Accessible Search Form           Advanced Search

Skip left side navigation and go to content

Health Professionals

10. Overweight and Obesity

INTRODUCTION

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 at http://www.nhlbi.nih.gov/health-pro/guidelines/current/cardiovascular-health-pediatric-guidelines/index.htm. 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.

BACKGROUND

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.[1] 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.[2],[3],[4],[5] 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.[6],[7],[8],[9],[10],[11],[12] Longitudinal studies have demonstrated tracking of elevated BMI and increased adiposity in childhood to the presence of obesity in adulthood.[13],[14],[15],[16] Improvement in weight status and decrease in body fatness have been shown to be associated with decreases in systolic and diastolic blood pressures (BPS),[17],[18],[19],[20] total cholesterol (TC), low-density lipoprotein cholesterol (LDL–C) and/or triglycerides (TG),[18],[20],[21],[22],[23],[24] IR,[17],[20],[22],[24] and inflammatory markers.[20],[25] Subclinical vascular changes indicative of atherosclerosis have been demonstrated in overweight and obese children;[20],[26],[27],[28] exercise and weight loss have been shown to result in significant improvement in these measures.[20],[28] 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.[29],[30],[31],[32],[33] 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 7–13 years in males and ages 10–13 years in girls, there was a significant increase in risk for a coronary heart disease event.[34] 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 5–16 percent over the next 25 years, with more than 100,000 excess cases of CHD attributable to obesity in childhood.[35]

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.[36] 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 in children.[37] 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.[38] 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.[39] 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 2–18 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).[40] 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 children—promotion of CV health and prevention of obesity—the majority of the obesity prevention recommendations are the same as those developed for the promotion of CV health in all children.

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 outcome measures.[41] 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 levels.[42],[43],[44],[45],[46],[47],[48],[49],[50],[51],[52] 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 6–8 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.[46] 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 96 schools.[51] 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 the trial.[52] 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.[53]

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.[54] 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.[55],[56] 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.[57]

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.[58] 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.[59]

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.[43] 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.[60]

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 PHYSICAL ACTIVITY

There is strong evidence for the beneficial effects of physical activity and limiting sedentary time on the overall health of children and adolescents.[61] [62] 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.[63] 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.[64] 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 classes.[65] 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.[66] 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.[67] 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 12 months.[68]

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.[69] Among second-grade American Indian children enrolled in a physical activity intervention, boys were seen to be more active at baseline and followup.[70] 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 PHYSICAL ACTIVITY

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:

  1. Children with BMI between the 85th and 95th percentiles.[14],[15],[16],[71],[72]
  2. Children in whom there is a positive family history of obesity in one or both parents.[13],[14],[15],[16],[73],[74],[75]
  3. Early onset of increasing weight beyond that appropriate for increase in height. This can be identified early, beginning in the first year of life.[72],[74]
  4. Excessive increase in weight during adolescence, particularly in Black girls.[71],[72]
  5. 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).[76]

No RCTs that specifically address these populations were identified. Despite this absence of RCT evidence, the Expert Panel believes that lifestyle recommendations addressing energy balance—diet and physical activity—with 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 BPs;[17],[18],[19],[20],[77],[78] decreases in TC, LDL–C, and/or TG[18],[19],[20],[21],[22] decrease in IR;[17],[19],[20],[22],[23],[24] decrease in inflammatory markers;[25] and improvement in subclinical measures of atherosclerosis.[20],[28],[79] 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.[80] 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.[81] 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.[82] 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 interventions—defined as any combination of diet, physical activity, and/or behavioral treatment—published 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.[83]

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.[84],[85],[86],[87],[88],[89],[90],[91],[92],[93],[94],[95],[96] 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.[93] Ten-year followup of obese children (ages 6–12 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.[88],[94] 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 this age.[92],[94],[95],[96] Another RCT tested an intervention designed for weight maintenance after an active weight loss treatment program in 204 healthy children ages 7–12 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.[97]

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.[79],[98],[99],[100],[101],[102],[103],[104],[105],[106],[107] 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.[104] 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 IR[102],[105] and improve subclinical measures of atherosclerosis even without weight change.[79],[98],[100] In the remainder of these studies, an activity intervention and diet change were compared with diet alone.[17],[18],[20],[23],[108],[109],[110],[111],[112],[113],[114] 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 18–40 years), and one was in adolescents.[78],[115],[116] 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 group.[19] In two studies, a fiber supplement was added to a hypocaloric diet with no difference in outcomes when compared with diet alone.[117],[118] Finally, a short-term, protein-sparing modified fast was compared with a hypocaloric balanced diet in a very small group of children ages 7–15 years, with marked decrease in weight and BMI at 10-week followup for the protein-sparing, modified-fast diet group.[119] 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 at baseline.

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 = 24–29) 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 mg–1 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.[24],[120],[121]

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.[122] 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 significant.[123] In a small 6-month trial, orlistat was not associated with a significant difference in any obesity measure.[124] 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.[125] 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 12–16 years) with severe elevation of BMI (32–44 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,[126],[127],[128] 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 12–16 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.[22] Potential CV side effects were investigated in a separate analysis of this trial.[126] 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.[22],[126] 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.[128] 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.[129]

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 alone.[130]

Recent studies have examined adolescents receiving bariatric surgery.[131],[132] 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 conditions.[131] 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.[132] 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 years.
  • 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 6–12 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 (Grade A).
  • 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 (Grade B).
  • 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 (Grade A).
    • In children ages 7–12 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 4–12 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 2–11 years or 2 pounds per week in adolescents (no grade).
  • 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 outcomes—such as IR, glucose tolerance, and CV measures—in a small case series (Grade D).

Table 10–1. 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 Panel.

Birth-24 months 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
 
2-5 years 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
Grade B
Recommend
2-5 years
(cont.d)
BMI 85th-95th percentile:  
2-5 years
(cont.d)
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
Grade D
Recommend
2-5 years
(cont.d)
BMI ≥ 95th percentile:  
2-5 years
(cont.d)
Specific assessment for comorbidities* Grade B
Strongly recommend
2-5 years
(cont.d)
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 Grade B
Recommend
6-11 years 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 activity education
  • 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
Grade B
Recommend
6-11 years
(cont.d)
BMI 85th-95th percentile:  
6-11 years
(cont.d)
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
Grade D
Recommend
6-11 years
(cont.d)
BMI ≥ 95th percentile:  
6-11 years
(cont.d)
Specific assessment for comorbidities.* Grade B
Recommend
6-11 years
(cont.d)
BMI ≥ 95th percentile with no comorbidities:  
6-11 years
(cont.d)
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
Grade A
Recommend
6-11 years
(cont.d)
BMI ≥ 95th %ile with co-morbidities, BMI > 97th percentile, or progressive rise in BMI despite therapy: Grade A
Strongly Recommend
6-11 years
(cont.d)
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
 
12-21 years 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
Grade B
Recommend
12-21 years
(cont.d)
BMI 85th-95th percentile:  
12-21 years
(cont.d)
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
Grade B
Recommend
12-21 years
(cont.d)
BMI ≥ 95th percentile:  
12-21 years
(cont.d)
Specific assessment for comorbidities* : Grade B
Strongly Recommend
12-21 years
(cont.d)
BMI ≥ 95th percentile with no comorbidities:  
12-21 years
(cont.d)
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
Grade B
Strongly Recommend
12-21 years
(cont.d)
BMI ≥ 95th %ile with comorbidities or BMI > 35 kg/m2:  
12-21 years
(cont.d)
Refer to comprehensive lifestyle weight loss program for intensive management x 6-12 months
  • 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 in procedures
Grade B
Strongly Recommend

* Comorbidities: Hypertension, dyslipidemia, type 2 diabetes mellitus (T2DM)


REFERENCES

[1] Ogden CL, Carroll MD, Flegal KM. Prevalence of high body mass index in US children and adolescents, 2007-2008. JAMA 2010;303(3):242-249.

[2] Berenson GS, Srinivasan SR, Bao W, Newman WP, III, Tracy RE, Wattigney WA. Association between multiple cardiovascular risk factors and atherosclerosis in children and young adults. The Bogalusa Heart Study. N Engl J Med 1998;338(23):1650-1656. (PM:9614255)

[3] Berenson GS, Wattigney WA, Tracy RE, Newman WP, III, Srinivasan SR, Webber LS, Dalferes ER, Jr., Strong JP. Atherosclerosis of the aorta and coronary arteries and cardiovascular risk factors in persons aged 6 to 30 years and studied at necropsy (The Bogalusa Heart Study). Am J Cardiol 1992;70(9):851-858. (PM:1529936)

[4] Strong JP, Malcom GT, McMahan CA, Tracy RE, Newman WP, III, Herderick EE, Cornhill JF. Prevalence and extent of atherosclerosis in adolescents and young adults: implications for prevention from the Pathobiological Determinants of Atherosclerosis in Youth Study. JAMA 1999;281(8):727-735. (PM:10052443)

[5] McGill HC, Jr., McMahan CA, Zieske AW, Malcom GT, Tracy RE, Strong JP. Effects of nonlipid risk factors on atherosclerosis in youth with a favorable lipoprotein profile. Circulation 2001;103(11):1546-1550. (PM:11257083)

[6] Clarke WR, Woolson RF, Lauer RM. Changes in ponderosity and blood pressure in childhood: the Muscatine Study. Am J Epidemiol 1986;124(2):195-206. (PM:3728436)

[7] Katzmarzyk PT, Srinivasan SR, Chen W, Malina RM, Bouchard C, Berenson GS. Body mass index, waist circumference, and clustering of cardiovascular disease risk factors in a biracial sample of children and adolescents. Pediatrics 2004;114(2):e198-e205. (PM:15286257)

[8] Chen W, Bao W, Begum S, Elkasabany A, Srinivasan SR, Berenson GS. Age-related patterns of the clustering of cardiovascular risk variables of syndrome X from childhood to young adulthood in a population made up of black and white subjects: the Bogalusa Heart Study. Diabetes 2000;49(6):1042-1048. (PM:10866058)

[9] Chen W, Srinivasan SR, Elkasabany A, Berenson GS. Cardiovascular risk factors clustering features of insulin resistance syndrome (Syndrome X) in a biracial (Black-White) population of children, adolescents, and young adults: the Bogalusa Heart Study. Am J Epidemiol 1999;150(7):667-674. (PM:10512420)

[10] Freedman DS, Dietz WH, Srinivasan SR, Berenson GS. The relation of overweight to cardiovascular risk factors among children and adolescents: the Bogalusa Heart Study. Pediatrics 1999;103(6 Pt 1):1175-1182. (PM:10353925)

[11] Klein DJ, Aronson FL, Harlan WR, Barton BA, Schreiber GB, Cohen RM, Harlan LC, Morrison JA. Obesity and the development of insulin resistance and impaired fasting glucose in black and white adolescent girls: a longitudinal study. Diabetes Care 2004;27(2):378-383. (PM:14747217)

[12] Cook S, Weitzman M, Auinger P, Nguyen M, Dietz WH. Prevalence of a metabolic syndrome phenotype in adolescents: findings from the third National Health and Nutrition Examination Survey, 1988-1994. Arch Pediatr Adolesc Med 2003;157(8):821-7. (PM:12912790)

[13] Freedman DS, Khan LK, Serdula MK, Dietz WH, Srinivasan SR, Berenson GS. The relation of childhood BMI to adult adiposity: the Bogalusa Heart Study. Pediatrics 2005;115(1):22-27. (PM:15629977)

[14] Clarke WR, Lauer RM. Does childhood obesity track into adulthood? Crit Rev Food Sci Nutr 1993;33(4-5):423-430. (PM:8357505)

[15] Field AE, Cook NR, Gillman MW. Weight status in childhood as a predictor of becoming overweight or hypertensive in early adulthood. Obes Res 2005;13(1):163-169. (PM:15761176)

[16] Freedman DS, Mei Z, Srinivasan SR, Berenson GS, Dietz WH. Cardiovascular risk factors and excess adiposity among overweight children and adolescents: the Bogalusa Heart Study. J Pediatr 2007;150(1):12-17. (PM:17188605)

[17] Rocchini AP, Katch V, Schork A, Kelch RP. Insulin and blood pressure during weight loss in obese adolescents. Hypertension 1987;10(3):267-273. (PM:3305355)

[18] Becque MD, Katch VL, Rocchini AP, Marks CR, Moorehead C. Coronary risk incidence of obese adolescents: reduction by exercise plus diet intervention. Pediatrics 1988;81(5):605-612. (PM:3357722)

[19] Sondike SB, Copperman N, Jacobson MS. Effects of a low-carbohydrate diet on weight loss and cardiovascular risk factor in overweight adolescents. J Pediatr 2003;142(3):253-258. (PM:12640371)

[20] Meyer AA, Kundt G, Lenschow U, Schuff-Werner P, Kienast W. Improvement of early vascular changes and cardiovascular risk factors in obese children after a six-month exercise program. J Am Coll Cardiol 2006;48(9):1865-1870. (PM:17084264)

[21] Epstein LH, Kuller LH, Wing RR, Valoski A, McCurley J. The effect of weight control on lipid changes in obese children. Am J Dis Child 1989;143(4):454-457. (PM:2929526)

[22] Berkowitz RI, Fujioka K, Daniels SR, Hoppin AG, Owen S, Perry AC, Sothern MS, Renz CL, Pirner MA, Walch JK, Jasinsky O, Hewkin AC, Blakesley VA; Sibutramine Adolescent Study Group. Effects of sibutramine treatment in obese adolescents: a randomized trial. Ann Intern Med 2006;145(2):81-90. (PM:16847290)

[23] Kang HS, Gutin B, Barbeau P, Owens S, Lemmon CR, Allison J, Litaker MS, Le NA. Physical training improves insulin resistance syndrome markers in obese adolescents. Med Sci Sports Exerc 2002;34(12):1920-1927. (PM:12471297)

[24] Kay JP, Alemzadeh R, Langley G, D'Angelo L, Smith P, Holshouser S. Beneficial effects of metformin in normoglycemic morbidly obese adolescents. Metabolism 2001;50(12):1457-1461. (PM:11735093)

[25] Balagopal P, George D, Patton N, Yarandi H, Roberts WL, Bayne E, Gidding S. Lifestyle-only intervention attenuates the inflammatory state associated with obesity: a randomized controlled study in adolescents. J Pediatr 2005;146(3):342-348. (PM:15756217)

[26] Urbina EM, Gidding SS, Bao W, Elkasabany A, Berenson GS. Association of fasting blood sugar level, insulin level, and obesity with left ventricular mass in healthy children and adolescents: The Bogalusa Heart Study. Am Heart J 1999;138(1 Pt 1):122-127. (PM:10385774)

[27] Urbina EM, Kieltkya L, Tsai J, Srinivasan SR, Berenson GS. Impact of multiple cardiovascular risk factors on brachial artery distensibility in young adults: the Bogalusa Heart Study. Am J Hypertens 2005;18(6):767-771. (PM:15925733)

[28] Woo KS, Chook P, Yu CW, Sung RY, Qiao M, Leung SS, Lam CW, Metreweli C, Celermajer DS. Effects of diet and exercise on obesity-related vascular dysfunction in children. Circulation 2004;109(16):1981-1986. (PM:15066949)

[29] Juonala M, Jarvisalo MJ, Maki-Torkko N, Kahonen M, Viikari JS, Raitakari OT. Risk factors identified in childhood and decreased carotid artery elasticity in adulthood: the Cardiovascular Risk in Young Finns Study. Circulation 2005;112(10):1486-1493. (PM:16129802)

[30] Raitakari OT, Juonala M, Kähönen M, Taittonen L, Laitinen T, Mäki-Torkko N, Järvisalo MJ, Uhari M, Jokinen E, Rönnemaa T, Akerblom HK, Viikari JS. Cardiovascular risk factors in childhood and carotid artery intima-media thickness in adulthood: the Cardiovascular Risk in Young Finns Study. JAMA 2003;290(17):2277-2283. (PM:14600186)

[31] Mahoney LT, Burns TL, Stanford W, Thompson BH, Witt JD, Rost CA, Lauer RM. Coronary risk factors measured in childhood and young adult life are associated with coronary artery calcification in young adults: the Muscatine Study. J Am Coll Cardiol 1996;27(2):277-284. (PM:8557894)

[32] Davis PH, Dawson JD, Riley WA, Lauer RM. Carotid intimal-medial thickness is related to cardiovascular risk factors measured from childhood through middle age: The Muscatine Study. Circulation 2001;104(23):2815-2819. (PM:11733400)

[33] Li S, Chen W, Srinivasan SR, Bond MG, Tang R, Urbina EM, Berenson GS. Childhood cardiovascular risk factors and carotid vascular changes in adulthood: the Bogalusa Heart Study. JAMA 2003;290(17):2271-2276. (PM:14600185)

[34] Baker JL, Olsen LW, Sorensen TI. Childhood body-mass index and the risk of coronary heart disease in adulthood. N Engl J Med 2007;357(23):2329-2337.

[35] Bibbins-Domingo K, Coxson P, Pletcher MJ, Lightwood J, Goldman L. Adolescent overweight and future adult coronary heart disease. N Engl J Med 2007;357:2371-2379.

[36] Kuczmarski RJ, Ogden CL, Grummer-Strawn LM, Flegal KM, Guo SS, Wei R, Mei Z, Curtin LR, Roche AF, Johnson CL. CDC growth charts: United States. Adv Data 2000;(314):1-27.

[37] Barlow SE, Expert Committee. Expert committee recommendations regarding the prevention, assessment, and treatment of child and adolescent overweight and obesity: summary report. Pediatrics 2007;120 Suppl 4:S164-192. (PM:18055651)

[38] Krebs NF, Himes JH, Jacobson D, Nicklas TA, Guilday P, Styne D. Assessment of child and adolescent overweight and obesity. Pediatrics 2007;120 Suppl 4:S193-S228.

[39] Parry LL, Netuveli G, Parry J, Saxena S. A systematic review of parental perception of overweight status in children. J Ambul Care Manage 2008;31(3):253-268. (PM:18574384)

[40] U.S. Department of Agriculture and U.S. Departent of Health and Human Services and U.S. Department of Agriculture. Dietary Guidelines for Americans, 2010. 7th Edition, Washington, DC: U.S. Government Printing Office, 2011.

[41] Flodmark CE, Marcus C, Britton M. Interventions to prevent obesity in children and adolescents: a systematic literature review. Int J Obes (Lond) 2006;30(4):579-589. (PM:16570086)

[42] Cottrell L, Spangler-Murphy E, Minor V, Downes A, Nicholson P, Neal WA. A kindergarten cardiovascular risk surveillance study: CARDIAC-Kinder. Am J Health Behav 2005;29(6):595-606. (PM:16336114)

[43] Turnin MC, Tauber MT, Couvaras O, Jouret B, Bolzonella C, Bourgeois O, Buisson JC, Fabre D, Cance-Rouzaud A, Tauber JP, Hanaire-Broutin H. Evaluation of microcomputer nutritional teaching games in 1,876 children at school. Diabetes Metab 2001;27(4 Pt 1):459-464. (PM:11547219)

[44] Haerens L, Deforche B, Maes L, Stevens V, Cardon G, De B, I. Body mass effects of a physical activity and healthy food intervention in middle schools. Obesity (Silver Spring) 2006;14(5):847-854. (PM:16855194)

[45] Fitzgibbon ML, Stolley MR, Schiffer L, Van HL, KauferChristoffel K, Dyer A. Two-year follow-up results for Hip-Hop to Health Jr.: a randomized controlled trial for overweight prevention in preschool minority children. J Pediatr 2005;146(5):618-625. (PM:15870664)

[46] Gortmaker SL, Peterson K, Wiecha J, Sobol AM, Dixit S, Fox MK, Laird N. Reducing obesity via a school-based interdisciplinary intervention among youth: Planet Health. Arch Pediatr Adolesc Med 1999;153(4):409-418. (PM:10201726)

[47] Warren JM, Henry CJ, Lightowler HJ, Bradshaw SM, Perwaiz S. Evaluation of a pilot school programme aimed at the prevention of obesity in children. Health Promot Int 2003;18(4):287-296. (PM:14695360)

[48] Sahota P, Rudolf MC, Dixey R, Hill AJ, Barth JH, Cade J. Randomised controlled trial of primary school based intervention to reduce risk factors for obesity. BMJ 2001;323(7320):1029-1032. (PM:11691759)

[49] Himes JH, Ring K, Gittelsohn J, Cunningham-Sabo L, Weber J, Thompson J, Harnack L, Suchindran C. Impact of the Pathways intervention on dietary intakes of American Indian schoolchildren. Prev Med 2003;37(6 Pt 2):S55-S61. (PM:14636809)

[50] Birnbaum AS, Lytle LA, Story M, Perry CL, Murray DM. Are differences in exposure to a multicomponent school-based intervention associated with varying dietary outcomes in adolescents? Health Educ Behav 2002;29(4):427-443. (PM:12137237)

[51] Luepker RV, Perry CL, McKinlay SM, Nader PR, Parcel GS, Stone EJ, Webber LS, Elder JP, Feldman HA, Johnson CC. Outcomes of a field trial to improve children's dietary patterns and physical activity. The Child and Adolescent Trial for Cardiovascular Health. CATCH collaborative group. JAMA 1996;275(10):768-776. (PM:8598593)

[52] Nader PR, Stone EJ, Lytle LA, Perry CL, Osganian SK, Kelder S, Webber LS, Elder JP, Montgomery D, Feldman HA, Wu M, Johnson C, Parcel GS, Luepker RV. Three-year maintenance of improved diet and physical activity: the CATCH cohort. Child and Adolescent Trial for Cardiovascular Health. Arch Pediatr Adolesc Med 1999;153(7):695-704. (PM:10401802)

[53] Caballero B, Clay T, Davis SM, Ethelbah B, Rock BH, Lohman T, Norman J, Story M, Stone EJ, Stephenson L, Stevens J: Pathways Study Research group. Pathways: a school-based, randomized controlled trial for the prevention of obesity in American Indian schoolchildren. Am J Clin Nutr 2003;78(5):904-905. (PM:14594792)

[54] Hakanen M, Lagström H, Kaitosaari T, Niinikoski H, Näntö-Salonen K, Jokinen E, Sillanmäki L, Viikari J, Rönnemaa T, Simell O. Development of overweight in an atherosclerosis prevention trial starting in early childhood. The STRIP study. Int J Obes (Lond) 2006;30(4):618-626. (PM:16446743)

[55] Kaitosaari T, Rönnemaa T, Viikari J, Raitakari O, Arffman M, Marniemi J, Kallio K, Pahkala K, Jokinen E, Simell O. Low-saturated fat dietary counseling starting in infancy improves insulin sensitivity in 9-year-old healthy children: the Special Turku Coronary Risk Factor Intervention Project for Children (STRIP) study. Diabetes Care 2006;29(4):781-785. (PM:16567815)

[56] Talvia S, Lagström H, Räsänen M, Salminen M, Räsänen L, Salo P, Viikari J, Rönnemaa T, Jokinen E, Vahlberg T, Simell O. A randomized intervention since infancy to reduce intake of saturated fat: calorie (energy) and nutrient intakes up to the age of 10 years in the Special Turku Coronary Risk Factor Intervention Project. Arch Pediatr Adolesc Med 2004;158(1):41-47. (PM:14706957)

[57] DeJongh ED, Binkley TL, Specker BL. Fat mass gain is lower in calcium-supplemented than in unsupplemented preschool children with low dietary calcium intakes. Am J Clin Nutr 2006;84(5):1123-1127. (PM:17093165)

[58] Ebbeling CB, Feldman HA, Osganian SK, Chomitz VR, Ellenbogen SJ, Ludwig DS. Effects of decreasing sugar-sweetened beverage consumption on body weight in adolescents: a randomized, controlled pilot study. Pediatrics 2006;117(3):673-680. (PM:16510646)

[59] James J, Thomas P, Cavan D, Kerr D. Preventing childhood obesity by reducing consumption of carbonated drinks: cluster randomised controlled trial. BMJ 2004;328(7450):1237. (PM:15107313)

[60] Baranowski T, Baranowski J, Cullen KW, Marsh T, Islam N, Zakeri I, Honess-Morreale L, deMoor C. Squire's Quest! Dietary outcome evaluation of a multimedia game. Am J Prev Med 2003;24(1):52-61. (PM:12554024)

[61] Strong WB, Malina RM, Blimkie CJ, Daniels SR, Dishman RK, Gutin B, Hergenroeder AC, Must A, Nixon PA, Pivarnik JM, Rowland T, Trost S, Trudeau F. Evidence based physical activity for school-age youth. J Pediatr 2005;146(6):732-737. (PM:15973308)

[62] U.S. Department of Health and Human Services: Physical Activity and Health: A Report of the Surgeon General, Atlanta, GA. U.S Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease and Prevention and Health Promotion,1996.

[63] Summerbell CD, Waters E, Edmunds LD, Kelly S, Brown T, Campbell KJ. Interventions for preventing obesity in children. Cochrane Database Syst Rev 2005(3):CD001871. (PM:16034868)

[64] Robinson TN. Reducing children's television viewing to prevent obesity: a randomized controlled trial. JAMA 1999;282(16):1561-1567.(PM:10546696)

[65] Sallis JF, McKenzie TL, Alcaraz JE, Kolody B, Hovell MF, Nader PR. Project SPARK. Effects of physical education on adiposity in children. Ann N Y Acad Sci. 1993 Oct 29;699:127-36. (PM:8267303)

[66] Eliakim A, Makowski GS, Brasel JA, Cooper DM. Adiposity, lipid levels, and brief endurance training in nonobese adolescent males. Int J Sports Med 2000;21(5):332-337. (PM:10950441)

[67] Robinson TN, Killen JD, Kraemer HC, Wilson DM, Matheson DM, Haskell WL, Pruitt LA, Powell TM, Owens AS, Thompson NS, Flint-Moore NM, Davis GJ, Emig KA, Brown RT, Rochon J, Green S, Varady A. Dance and reducing television viewing to prevent weight gain in African-American girls: the Stanford GEMS pilot study. Ethn Dis 2003;13(1 Suppl 1):S65-S77. (PM:12713212)

[68] Reilly JJ, Kelly L, Montgomery C, Williamson A, Fisher A, McColl JH, Lo Conte R, Paton JY, Grant S. Physical activity to prevent obesity in young children: cluster randomised controlled trial. BMJ 2006;333(7577):1041. (PM:17028105)

[69] Fardy PS, White RE, Haltiwanger-Schmitz K, Magel JR, McDermott KJ, Clark LT, Hurster MM. Coronary disease risk factor reduction and behavior modification in minority adolescents: the PATH program. J Adolesc Health 1996;18(4):247-53. (PM:8860788)

[70] Going S, Thompson J, Cano S, Stewart D, Stone E, Harnack L, Hastings C, Norman J, Corbin C. The effects of the Pathways Obesity Prevention Program on physical activity in American Indian children. Prev Med 2003;37(6 Pt 2):S62-S69. (PM:14636810)

[71] Kimm SY, Barton BA, Obarzanek E, McMahon RP, Kronsberg SS, Waclawiw MA, Morrison JA, Schreiber GB, Sabry ZI, Daniels SR; NHLBI Growth and Health Study. Obesity development during adolescence in a biracial cohort: the NHLBI Growth and Health Study. Pediatrics 2002;110(5):e54. (PM:12415060)

[72] Sinaiko AR, Donahue RP, Jacobs DR, Jr., Prineas RJ. Relation of weight and rate of increase in weight during childhood and adolescence to body size, blood pressure, fasting insulin, and lipids in young adults. The Minneapolis Children's Blood Pressure Study. Circulation 1999;99(11):1471-1476. (PM:10086972)

[73] Bao W, Srinivasan SR, Valdez R, Greenlund KJ, Wattigney WA, Berenson GS. Longitudinal changes in cardiovascular risk from childhood to young adulthood in offspring of parents with coronary artery disease: the Bogalusa Heart Study. JAMA 1997;278(21):1749-1754. (PM:9388151)

[74] Rosenbaum PA, Elston RC, Srinivasan SR, Webber LS, Berenson GS. Cardiovascular risk factors from birth to 7 years of age: the Bogalusa Heart Study. Predictive value of parental measures in determining cardiovascular risk factor variables in early life. Pediatrics 1987;80(5 Pt 2):807-816. (PM:3670991)

[75] Youssef AA, Valdez R, Elkasabany A, Srinivasan SR, Berenson GS. Time-course of adiposity and fasting insulin from childhood to young adulthood in offspring of parents with coronary artery disease: the Bogalusa Heart Study. Ann Epidemiol 2002;12(8):553-559. (PM:12495828)

[76] Yang X, Telama R, Viikari J, Raitakari OT. Risk of obesity in relation to physical activity tracking from youth to adulthood. Med Sci Sports Exerc 2006;38(5):919-925. (PM:16672846)

[77] Rocchini AP, Katch V, Anderson J, Hinderliter J, Becque D, Martin M, Marks C. Blood pressure in obese adolescents: effect of weight loss. Pediatrics 1988;82(1):16-23. (PM:3288957)

[78] Pereira MA, Swain J, Goldfine AB, Rifai N, Ludwig DS. Effects of a low-glycemic load diet on resting energy expenditure and heart disease risk factors during weight loss. JAMA. 2004 Nov 24;292(20):2482-90. (PM:15562127)

[79] Watts K, Beye P, Siafarikas A, O'Driscoll G, Jones TW, Davis EA, Green DJ. Effects of exercise training on vascular function in obese children. J Pediatr 2004;144(5):620-625. (PM:15126996)

[80] Whitlock EP, Williams SB, Gold R, Smith PR, Shipman SA. Screening and interventions for childhood overweight: a summary of evidence for the US Preventive Services Task Force. Pediatrics 2005;116(1):e125-e144. (PM:15995013)

[81] Stuart WP, Broome ME, Smith BA, Weaver M. An integrative review of interventions for adolescent weight loss. J Sch Nurs 2005;21(2):77-85. (PM:15801573)

[82] Effectiveness of Weight Management Programs in Children and Adolescents, Structured Abstract. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/clinic/tp/chwghttp.htm

[83] Wilfley DE, Tibbs TL, Van Buren DJ, Reach KP, Walker MS, Epstein LH. Lifestyle interventions in the treatment of childhood overweight: a meta-analytic review of randomized controlled trials. Health Psychol 2007;26(5):521-532. (PM:17845100)

[84] Mellin LM, Slinkard LA, Irwin CE, Jr. Adolescent obesity intervention: validation of the SHAPEDOWN program. J Am Diet Assoc 1987;87(3):333-338. (PM:3819254)

[85] Duffy G, Spence SH. The effectiveness of cognitive self-management as an adjunct to a behavioural intervention for childhood obesity: a research note. J Child Psychol Psychiatry 1993;34(6):1043-1050. (PM:8408368)

[86] Rodearmel SJ, Wyatt HR, Barry MJ, Dong F, Pan D, Israel RG, Cho SS, McBurney MI, Hill JO. A family-based approach to preventing excessive weight gain. Obesity (Silver Spring) 2006;14(8):1392-1401. (PM:16988082)

[87] Epstein LH, Roemmich JN, Stein RI, Paluch RA, Kilanowski CK. The challenge of identifying behavioral alternatives to food: clinic and field studies. Ann Behav Med 2005;30(3):201-209. (PM:16336071)

[88] Epstein LH, Valoski A, Wing RR, McCurley J. Ten-year outcomes of behavioral family-based treatment for childhood obesity. Health Psychol 1994;13(5):373-383. (PM:7805631)

[89] Williamson DA, Martin PD, White MA, Newton R, Walden H, York-Crowe E, Alfonso A, Gordon S, Ryan D. Efficacy of an internet-based behavioral weight loss program for overweight adolescent African-American girls. Eat Weight Disord 2005;10(3):193-203. (PM:16277142)

[90] Resnicow K, Taylor R, Baskin M, McCarty F. Results of go girls: a weight control program for overweight African-American adolescent females. Obes Res 2005;13(10):1739-1748. (PM:16286521)

[91] Epstein LH, Paluch RA, Gordy CC, Saelens BE, Ernst MM. Problem solving in the treatment of childhood obesity. J Consult Clin Psychol 2000;68(4):717-721. (PM:10965646)

[92] Golan M, Kaufman V, Shahar DR. Childhood obesity treatment: targeting parents exclusively v. parents and children. Br J Nutr 2006;95(5):1008-1015. (PM:16611394)

[93] Jelalian E, Mehlenbeck R, Lloyd-Richardson EE, Birmaher V, Wing RR. 'Adventure therapy' combined with cognitive-behavioral treatment for overweight adolescents. Int J Obes (Lond) 2006;30(1):31-39. (PM:16158087)

[94] Epstein LH, Valoski A, Wing RR, McCurley J. Ten-year follow-up of behavioral, family-based treatment for obese children. JAMA 1990;264(19):2519-2523. (PM:2232019)

[95] Golan M, Fainaru M, Weizman A. Role of behaviour modification in the treatment of childhood obesity with the parents as the exclusive agents of change. Int J Obes Relat Metab Disord 1998;22(12):1217-1224. (PM:9877257)

[96] Golan M, Weizman A, Apter A, Fainaru M. Parents as the exclusive agents of change in the treatment of childhood obesity. Am J Clin Nutr 1998;67(6):1130-1135. (PM:9625084)

[97] Wilfley DE, Stein RI, Saelens BE, Mockus DS, Matt GE, Hayden-Wade HA, Welch RR, Schechtman KB, Thompson PA, Epstein LH. Efficacy of maintenance treatment approaches for childhood overweight: a randomized controlled trial. JAMA 2007;298(14):1661-1673. (PM:17925518)

[98] Watts K, Beye P, Siafarikas A, Davis EA, Jones TW, O'Driscoll G, Green DJ. Exercise training normalizes vascular dysfunction and improves central adiposity in obese adolescents. J Am Coll Cardiol 2004;43(10):1823-1827. (PM:15145107)

[99] Shaibi GQ, Cruz ML, Ball GD, Weigensberg MJ, Salem GJ, Crespo NC, Goran MI. Effects of resistance training on insulin sensitivity in overweight Latino adolescent males. Med Sci Sports Exerc 2006;38(7):1208-1215. (PM:16826016)

[100] Kelly AS, Wetzsteon RJ, Kaiser DR, Steinberger J, Bank AJ, Dengel DR. Inflammation, insulin, and endothelial function in overweight children and adolescents: the role of exercise. J Pediatr 2004;145(6):731-736. (PM:15580192)

[101] Ferguson MA, Gutin B, Owens S, Barbeau P, Tracy RP, Litaker M. Effects of physical training and its cessation on the hemostatic system of obese children. Am J Clin Nutr 1999;69(6):1130-1134. (PM:10357730)

[102] Gutin B, Ramsey L, Barbeau P, Cannady W, Ferguson M, Litaker M, Owens S. Plasma leptin concentrations in obese children: changes during 4-mo periods with and without physical training. Am J Clin Nutr 1999;69(3):388-394. (PM:10075321)

[103] Faith MS, Berman N, Heo M, Pietrobelli A, Gallagher D, Epstein LH, Eiden MT, Allison DB. Effects of contingent television on physical activity and television viewing in obese children. Pediatrics 2001;107(5):1043-1048. (PM:11331684)

[104] Goldfield GS, Mallory R, Parker T, Cunningham T, Legg C, Lumb A, Parker K, Prud'homme D, Gaboury I, Adamo KB. Effects of open-loop feedback on physical activity and television viewing in overweight and obese children: a randomized, controlled trial. Pediatrics 2006;118(1):e157-e166. (PM:16818530)

[105] Ferguson MA, Gutin B, Le NA, Karp W, Litaker M, Humphries M, Okuyama T, Riggs S, Owens S. Effects of exercise training and its cessation on components of the insulin resistance syndrome in obese children. Int J Obes Relat Metab Disord 1999;23(8):889-895. (PM:10490792)

[106] Epstein LH, Paluch RA, Raynor HA. Sex differences in obese children and siblings in family-based obesity treatment. Obes Res 2001;9(12):746-753. (PM11743058)

[107] Epstein LH, Valoski AM, Vara LS, McCurley J, Wisniewski L, Kalarchian MA, Klein KR, Shrager LR. Effects of decreasing sedentary behavior and increasing activity on weight change in obese children. Health Psychol 1995;14(2):109-115. (PM:7789345)

[108] Mitchell BM, Gutin B, Kapuku G, Barbeau P, Humphries MC, Owens S, Vemulapalli S, Allison J. Left ventricular structure and function in obese adolescents: relations to cardiovascular fitness, percent body fat, and visceral adiposity, and effects of physical training. Pediatrics 2002;109(5):E73. (PM:11986479)

[109] Epstein LH, Paluch RA, Gordy CC, Dorn J. Decreasing sedentary behaviors in treating pediatric obesity. Arch Pediatr Adolesc Med 2000;154(3):220-226. (PM:10710017)

[110] Schwingshandl J, Sudi K, Eibl B, Wallner S, Borkenstein M. Effect of an individualised training programme during weight reduction on body composition: a randomised trial. Arch Dis Child 1999;81(5):426-428. (PM:10519718)

[111] Gutin B, Barbeau P, Owens S, Lemmon CR, Bauman M, Allison J, Kang HS, Litaker MS. Effects of exercise intensity on cardiovascular fitness, total body composition, and visceral adiposity of obese adolescents. Am J Clin Nutr 2002;75(5):818-826. (PM:11976154)

[112] Epstein LH, Paluch RA, Raynor HA. Sex differences in obese children and siblings in family-based obesity treatment. Obes Res 2001;9(12):746-753. (PM:15805347)

[113] Epstein LH, Paluch RA, Kilanowski CK, Raynor HA. The effect of reinforcement or stimulus control to reduce sedentary behavior in the treatment of pediatric obesity. Health Psychol. 2004 Jul;23(4):371-380. (PM:15264973)

[114] Epstein LH, Wing RR, Penner BC, Kress MJ. Effect of diet and controlled exercise on weight loss in obese children. J Pediatr 1985;107(3):358-361. (PM:4032130)

[115] Ebbeling CB, Leidig MM, Sinclair KB, Seger-Shippee LG, Feldman HA, Ludwig DS. Effects of an ad libitum low-glycemic load diet on cardiovascular disease risk factors in obese young adults. Am J Clin Nutr. 2005 May;81(5):976-82. (PM:15883418)

[116] Ebbeling CB, Leidig MM, Sinclair KB, Hangen JP, Ludwig DS. A reduced-glycemic load diet in the treatment of adolescent obesity. Arch Pediatr Adolesc Med 2003;157(8):773-779. (PM:12912783)

[117] Gropper SS, Acosta PB. The therapeutic effect of fiber in treating obesity. J Am Coll Nutr 1987;6(6):533-535. (PM:2826563)

[118] Vido L, Facchin P, Antonello I, Gobber D, Rigon F. Childhood obesity treatment: double blinded trial on dietary fibres (glucomannan) versus placebo. Padiatr Padol 1993;28(5):133-136. (PM:8247594)

[119] Figueroa-Colon R, von Almen TK, Franklin FA, Schuftan C, Suskind RM. Comparison of two hypocaloric diets in obese children. Am J Dis Child 1993;147(2):160-166. (PM:8427238)

[120] Srinivasan S, Ambler GR, Baur LA, Garnett SP, Tepsa M, Yap F, Ward GM, Cowell CT. Randomized, controlled trial of metformin for obesity and insulin resistance in children and adolescents: improvement in body composition and fasting insulin. J Clin Endocrinol Metab 2006;91(6):2074-2080. (PM:16595599)

[121] Freemark M, Bursey D. The effects of metformin on body mass index and glucose tolerance in obese adolescents with fasting hyperinsulinemia and a family history of type 2 diabetes. Pediatrics 2001;107(4):E55. (PM:11335776)

[122] Chanoine JP, Hampl S, Jensen C, Boldrin M, Hauptman J. Effect of orlistat on weight and body composition in obese adolescents: a randomized controlled trial. JAMA 2005;293(23):2873-2883. (PM:15956632)

[123] Ozkan B, Bereket A, Turan S, Keskin S. Addition of orlistat to conventional treatment in adolescents with severe obesity. Eur J Pediatr 2004;163(12):738-741. (PM:15378354)

[124] Maahs D, de Serna DG, Kolotkin RL, Ralston S, Sandate J, Qualls C, Schade DS. Randomized, double-blind, placebo-controlled trial of orlistat for weight loss in adolescents. Endocr Pract 2006;12(1):18-28. (PM:16524859)

[125] Zhi J, Moore R, Kanitra L. The effect of short term (21-day) orlistat treatment on the physiologic balance of six selected macrominerals and microminerals in obese adolescents. J Am Coll Nutr 2003:22(5):357-362. (PM:14559927)

[126] Daniels SR, Long B, Crow S, Styne D, Sothern M, Vargas-Rodriguez I, Harris L, Walch J, Jasinsky O, Cwik K, Hewkin A, Blakesley V; Sibutramine Adolescent Study Group. Cardiovascular effects of sibutramine in the treatment of obese adolescents: results of a randomized, double-blind, placebo-controlled study. Pediatrics 2007;120(1):e147-e157. (PM:17576783)

[127] Berkowitz RI, Wadden TA, Tershakovec AM, Cronquist JL. Behavior therapy and sibutramine for the treatment of adolescent obesity: a randomized controlled trial. JAMA 2003;289(14):1805-1812. (PM:12684359)

[128] García-Morales LM, Berber A, Macias-Lara CC, Lucio-Ortiz C, Del-Rio-Navarro BE, Dorantes-Alvárez LM. Use of sibutramine in obese Mexican adolescents: a 6-month, randomized, double-blind, placebo-controlled, parallel-group trial. Clin Ther. 2006 May;28(5):770-82. (PM:16861099)

[129] James WP, Caterson ID, Coutinho W, Finer N, Van Gaal LF, Maggioni AP, Torp-Pedersen C, Sharma AM, Shepherd GM, Rode RA, Renz CL; SCOUT Investigators. Effect of sibutramine on cardiovascular outcomes in overweight and obese subjects. N Engl J Med. 2010;363(10):905-17.

[130] Grugni G, Guzzaloni G, Ardizzi A, Moro D, Morabito F. Dexfenfluramine in the treatment of juvenile obesity. Minerva Pediatr 1997;49(3):109-117. (PM:9198730)

[131] Tsai WS, Inge TH, Burd RS. Bariatric surgery in adolescents: recent national trends in use and in-hospital outcome. Arch Pediatr Adolesc Med 2007;161(3):217-221.

[132] Ippisch HM, Inge TH, Daniels SR, Wang B, Khoury PR, Witt SA, Glascock BJ, Garcia VF, Kimball TR. Reversibility of cardiac abnormalities in morbidly obese adolescents. J Am Coll Cardiol 2008;51:1342-1348.


Back to Top

Back to Table of Contents

Twitter iconTwitterimage of external icon Facebook iconFacebookimage of external icon YouTube iconYouTubeimage of external icon Google+ iconGoogle+image of external icon