achieving
significant weight loss sustained at 10-month followup. Ten-year followup
of obese children (ages 612 years at enrollment) documented sustained improvement
in weight-for-height measures of family-based interventions based on training children
and parents in optimal food choices in a research setting.,
This is the first evidence that weight regulation in children can be achieved and
maintained over extended periods from childhood through adolescence. Change in physical
activity in addition to dietary change was significantly associated with reduced
obesity in this report. Another significant variable from this study that has been
replicated by others was the importance of a treatment focus on parents in children
Another RCT tested an intervention designed for weight maintenance after an active
weight loss treatment program in 204 healthy children ages 712 years with
elevated BMI; the trial found that maintenance-targeted treatment improved weight
loss short term compared with no maintenance treatment, but effects were not significant
at 2 years.
There were 21 studies in this evidence review that specifically evaluated an exercise
intervention alone or in combination with dietary change, either an increase in
physical activity, a decrease in sedentary activity, or a combination. Of these,
nine involved a pure physical activity intervention with no recommended diet change
versus no intervention.,,,,,,,,,,
Most showed a decrease in body fat and/or an increase in fat-free mass in
the exercise group, but only one showed a decrease in weight and BMI.
In this study, points scored with activity allowed children to earn TV time, and
weight changes were accompanied by a significant increase in moderate to vigorous
activity and a decrease in sedentary activity. Exercise alone was shown to decrease
and improve subclinical measures of atherosclerosis even without weight change.,,
In the remainder of these studies, an activity intervention and diet change were
compared with diet alone.,,,,,,,,,,
The combination of dietary change and a specific exercise intervention was universally
more effective at achieving decreases in weight and BMI, as well as decreases in
body fat when compared with an isolated dietary intervention.
Seven studies that met the criteria for inclusion in the Expert Panel evidence review
evaluated specific dietary interventions. Three studies compared a low glycemic-load
diet to a low-fat diet; two of these were in young adults (ages 1840 years),
and one was in adolescents.,,
In all three trials, both diet groups lost weight, but loss was greater in
the low-glycemic index group. One study compared a low-carbohydrate diet to a low-fat
diet over 12 weeks in 39 adolescents, with greater BMI decrease in the low-carbohydrate
In two studies, a fiber supplement was added to a hypocaloric diet with no difference
in outcomes when compared with diet alone., Finally,
a short-term, protein-sparing modified fast was compared with a hypocaloric balanced
diet in a very small group of children ages 715 years, with marked decrease
in weight and BMI at 10-week followup for the protein-sparing, modified-fast diet
Results were sustained at 4.5-months followup but not at 10.5 months when loss to
followup was significant. In addition, in this study, the two groups were not comparable
Addition of medication to behavioral lifestyle counseling for diet and exercise
was investigated in a series of RCTs in pediatric populations, which are detailed
below. Three small metformin trials (N = 2429) enrolled male and female adolescents
with severe elevation of BMI (mean greater than 35 kg/m2) and hyperinsulinism
without diabetes or with impaired glucose tolerance. Each study used a different
metformin dose (500 mg1 g bid). Treatment duration was 6 months in two studies
and 8 weeks in the third. All three reported statistically significant decreases
in weight and/or BMI and fasting insulin with metformin compared to placebo. In
the two studies that included lipids as a secondary outcome, the effect was improvement
in one and no effect in the other.,,
For adolescents older than age 12 years, adding orlistat, which causes fat malabsorption
through inhibition of enteric lipase, to a comprehensive lifestyle weight loss program
was investigated in four trials. A large multicenter RCT enrolled 539 obese 12-
to 16-year-olds, excluding those with BMI 44 kg/m2 or higher, diabetes
requiring medication, and other medical and psychiatric conditions. After 52 weeks,
65 percent of participants were retained; there was significantly greater lowering
of all obesity measures in the orlistat group compared with controls.
In a smaller trial, use of orlistat was associated with a significantly greater
decrease in BMI and body weight from baseline after 1 year of treatment; absolute
BMI was also lower in the orlistat treatment group, but this difference was not
In a small 6-month trial, orlistat was not associated with a significant difference
in any obesity measure.
In a small study designed to investigate mineral balance in adolescent obese volunteers,
there was no difference in any of 6 selected microminerals or macrominerals after
21 days of orlistat treatment. In all of these studies, there
was a high reported rate of gastrointestinal symptoms with orlistat involving up
to 32 percent of subjects.
In adolescents (ages 1216 years) with severe elevation of BMI (3244
kg/m2), the addition of sibutramine, a serotonin reuptake inhibitor,
to a comprehensive lifestyle weight loss program significantly improved weight loss,
BMI, and measures of metabolic risk at 6- to 12-month followup in three RCTs.22,,,
The trials excluded subjects with comorbidities, such as elevated BP, diabetes mellitus,
CV disease, and/or elevated heart rate. A large RCT involved 498 participants, ages
1216 years. After 1 year, 76 percent of sibutramine subjects and 62 percent
of placebo subjects completed the study. The sibutramine group had significantly
greater decreases in BMI and body weight. Potential CV side effects were
investigated in a separate analysis of this trial. Tachycardia
was significantly more common in the sibutramine group but did not lead to increased
drug withdrawal. Medication was stopped for BP in 1 percent of subjects in the sibutramine
group versus none in the placebo group. After 1 year, systolic and diastolic BPs
and heart rates were decreased from baseline in both intervention and control subjects,
with no significant difference between groups.,
In one small trial, 9 of 43 subjects on sibutramine had medication decreased or
stopped for an increase in BP, heart rate, or both, above a prespecified threshold.127 A third small trial (N = 46) did
not report stopping sibutramine for BP or heart rate in any subject.
Sibutramine was withdrawn from the U.S. market on October 8, 2010. This withdrawal
was due to a 16-percent increase in risk of major CV adverse events demonstrated
in the Sibutramine Cardiovascular Outcomes trial in adults: a composite of
nonfatal myocardial infarction, nonfatal stroke, resuscitation after cardiac arrest
and CV death.
A single study of hospitalized adolescents with severe elevation of BMI (all greater
than 35 kg/m2) treated with fenfluramine showed no advantage over diet
Recent studies have examined adolescents receiving bariatric surgery.,
One examined nationwide use of bariatric surgery in adults and adolescents, concluding
that bariatric surgery in adolescents is uncommon compared with use in adults. There
were 771 bariatric procedures performed in the United States in 2003, triple the
number performed in 2000; 12 percent of adolescents receiving the surgery had comorbid
The other study was a case series (N = 38) examining outcomes from bariatric surgery
in adolescents; mean preoperative BMI was 60 +/- 8 kg/m2 compared with
40 +/- 8 kg/m2 at a mean followup of 10 months. The study found significant
improvements in CV measures on postoperative followup. Generally, bariatric
procedures have been performed in academic centers as part of research protocols.
There are no long-term data on followup after bariatric surgery in adolescents.
CONCLUSIONS AND GRADING OF THE EVIDENCE REVIEW ON TREATMENT OF OBESITY
- There is good evidence for the effectiveness of combined weight loss programs that
included behavior change counseling, negative energy balance through diet, and increased
physical activity in addressing obesity in children older than age 6 years with
a BMI at or greater than 95th percentile and no comorbidities (Grade A). However,
such programs have primarily been shown to be effective in a comprehensive weight
loss program or research settings, with only a small number shown to be effective
in primary care settings.
- No data were identified on weight loss programs for children younger than age 6
- No single negative energy diet plan was identified from the evidence review. Dietary
plans should be determined for each child, based on baseline body size, energy requirements
for growth, and physical activity level (Grade D).
- Increasing dietary fiber from corn bran, wheat flour, wheat bran, oat flakes, corn
germ meal, or glucomannan does not significantly improve weight loss (Grade A).
- Various diets have been inadequately studied as to their effects on obesity in children
and adolescents, including low glycemic-load diets, low-carbohydrate diets, fiber
supplements, and protein-sparing modified fasts.
- For children ages 612 years:
- Family-based programs in research settings have been shown to be effective at initiating
and sustaining weight loss over a followup of 10 years (Grade A).
- The greatest weight loss is achieved when parents are the focus of the intervention
- For adolescents:
- Comprehensive programs in research settings were effective at achieving weight loss
in the short term (Grade A).
- The greatest weight change was achieved when the adolescent was the primary focus
of the intervention (Grade B).
- Behavior change programs that involved peers achieved more sustained weight loss
- In overweight and obese youth, the combination of diet and a specific physical activity
intervention that reduced sedentary activity and/or increased physical activity
was universally more effective at achieving decreases in weight and BMI, as well
as decreases in body fat compared with an isolated diet intervention:
- In both children and adolescents, exercise training improved weight loss and body
composition (decreasing fat mass and reducing visceral fat), decreased IR, reduced
BP, normalized dyslipidemia, and normalized subclinical measures of atherosclerosis
- In children ages 712 years, reduction in sedentary activity, independent of
increasing physical activity, produced weight loss (Grade B). In this age group,
reductions in sedentary activity were effectively accomplished by rewarding children
for time spent being physically active with TV viewing time (Grade B).
- Girls did not respond as well as boys to combined treatments that both reduced sedentary
behaviors and increased physical activity (Grade B).
- For adolescents with or without significant comorbidities, with a BMI greater than
or equal to the 95th percentile and for adolescents with a BMI greater than 35 kg/m2
who have failed a comprehensive lifestyle weight loss program, addition of medication
under the care of a physician experienced in managing weight loss with medication
can be safe and effective in achieving weight loss with followup of 412 months.
However, long-term safety and efficacy data are not available:
- In adolescents with severe obesity and IR, the addition of metformin to a comprehensive
lifestyle weight loss program improved fasting insulin and significantly reduced
weight and BMI (Grade B). (metformin is currently approved by the U.S. Food and
Drug Administration (FDA) for pediatric patients ages 10 years and older with T2DM
but is not approved for weight loss for either children or adults.)
- For obese adolescents older than age 12 years, the addition of orlistat to a comprehensive
lifestyle weight loss program improved weight loss and BMI (Grade A); however, use
of this medication had a high rate of gastrointestinal side effects. Orlistat (under
the trade name xenical) is approved by the FDA for weight loss in pediatric patients
ages 12 years and older in conjunction with a reduced calorie diet. In August 2009,
the FDA released an early communication about an ongoing safety review regarding
reports of liver-related adverse events in some patients taking orlistat. In May
2010, the orlistat labeling was updated to incorporate safety information pertaining
to the occurrence of rare postmarketing cases of severe liver injury, including
hepatic failure resulting in liver transplant or death.
- Dropout rates are substantial for all weight treatment programs.
- No studies defining an appropriate rate for weight loss in any age group were identified
by the Guidelines evidence review. The 2010 DGA recommends slowing weight
gain while allowing normal growth and development. For those with BMI greater
than or equal to the 95th percentile without comorbidities, both the
AMA/CDC/MCHB Expert Committee and the American Academy of Pediatrics (AAP) recommend
weight maintenance resulting in decreasing BMI as age increases. With BMI greater
than or equal to the 95th percentile with comorbidities, the AMA/CDC/MCHB
Expert Committee and the AAP recommend gradual weight loss not exceeding 1 pound
per month in children ages 211 years or 2 pounds per week in adolescents (no
- For adolescents with BMI far above 35 kg/m2 and associated comorbidities,
bariatric surgery on a research protocol, in conjunction with a comprehensive lifestyle
weight loss program, improved weight loss, BMI, and other outcomessuch as
IR, glucose tolerance, and CV measuresin a small case series (Grade D).
Table 101. Evidence-Based Recommendations for Management of Child and Adolescent
Patients With Overweight and Obesity
Grades reflect the findings of the evidence review.
Recommendation levels reflect the consensus opinion of the Expert
No weight-for-height specific recommendations
CHILD 1 diet is recommended for pediatric care providers to use with their child
and adolescent patients to reduce CV risk
Identify children at high risk for obesity because of Grade B parental obesity and
excessive BMI increase
→Focused CHILD 1 diet and physical activity education
BMI percentile stable→ reinforce current program, followup in 6 months
Increasing BMI percentile→ registered dietitian (RD) counseling for energy
balanced diet, intensify physical activity change; 6 month followup
BMI 85th-95th percentile:
Excess weight gain prevention with parents as focus for energy- balanced diet; reinforce
physical activity recommendations X 6 months
- Improvement in BMI percentile → continue current program
- Increasing BMI percentile → RD counseling for energy-balanced diet; intensify
physical activity recommendations; 6 month followup
BMI ≥ 95th percentile:
Specific assessment for comorbidities*
Family-based weight gain prevention with parents as focus; RD counseling and followup
for energy-balanced diet; moderate-to-vigorous physical activity (MVPA) prescription;
limit sedentary screen time; 3 month followup
Identify children at increased risk for obesity because of parental obesity, change
in physical activity +/- excessive gain in BMI for focused CHILD 1 diet/physical
- BMI percentile stable→ reinforce current program, 6 month followup
- Increasing BMI percentile→ RD counseling for Energy-balanced CHILD 1 diet,
intensified physical activity, 3 m followup
BMI 85th-95th percentile:
Excessive weight gain prevention with parents as focus for energy-balanced diet;
reinforce physical activity recommendations 6 month followup
- Stable/improving BMI percentile→ reinforce current program, 6 m followup
- Increasing BMI percentile→ RD counseling for energy-balanced CHILD 1 diet,
intensified physical activity recommendations, 3 month followup
BMI ≥ 95th percentile:
Specific assessment for comorbidities.*
BMI ≥ 95th percentile with no comorbidities:
Office-based weight loss plan: Family-centered program with parents as focus for
behavior modification, (-) energy balance diet counseling by RD, Rx for increased
MVPA, decreased sedentary time x 6 months
- Improvement in BMI percentile/comorbidities→ continue current plan
- No improvement in BMI percentile→ referral to comprehensive multidisciplinary
lifestyle weight loss program
BMI ≥ 95th %ile with co-morbidities, BMI > 97th percentile, or progressive
rise in BMI despite therapy:
Refer to comprehensive multidisciplinary weight loss program for intensive management
x 6 months
- Improvement in BMI percentile→ continue present program
- No improvement in BMI percentile→ consider referral to another comprehensive
multidisciplinary weight loss program
Identify adolescents at increased risk for obesity because of parental obesity,
change in physical activity +/- excess gain in BMI for focused diet/physical activity
education x 6 months
- BMI/BMI percentile stable → reinforce current program, 6 months followup
- Increasing BMI/BMI percentile→ RD counseling for energy-balanced CHILD 1 diet,
intensified physical activity x 3 months
BMI 85th-95th percentile:
Excess weight gain prevention with adolescent as change agent for energy-balanced
CHILD 1 diet, reinforced physical activity recommendations x 6 months
- Improvement in BMI percentile→ continue current program
- Increasing BMI percentile→ RD counseling for energy-balanced weight control
diet, intensified physical activity, 3 month followup
BMI ≥ 95th percentile:
Specific assessment for comorbidities* :
BMI ≥ 95th percentile with no comorbidities:
Office-based weight loss plan: Family-centered with adolescent as change agent for
behavior modification counseling, RD counseling for (-) energy-balanced diet, Rx
for increased MVPA, decreased sedentary time x 6 months
- Improvement in BMI/BMI percentile → continue current program
- No improvement in BMI/ BMI percentile → referral to comprehensive multidisciplinary
weight loss program with peers
- No improvement in BMI/BMI percentile→ consider initiation of medication (orlistat)
under care of experienced MD x 6-12 months
BMI ≥ 95th %ile with comorbidities or BMI > 35 kg/m2:
Refer to comprehensive lifestyle weight loss program for intensive management x
- Improvement in BMI/BMI percentile→ continue present program
- No improvement in BMI/ BMI percentile→ consider initiation of orlistat under
care of experienced clinician x 6-12 months
- BMI far above 35 kg/m2 and comorbidities unresponsive to lifestyle therapy
for > 1 y, consider bariatric surgery/ referral to center with experience/ expertise
* Comorbidities: Hypertension, dyslipidemia,
type 2 diabetes mellitus (T2DM)
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