Clinical Briefs: Treatment and Management of Pediatric Obesity

With Comments from John La Puma, MD, FACP

Source: Barlow SE, et al. Treatment of child and adolescent obesity: Reports from pediatricians, pediatric nurse practitioners, and registered dietitians. Pediatrics 2002;110(1 Pt 2):229-235; Trowbridge FL, et al. Management of child and adolescent obesity: Study design and practitioner characteristics. Pediatrics 2002;110(1 Pt 2):205-209.

The primary aim of this study was to identify interventions used by pediatric health care providers in treatment of overweight children and adolescents to identify provider educational needs. A secondary aim was to examine the association of certain provider characteristics with recommended evaluation practices.

A random sample of pediatricians, pediatric nurse practitioners, and registered dietitians (RDs) received questionnaires about their diet, activity, and medication recommendations for overweight patients and about refer- rals to specialists and programs. Results were examined for adherence to published recommendations and for associations with certain respondent characteristics.

A total of 940 providers responded (response rate: 19-33%). The majority recommended "changes in eating patterns" and "limitations of specific foods." Half or more encouraged "low-fat diet" and "modest calorie restriction." Less than 15% used "very low-calorie diet." Fewer RDs recommended more restrictive diets. More than 60% of all groups followed recommended eating interventions for school-aged children and adolescents. More than 80% followed recommended physical activity interventions for all age groups.

In each group, about 5% sometimes recommended prescription medication and herbal remedies for adolescents. None recommended surgery. Two-thirds of pediatricians and pediatric nurse practitioners often referred to RDs. Approximately 20% referred to child/adolescent weight programs, but for 27-42%, these programs or pediatric obesity specialists were not available. No consistent associations between respondent characteristics and adherence to recommended interventions were identified.

The providers generally promoted healthy eating and activity with minimal use of highly restrictive diets or medication to control weight.

Comment

Pediatric obesity is truly alarming. In the United Kingdom, for example, pediatric obesity has doubled in the last 20 years: 20% of 9-year-olds are overweight, and 10% are obese—almost as bad as in the United States.

Pediatric obesity is not about cosmetics, appearances, willpower, or morality. It’s about calories in/calories out; it’s about role modeling and family dynamics; and it’s about medical consequences. Effective clinical practice is just developing, and the condition is one with which many clinicians feel ill-equipped.

Arguably, the "recommended eating and exercise interventions" that the authors cite are either ineffective or not implemented. Few referrals are made to specialists by dietitians, and the U.S. Department of Agriculture’s flawed Food Pyramid is part of many schools’ curricula. Clearly, change is needed.

One intervention that is effective is limiting TV viewing. It’s not just that kids are sitting around. It’s that every hour, an average of 10 food commercials—fun, bright, upbeat—offer fast food, soda, candy, and sugary breakfast cereal. And those high-calorie, low-nutrient foods often are just a few steps, or a cry to Mom, away.

Cost is one objection to eating better that often is raised by parents. Cost analyses show that the cost of a healthful diet in a family-based obesity treatment program is significantly less expensive at 12 months than at baseline (J Am Dietetic Assoc 2002;102:645-656). This research also shows that pediatric obesity programs that involve parents are the most effective. Unfortunately, parents often have their own personal, psychological, and physical problems with this dilemma.

Recommendation

Because there is no consensus about how to treat pediatric obesity, except as a family, and because it is difficult to treat, seek out a practitioner, program, or web site that can work one-on-one with parents and kids.

Limiting television to a maximum of two hours daily is an evidence- based behavioral start—one clinicians should recommend and parents should track.