Obesity in Adolescents: Prevention and Treatment to Change Their Future

      Highlights

      • Risk factors, comorbidities, and interventions for adolescent obesity are reviewed.
      • The key is the combination of dietary and physical interventions consistently.
      • Adolescents with obesity are 4 times more likely to have academic problems.
      • Obesity can affect immediate health, future health, and quality of life.
      • Obesity can lead to feelings of isolation, stigmatization, and depression.

      Abstract

      The rates of adolescents with obesity continue to climb at alarming rates, contributing to current and future metabolic, physiological, and psychological problems. Careful screening and assessment by providers using growth charts is crucial to prevent obesity in adolescence. Consistent education on nutrition and physical activity, as well as expected changes, helps to prevent obesity from occurring. Once an adolescent is diagnosed with obesity, providers seek assistance from multiple disciplines to develop a team approach to achieve specific and individualized goals for each patient and family. Tools for screening, prevention, diagnosing, and treating obesity in adolescents ensure optimal results.

      Keywords

      American Association of Nurse Practitioners (AANP) members may receive 1.0 continuing education contact hour, approved by AANP, by reading this article and completing the online posttest and evaluation at aanp.inreachce.com.

      Background

      The Centers for Disease Control and Prevention (CDC) has described childhood obesity as an ongoing serious problem in the United States (US), putting adolescents at a greater risk for serious health conditions.
      Centers for Disease Control and Prevention
      Childhood Obesity Facts. June 24, 2019.
      The prevalence of adolescent obesity has quadrupled in the US in the last 30 years.
      • Quek Y.-H.
      • Tam W.W.S.
      • Zhang M.W.B.
      • Ho R.C.M.
      Exploring the association between childhood and adolescent obesity and depression: a meta-analysis.
      As a result of childhood obesity alone, the US has an economic burden of more than $14 billion annually.
      • Quek Y.-H.
      • Tam W.W.S.
      • Zhang M.W.B.
      • Ho R.C.M.
      Exploring the association between childhood and adolescent obesity and depression: a meta-analysis.
      As of the fiscal year 2015-2016, the National Center for Health Statistics
      • Hales C.M.
      • Carroll M.D.
      • Fryar C.D.
      • Ogden C.L.
      Prevalence of Obesity Among Adults and Youth: United States, 2015-2016. NCHS data brief, No. 288., October 2017. Hyattsville, MD: National Center for Health Statistics.
      reported the prevalence of obesity among children in the US aged 6 to 11 years was 18.4% and among adolescents aged 12 to 19 years was 20.6%, which were both greater than the 13.9% rate in children aged 2 to 5 years. The CDC has not discovered a significant difference between the obesity prevalence of boys and girls,
      Centers for Disease Control and Prevention
      Childhood Obesity Facts. June 24, 2019.
      but data gathered from children and adolescents aged 2 to 19 years show that Hispanics currently rank the highest at 25.8%, followed by non-Hispanic Blacks at 22%, and non-Hispanic Whites at 14.1%.
      Centers for Disease Control and Prevention
      Childhood Obesity Facts. June 24, 2019.
      Regarding obesity in children, the CDC reported a decrease in the prevalence of obesity associated with a higher level of parental education.
      Centers for Disease Control and Prevention
      Childhood Obesity Facts. June 24, 2019.
      There is also a correlation between household income and obesity. The middle-income group has the highest obesity rate at 19.9%, the lowest income group is at 18.9%, and the rate of the highest income group is 10.9%.
      There is evidence supporting genetic makeup as a contributing factor, but most childhood obesity today is related to energy expenditure vs energy intake and lifestyle choices.
      • Sahoo K.
      • Sahoo B.
      • Choudhury A.K.
      • Sofi N.Y.
      • Kumar R.
      • Bhadoria A.S.
      Childhood obesity: causes and consequences.
      American adolescents are much less physically active than previous generations, which makes obesity much more likely to occur today and leads to more complicated health issues.
      • Sutherland R.
      • Reeves P.
      • Campbell E.
      • et al.
      Cost effectiveness of a multi-component school-based physical activity intervention targeting adolescents: the Physical Activity 4 Everyone' cluster randomized trial.
      Adolescent obesity increases an individual’s risk for adult mortality and morbidity as well as amplified future health care costs.
      • Daniels S.R.
      • Hassink S.G.
      Committee on Nutrition
      The role of the pediatrician in primary prevention of obesity.
      The most common medical problems seen with obesity in adolescents include cardiovascular health, the endocrine system, and mental health.
      • Reinehr T.
      Long-term effects of adolescent obesity: time to act.
      Understanding the negative effect that adolescent obesity has on an individual and how to educate patients and families regarding this issue may improve early intervention and management.
      World Health Organization
      Report of the Commission on Ending Childhood Obesity. [eBook edition]. World Health Organization, 2016.

      Pathophysiology

      The pathophysiology of obesity includes anatomical, metabolic, physiological, and psychological effects.
      • Heymsfield S.B.
      • Wadden T.A.
      Mechanisms, pathophysiology, and management of obesity.
      As adiposity increases over time, lipids accumulate within the adipose tissue, causing the volume of organs and tissues to increase and resulting in higher cardiac output, blood pressure, resting energy expenditure, and pancreatic β-cell mass.
      • Heymsfield S.B.
      • Wadden T.A.
      Mechanisms, pathophysiology, and management of obesity.
      As adipose tissue changes, the immune system is triggered, contributing to the insulin resistance commonly seen in patients with obesity.
      • Bhattacharya K.
      • Sengupta P.
      • Dutta S.
      • Bhattacharya S.
      Pathophysiology of obesity: endocrine, inflammatory and neural regulators.
      The increased levels of free fatty acids, lipids, and inflammatory cytokines in nonadipose tissues cause insulin resistance to continue to develop.
      • Heymsfield S.B.
      • Wadden T.A.
      Mechanisms, pathophysiology, and management of obesity.
      The constant stimulation of the immune system paves the way for vascular dysfunction to occur, which often manifests as hypercholesterolemia and triglyceridemia, resulting in hypertension and dyslipidemia.
      • Bhattacharya K.
      • Sengupta P.
      • Dutta S.
      • Bhattacharya S.
      Pathophysiology of obesity: endocrine, inflammatory and neural regulators.
      With chronic increased activity of the sympathetic nervous system, which is evidenced by the changes that occur to the body with obesity, Heymsfield et al
      • Heymsfield S.B.
      • Wadden T.A.
      Mechanisms, pathophysiology, and management of obesity.
      concluded it might be the cause for multiple diseases, including hypertension, which is most often the root cause of kidney diseases, strokes, and heart diseases. Obesity also can cause issues with an individual’s airway due to an increase in pharyngeal soft tissue, joints as the mechanical load increases, and the abdomen as increased pressure raises risks for developing gastroesophageal reflux disease.
      • Heymsfield S.B.
      • Wadden T.A.
      Mechanisms, pathophysiology, and management of obesity.
      The Figure shows several ways that obesity leads to increased risk factors that can contribute to common chronic diseases. Considering adolescence is an important time for growth and development, these extra changes to an individual’s body due to obesity have the potential to cause even more harmful effects.
      • Heymsfield S.B.
      • Wadden T.A.
      Mechanisms, pathophysiology, and management of obesity.
      Figure thumbnail gr1
      FigureCommon diseases caused by obesity (from The New England Journal of Medicine, Heymsfield SB, Wadden TA, Mechanisms, Pathophysiology, and Management of Obesity, Volume 376, Pages 254-266. Copyright © 2017 Massachusetts Medical Society. Reprinted with permission from Massachusetts Medical Society.)

      Literature Review of Current Recommendations

       Objective Measurements

      Obesity is most accurately diagnosed using body mass index (BMI) and the CDC growth charts that include normative percentiles based on height and weight for age- and sex-specific categories.
      • Daniels S.R.
      • Hassink S.G.
      Committee on Nutrition
      The role of the pediatrician in primary prevention of obesity.
      An adolescent is diagnosed with obesity if their BMI is at or above the 95th percentile on the appropriate growth chart.
      • Styne D.M.
      • Arslanian S.A.
      • Connor E.L.
      • et al.
      Pediatric obesity—assessment, treatment, and prevention: an Endocrine Society Clinical Practice Guideline.
      Current recommendations suggest that the provider plot, calculate, and review BMI at least once each year.
      • Styne D.M.
      • Arslanian S.A.
      • Connor E.L.
      • et al.
      Pediatric obesity—assessment, treatment, and prevention: an Endocrine Society Clinical Practice Guideline.
      According to the American Academy of Pediatrics,
      American Academy of Pediatrics
      Healthy Children. Obesity; 2015.
      any significant changes in growth patterns demonstrated on an adolescent’s linear growth chart should be recognized, addressed with caregivers, and investigated to prevent obesity and its complications. Significant changes include a child that is overweight and approaching the 95th percentile on their growth chart or crossing percentile lines.
      • Styne D.M.
      • Arslanian S.A.
      • Connor E.L.
      • et al.
      Pediatric obesity—assessment, treatment, and prevention: an Endocrine Society Clinical Practice Guideline.

       Nutrition

      Current dietary guidelines, as established by the US Department of Health and Human Services (HHS) and the US Department of Agriculture (USDA),
      U.S. Department of Health and Human Services and U.S. Department of Agriculture
      Dietary Guidelines for Americans 2015-2020, Eighth Edition.
      are based on the “MyPlate” guide, which replaced the previous food pyramid. “MyPlate” is a color-coded illustration created to quickly remind individuals of the recommended portions of fruits, grains, vegetables, protein, and dairy at each meal.
      U.S. Department of Health and Human Services and U.S. Department of Agriculture
      Dietary Guidelines for Americans 2015-2020, Eighth Edition.
      As a part of the 2015-2016 Dietary Guidelines for Americans, the HHS and USDA
      U.S. Department of Health and Human Services and U.S. Department of Agriculture
      Dietary Guidelines for Americans 2015-2020, Eighth Edition.
      recommend less consumption of added sugars, saturated fats, and sodium, and an increased intake of nutrient-dense foods with close attention to total caloric intake per day, which is determined by an individual’s age, sex, and physical activity level. The HHS and USDA recommended educating individuals to make small alterations to their dietary choices instead of drastic changes to successfully make shifts that will last a lifetime.
      U.S. Department of Health and Human Services and U.S. Department of Agriculture
      Dietary Guidelines for Americans 2015-2020, Eighth Edition.

       Physical Activity

      The HHS and USDA also suggested attempting to align an individual’s environments, such as home or school, with the same goals for nutrition and physical activity.
      U.S. Department of Health and Human Services and U.S. Department of Agriculture
      Dietary Guidelines for Americans 2015-2020, Eighth Edition.
      Most adolescents spend time in various locations throughout each day, and ensuring that each location implements relatively the same goals is essential for successful lifestyle changes. Table 1 describes the recommendations for daily physical activity for adolescents set forth by the HHS and USDA.
      U.S. Department of Health and Human Services and U.S. Department of Agriculture
      Dietary Guidelines for Americans 2015-2020, Eighth Edition.
      Physical activity is strongly recommended by the HHS and USDA to include activities that are enjoyable to the individual to ensure motivation to continue the activity as a part of the individual’s daily routine.
      U.S. Department of Health and Human Services and U.S. Department of Agriculture
      Dietary Guidelines for Americans 2015-2020, Eighth Edition.
      The World Health Organization
      World Health Organization
      recommends that children older than 5 years have no more than 2 hours of screen time per day. The limited screen time allows more time for physical activity.
      Table 1Principles of Obesity Treatment
      Principles of Obesity Treatment
      Assess and manage obesity-associated disorders

      Assess for anxiety and depression

      Ensure a developmentally appropriate approach

      Support long-term behavior change

      Dietary Change

      Increased physical activity

      Decreased sedentary behaviors, included screen behaviors

      Improved sleep

      Strategies for long-term weight maintenance

      Consider more intensive dietary interventions

      Consider pharmacotherapy

      Consider bariatric surgery
      Adapted from Steinbeck KS, Lister NB, Gow ML, Baur LA. Treatment of adolescent obesity. Nat Rev Endocrinol. 2018;14(6):331-344 (https://doi.org/10.1038/s41574-018-0002-8) and Jebeile H, Gow ML, Baur LA, Garnett SP, Paxton SJ, Lister NB. Association of pediatric obesity treatment, including a dietary component, with change in depression and anxiety: a systematic review and meta-analysis. JAMA Pediatr. 2019;173(11):e192841. https://doi.org/10.1001/jamapediatrics.2019.2841

       Risk Factors

      Except for genetic conditions known to increase an individual’s risk for developing obesity, other genetic factors that influence this risk in adolescence include maternal diabetes, a familial history of obesity, and increased birth weight.
      • Daniels S.R.
      • Hassink S.G.
      Committee on Nutrition
      The role of the pediatrician in primary prevention of obesity.
      Although genetics increase the risk for an adolescent to develop obesity, environmental and behavioral factors most often must accompany a genetic predisposition to affect an individual’s BMI.
      • Sahoo K.
      • Sahoo B.
      • Choudhury A.K.
      • Sofi N.Y.
      • Kumar R.
      • Bhadoria A.S.
      Childhood obesity: causes and consequences.
      In addition to genetics being a risk factor, Sahoo et al
      • Sahoo K.
      • Sahoo B.
      • Choudhury A.K.
      • Sofi N.Y.
      • Kumar R.
      • Bhadoria A.S.
      Childhood obesity: causes and consequences.
      included dietary intake, sedentary behavior, and physical activity, which are all influenced by age, sex, family dynamics, sociocultural factors, and environmental factors.
      Sedentary behavior, which includes television viewing, was a major risk factor for obesity in adolescents due to the increased association with snacking and having exposure to food advertisements.
      • Mitchell J.A.
      • Dowda M.
      • Pate R.R.
      • et al.
      Physical activity and pediatric obesity: a quantile regression analysis.
      Screen time has changed to include more time on mobile devices, and recent studies showed that within the last 6 years, screen time has doubled among young people to include just under 5 hours daily for children 8 to 12 years old and approximately 7.5 hours for teens.
      Common Sense Media
      The Common Sense Census: Media Use by Tweens and Teens: New Research Finds YouTube Videos Beat Out TV and Video Games as Entertainment of Choice for Tweens and Teens: Access to streaming content grows as children get smartphones at younger and younger ages. October 29, 2018.
      Understanding the risk factors associated with adolescent obesity is crucial to providing care that will alter the current course of health for an individual.
      • Sahoo K.
      • Sahoo B.
      • Choudhury A.K.
      • Sofi N.Y.
      • Kumar R.
      • Bhadoria A.S.
      Childhood obesity: causes and consequences.

       Adolescent Development

      Before explaining the detriment that obesity can have on an adolescent, it is imperative to understand the developmental changes expected to occur during this time and the magnitude of their effects on the individual before adding the diagnosis of obesity.
      • Steinbeck K.S.
      • Lister N.B.
      • Gow M.L.
      • Baur L.A.
      Treatment of adolescent obesity.
      The most significant developmental changes during adolescence include pubertal changes, a heightened emotional state, changes in sleep patterns, social development, and the development of self-concept.
      • Rapee R.M.
      • Oar E.L.
      • Johnco C.J.
      • et al.
      Adolescent development and risk for the onset of social-emotional disorders: a review and conceptual model.
      Changes during puberty cause the female body to develop increased adiposity, influencing obesity development.
      • Taylor S.A.
      • Borzutzky C.
      • Jasik C.B.
      • et al.
      Society for Adolescent Health and Medicine
      Preventing and treating adolescent obesity: a position paper of the Society for Adolescent Health and Medicine.
      Obesity has been shown to accelerate puberty in girls and delay onset in boys, which alters physical and psychosocial aspects at different times than they would naturally occur.
      • Hassink S.
      Parents and adolescents: what’s the right mix in obesity treatment?.
      An adolescent’s increased autonomy plays a significant role in dietary intake choices and activity level, because they commonly have more access to unhealthy foods outside of the home, and decisions are typically swayed by their peers.
      • Taylor S.A.
      • Borzutzky C.
      • Jasik C.B.
      • et al.
      Society for Adolescent Health and Medicine
      Preventing and treating adolescent obesity: a position paper of the Society for Adolescent Health and Medicine.

       Mental Health

      In addition to the physical issues caused by obesity, an increased prevalence of psychiatric, mood, and anxiety disorders for individuals affected by obesity has been displayed.
      • Heymsfield S.B.
      • Wadden T.A.
      Mechanisms, pathophysiology, and management of obesity.
      A clear relationship between obesity and depression in adolescents has been identified.
      • Quek Y.-H.
      • Tam W.W.S.
      • Zhang M.W.B.
      • Ho R.C.M.
      Exploring the association between childhood and adolescent obesity and depression: a meta-analysis.
      ,
      • Jebeile H.
      • Gow M.L.
      • Baur L.A.
      • Garnett S.P.
      • Paxton S.J.
      • Lister N.B.
      Association of pediatric obesity treatment, including a dietary component, with change in depression and anxiety: a systematic review and meta-analysis.
      During the adolescent years, individuals are much more vulnerable to peer influence and have tendencies to make decisions that do not support healthy psychosocial behaviors.
      • Taylor S.A.
      • Borzutzky C.
      • Jasik C.B.
      • et al.
      Society for Adolescent Health and Medicine
      Preventing and treating adolescent obesity: a position paper of the Society for Adolescent Health and Medicine.

       Social and Emotional Well-being

      The consequences of adolescent obesity include effects on a child’s physical and mental health and the individual’s social and emotional well-being and self-esteem, which is a major concern with the adolescent population.
      • Sahoo K.
      • Sahoo B.
      • Choudhury A.K.
      • Sofi N.Y.
      • Kumar R.
      • Bhadoria A.S.
      Childhood obesity: causes and consequences.
      During this crucial developmental time in an adolescent’s life, obesity has the potential to cause detrimental effects as it has been explained as “one of the most stigmatizing and least socially acceptable conditions in childhood.”
      • Sahoo K.
      • Sahoo B.
      • Choudhury A.K.
      • Sofi N.Y.
      • Kumar R.
      • Bhadoria A.S.
      Childhood obesity: causes and consequences.
      Adolescents with obesity are often excluded from various physical activities because they have difficulties with endurance and shortness of breath during strenuous activities, which has led to feelings of isolation and stigmatization.
      • Sahoo K.
      • Sahoo B.
      • Choudhury A.K.
      • Sofi N.Y.
      • Kumar R.
      • Bhadoria A.S.
      Childhood obesity: causes and consequences.
      Adolescents confronted with negative social issues related to obesity, including discrimination and stereotyping, often have low self-esteem, a negative body image, and low self-confidence.
      • Sahoo K.
      • Sahoo B.
      • Choudhury A.K.
      • Sofi N.Y.
      • Kumar R.
      • Bhadoria A.S.
      Childhood obesity: causes and consequences.
      These issues, coupled with the brain’s expected pubertal changes referred to as “brain reorganization” during adolescence, could result in devastating issues.
      • Berenbaum S.A.
      • Beltz A.M.
      • Corley R.
      The importance of puberty for adolescent development: conceptualization and measurement.
      Adolescents with obesity are 4 times more likely than their peers to have academic problems.
      • Sahoo K.
      • Sahoo B.
      • Choudhury A.K.
      • Sofi N.Y.
      • Kumar R.
      • Bhadoria A.S.
      Childhood obesity: causes and consequences.
      These potential consequences stemming from childhood obesity necessitate early identification and appropriate and prompt treatment.
      • Steinbeck K.S.
      • Lister N.B.
      • Gow M.L.
      • Baur L.A.
      Treatment of adolescent obesity.

       Counseling

      In a study conducted by O’Malley et al,
      • O’Malley G.
      • Ring-Dimitriou S.
      • Nowicka P.
      • et al.
      Physical activity and physical fitness in pediatric obesity: what are the first steps for clinicians? Expert conclusion from the 2016 ECOG workshop.
      practitioners voiced great concern regarding counseling children with obesity and their families. Their concerns included how to effectively explain to parents the need for familial changes while being sensitive and providing relevant and helpful information. In an attempt to encourage pediatric primary care providers to motivate change in patients that are overweight and at high risk or diagnosed with obesity, O’Malley et al
      • O’Malley G.
      • Ring-Dimitriou S.
      • Nowicka P.
      • et al.
      Physical activity and physical fitness in pediatric obesity: what are the first steps for clinicians? Expert conclusion from the 2016 ECOG workshop.
      created a physical activity and sedentary time assessment referenced in Tables 2 and 3. The tables were created to allow practitioners to have a guide to begin difficult conversations with parents to try and introduce the idea of change.
      • O’Malley G.
      • Ring-Dimitriou S.
      • Nowicka P.
      • et al.
      Physical activity and physical fitness in pediatric obesity: what are the first steps for clinicians? Expert conclusion from the 2016 ECOG workshop.
      Table 2Assessment for Physical Activity in Child/Adolescent Obesity
      Physical Activity (PA) Overview
      Does parent know that 60 mins of PA is needed for the child's health every day for 6-18 year olds and 180 mins per day for children under 6 years? (Circle answer)YesNo
      Is child getting recommended 60 mins of PA (that makes them breathe hard) every day for 6-18 year olds and 180 mins per day for children under 6 years? (Circle answer)YesNo
      How does your child/adolescent get to school?
      Is there an available form of transportation to school that involves PA?YesNo
      Is the child/adolescent active at break times in school? For how many mins?YesNo
      Does the child engage in PA after school?YesNo
      Hours per week in planned activity (details: type, frequency, duration of activity/sport and time spent in play)?
      Does the child/adolescent have a safe place to play? (Circle answer)YesNo
      Does the child/adolescent have games/equipment? (Circle answers)TrampolineScooter
      BallsOther?_______
      PainNo time
      Barriers to PA? (Circle answers)Bad weatherFalls
      No friendsEnuresis
      Self-consciousBreathlessness
      Safety concerns
      Other?________________________
      Adapted from O’Malley G, Ring-Dimitriou S, Nowicka P, et al. Physical activity and physical fitness in pediatric obesity: what are the first steps for clinicians? Expert conclusion from the 2016 ECOG workshop. Int J Exerc Sci. 2017;10(4):487-496. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5466409/pdf/ijes-10-04-487.pdf
      Table 3Assessment for Sedentary Time in Adolescent Obesity
      Sedentary Time Overview
      Does the adolescent spend most of their free time sitting/doing inactive hobbies?YesNo
      Does the adolescent have a smartphone/tablet/laptop?YesNo
      Does the adolescent have a TV in the bedroom?YesNo
      Are screens left on when the adolescent is sleeping (eg, phone /tablet/ TV)?YesNo
      On an average school day, how many hours does the adolescent spend doing the following:
       Homework/study_______________________________________________
       Watching TV__________________________________________________
       Talking on phone_______________________________________________
       Texting_______________________________________________________
       Using a PC/laptop/tablet_______________________________________
       Video/online games_____________________________________________
       Watching movies_______________________________________________
       Reading for leisure_____________________________________________
       Listening to music______________________________________________
       Other:________________________________________________________
      On an average weekend day, how many hours does the adolescent spend doing the following:
       Homework/study_______________________________________________
       Watching TV__________________________________________________
       Talking on phone_______________________________________________
       Texting_______________________________________________________
       Using a PC/laptop/tablet_______________________________________
       Video/online games_____________________________________________
       Watching movies_______________________________________________
       Reading for leisure_____________________________________________
       Listening to music______________________________________________
       Other:________________________________________________________
      Are screens on when the adolescent is eating?YesNo
      When watching TV do you skip/mute the advertisements?YesNo
      Is the adolescent's use of the internet supervised?YesNo
      PC = personal computer; TV = television.
      Adapted from O’Malley G, Ring-Dimitriou S, Nowicka P, et al. Physical activity and physical fitness in pediatric obesity: what are the first steps for clinicians? Expert conclusion from the 2016 ECOG workshop. Int J Exerc Sci. 2017;10(4):487-496. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5466409/pdf/ijes-10-04-487
      Successful treatment of obesity in adolescent patients differs from adult treatment.
      • Steinbeck K.S.
      • Lister N.B.
      • Gow M.L.
      • Baur L.A.
      Treatment of adolescent obesity.
      Reported treatment effectiveness is not defined solely as a success or a failure. Effective treatment can be measured in various ways, including an improvement in a complication associated with obesity, a reduction in BMI, a reduction in risk factors for future diseases, and a changed weight trajectory for an adolescent.
      • Steinbeck K.S.
      • Lister N.B.
      • Gow M.L.
      • Baur L.A.
      Treatment of adolescent obesity.
      Table 1 displays principles of obesity treatment, starting with the least invasive and extending to the most complicated for the most severe cases.
      Current recommendations include considering the developing autonomy of the patient in need of treatment.
      • Steinbeck K.S.
      • Lister N.B.
      • Gow M.L.
      • Baur L.A.
      Treatment of adolescent obesity.
      Successful management of an obesity diagnosis will be largely due to a compliant patient with an encouraging support system.
      • Steinbeck K.S.
      • Lister N.B.
      • Gow M.L.
      • Baur L.A.
      Treatment of adolescent obesity.
      Behavior modifications, dietary interventions, physical activity changes, sleep modification, and digital technologies are major proponents of treatment for adolescent obesity.
      • Steinbeck K.S.
      • Lister N.B.
      • Gow M.L.
      • Baur L.A.
      Treatment of adolescent obesity.
      Once a problem is detected, the individual adolescent is assessed for their stage of neurodevelopment. The provider works with the patient and family as a whole unit while providing information that is most appropriate for the specific situation.
      • Daniels S.R.
      • Hassink S.G.
      Committee on Nutrition
      The role of the pediatrician in primary prevention of obesity.
      Treatment is guided by the goal of promoting healthy growth, confirming household nutrition is appropriate according to recommendation guidelines, and ensuring adolescents are active and creating a positive disposition between parents, children, and the provider so that future complications may be prevented.
      • Lobstein T.
      • Jackson-Leach R.
      • Moodie M.L.
      • et al.
      Child and adolescent obesity: part of a bigger picture.

      Proposed Interventions

       Prevention

      The key to the prevention of adolescent obesity is the combination of dietary and physical interventions consistently.
      • Daniels S.R.
      • Hassink S.G.
      Committee on Nutrition
      The role of the pediatrician in primary prevention of obesity.
      The most beneficial and maintainable methods to prevent obesity involve not one but multiple strategies that include focusing on physical activities, meals, playtime, and classroom activities in as many of the locations that an individual is active.
      • Lobstein T.
      • Jackson-Leach R.
      • Moodie M.L.
      • et al.
      Child and adolescent obesity: part of a bigger picture.
      The review by Lobstein et al
      • Lobstein T.
      • Jackson-Leach R.
      • Moodie M.L.
      • et al.
      Child and adolescent obesity: part of a bigger picture.
      concluded that the more consistently an environment promotes healthy behavior for adolescents, the greater the probability that the promoted behavior will occur. Providers are consistent by tracking the patient’s growth chart to notice trends early enough to educate patients and families on the causes and ways to correct an issue before an even larger one is present.
      • Daniels S.R.
      • Hassink S.G.
      Committee on Nutrition
      The role of the pediatrician in primary prevention of obesity.
      Styne et al
      • Styne D.M.
      • Arslanian S.A.
      • Connor E.L.
      • et al.
      Pediatric obesity—assessment, treatment, and prevention: an Endocrine Society Clinical Practice Guideline.
      suggested that providers promote and participate in healthy dietary and activity recommendations to set an example for patients and families. Each visit is an opportunity to stress the importance of a healthy diet and adequate exercise so that it becomes a constant theme. Families and adolescents are educated on the importance of moderation with diet instead of restrictive eating habits and appropriate daily exercise because this age-group is at a greater risk for developing eating disorders.
      • Daniels S.R.
      • Hassink S.G.
      Committee on Nutrition
      The role of the pediatrician in primary prevention of obesity.
      Mitchell et al
      • Mitchell J.A.
      • Dowda M.
      • Pate R.R.
      • et al.
      Physical activity and pediatric obesity: a quantile regression analysis.
      proposed decreasing television viewing and increasing moderate to vigorous physical activity to lower the prevalence of obesity in adolescents because television viewing is associated with adolescent obesity. Taylor et al
      • Taylor S.A.
      • Borzutzky C.
      • Jasik C.B.
      • et al.
      Society for Adolescent Health and Medicine
      Preventing and treating adolescent obesity: a position paper of the Society for Adolescent Health and Medicine.
      recommended the quick counseling tool, “5-2-1-0,” which serves as an easy reminder for daily recommendations to include the consumption of 5 vegetables and fruits, to limit screen time to 2 hours or less, to include physical activity for at least 1 hour, and to eliminate the intake of sugar-sweetened beverages.
      With most recommendations, the key to compliance is establishing confidence and trust with a patient and family, so comfort is established and allows for interventions to be accepted more readily if a problem arises, such as obesity.
      • O’Malley G.
      • Ring-Dimitriou S.
      • Nowicka P.
      • et al.
      Physical activity and physical fitness in pediatric obesity: what are the first steps for clinicians? Expert conclusion from the 2016 ECOG workshop.
      Table 4 contains resources to reference for a healthy diet and physical activity recommendations for parents and providers.
      Table 4Resources for Providers, Parents, and Patients
      Nutrition and Physical Activity Recommendation Resources
      Intended AudienceType of ResourceLink to Resource
      Parents
      • 1.
        Healthy Children website on obesity from the American Academy of Pediatrics
      • 2.
        Nutrition tip sheet to ensure a "great plate"
      • 3.
        Healthier holiday meal options
      • 4.
        School lunch tips
      • 5.
        Shift to whole grains
      • 6.
        Increase fruit intake
      Providers
      • 1.
        CDC Growth Charts
      • 2.
        NIH - WE CAN! Ways to enhance children’s activity and nutrition
      Patients
      • 1.
        How to make smarter choices about your body and health
      • 2.
        ChooseMyPlate Food Guide
      • 3.
        How to “Be a Fit Kid”
      • 4.
        Maintaining at a healthy weight
      Parents of adolescents who are overweight or struggling with obesity can assist with preventing worsening of weight imbalances by being a positive role model concerning their own bodies by being active each day, speaking positively about their health, and eating a healthy diet.
      • Lyness D.
      Encouraging a Healthy Body Image. June 2018. Kids Health.
      Parents should also help adolescents lead healthy lifestyles by avoiding using food as punishments or rewards, avoiding a “clean-plate” policy, and increasing family time during meals.
      • Gavin M.L.
      Overweight and Obesity. June 2018. Kids Health.

       Treatment

      Weight is a sensitive topic with the adolescent age-group, and adolescents often fear being stigmatized, so caution is taken when approaching the subject.
      • O’Malley G.
      • Ring-Dimitriou S.
      • Nowicka P.
      • et al.
      Physical activity and physical fitness in pediatric obesity: what are the first steps for clinicians? Expert conclusion from the 2016 ECOG workshop.
      The United States Preventive Services Task Force recommended that providers begin screening for overweight and obesity in children at the age of 6,
      • Grossman D.C.
      • Bibbins-Domingo K.
      • et al.
      US Preventive Services Task Force
      Screening for obesity in children and adolescents: US Preventive Services Task Force recommendation statement.
      by offering and referring them to receive comprehensive, intense behavioral interventions to reach an appropriate weight status, as necessary. O’Malley et al
      • O’Malley G.
      • Ring-Dimitriou S.
      • Nowicka P.
      • et al.
      Physical activity and physical fitness in pediatric obesity: what are the first steps for clinicians? Expert conclusion from the 2016 ECOG workshop.
      recommend practitioners set goals with patients and families that are attainable and can be built on to reach the individual patient’s goals and prevent future health complications.

       Multidisciplinary Team

      Immediately after delivering an obesity diagnosis, a provider initiates guidance from dieticians, behavioral health providers, and specialists in exercise.
      • Taylor S.A.
      • Borzutzky C.
      • Jasik C.B.
      • et al.
      Society for Adolescent Health and Medicine
      Preventing and treating adolescent obesity: a position paper of the Society for Adolescent Health and Medicine.
      Prompt treatment initiation for obesity allows for the evaluation of comorbidities, lifestyle counseling, and referrals for more intensive treatment for cases of higher severity to begin as soon as possible.
      • Taylor S.A.
      • Borzutzky C.
      • Jasik C.B.
      • et al.
      Society for Adolescent Health and Medicine
      Preventing and treating adolescent obesity: a position paper of the Society for Adolescent Health and Medicine.
      A list of comprehensive obesity management clinics in the area may help with complex and severe patients. Providers and patients establish the goals for obesity management, whether weight loss or weight stabilization, and how they may be reached with each patient.
      • Taylor S.A.
      • Borzutzky C.
      • Jasik C.B.
      • et al.
      Society for Adolescent Health and Medicine
      Preventing and treating adolescent obesity: a position paper of the Society for Adolescent Health and Medicine.
      If treatment involves medications, providers discuss potential adverse effects with the patient and family. The only 2 medications currently used for weight loss in individuals younger than 18 years are orlistat and phentermine.
      • Taylor S.A.
      • Borzutzky C.
      • Jasik C.B.
      • et al.
      Society for Adolescent Health and Medicine
      Preventing and treating adolescent obesity: a position paper of the Society for Adolescent Health and Medicine.

       Treatment of Complications

      Treatment also involves recognizing and providing care to patients with obesity-associated issues such as impaired glucose tolerance, obstructive sleep apnea, hypertension, dyslipidemia, and alterations in liver function.
      • Reinehr T.
      Long-term effects of adolescent obesity: time to act.
      In addition to treating acute issues, providers are cognizant of providing age-specific and culturally sensitive care to families and patients, including recommending appropriate guidelines based on each patient’s cultural background.
      • Styne D.M.
      • Arslanian S.A.
      • Connor E.L.
      • et al.
      Pediatric obesity—assessment, treatment, and prevention: an Endocrine Society Clinical Practice Guideline.
      Although adolescent obesity can be a difficult topic to begin discussing, the conversations must begin with patients and families as soon as possible to ensure that patients receive the best care possible with an educated and well-equipped support system guiding the way to prevent future harm.
      • O’Malley G.
      • Ring-Dimitriou S.
      • Nowicka P.
      • et al.
      Physical activity and physical fitness in pediatric obesity: what are the first steps for clinicians? Expert conclusion from the 2016 ECOG workshop.

      Provider’s Role

      Health care providers possess the skills, knowledge, and resources to screen, prevent, and treat obesity in adolescent patients taking careful consideration of the biopsychosocial stages of development unique to adolescents.
      • Taylor S.A.
      • Borzutzky C.
      • Jasik C.B.
      • et al.
      Society for Adolescent Health and Medicine
      Preventing and treating adolescent obesity: a position paper of the Society for Adolescent Health and Medicine.
      Providers monitor patients’ BMI percentiles at least once per year, and conduct treatment and guidance based on those results plotted on the growth charts.
      • Taylor S.A.
      • Borzutzky C.
      • Jasik C.B.
      • et al.
      Society for Adolescent Health and Medicine
      Preventing and treating adolescent obesity: a position paper of the Society for Adolescent Health and Medicine.
      Providers are consistent with updating medical records with past medical and family history, screening for current issues with nutrition and physical activity, and reinforcing healthy behaviors while providing counseling regarding problems as needed.
      • Taylor S.A.
      • Borzutzky C.
      • Jasik C.B.
      • et al.
      Society for Adolescent Health and Medicine
      Preventing and treating adolescent obesity: a position paper of the Society for Adolescent Health and Medicine.
      Once an obesity diagnosis is established, the provider transitions to a team approach and involves other disciplines as needed to serve the patient best, prevent further complications, and assist with appropriate management.
      • Taylor S.A.
      • Borzutzky C.
      • Jasik C.B.
      • et al.
      Society for Adolescent Health and Medicine
      Preventing and treating adolescent obesity: a position paper of the Society for Adolescent Health and Medicine.
      For an adolescent to have successful treatment of obesity, the patient must be equipped to move into a healthier lifestyle within the context of their own current environment.
      • Hassink S.
      Parents and adolescents: what’s the right mix in obesity treatment?.
      Transitioning an adolescent into a healthier lifestyle requires the provider to develop realistic expectations with the patient and family while considering any barriers the family may have and exhibiting a nonbiased approach to care.
      • Kebbe M.
      • Perez A.
      • Buchholz A.
      • et al.
      Health care providers’ weight management practices for adolescent obesity and alignment with clinical practice guidelines: a multi-centre, qualitative study.
      Providers use approved guidelines, as previously mentioned, to educate patients and families on the current recommendations regarding nutrition and physical activity.
      • Kebbe M.
      • Perez A.
      • Buchholz A.
      • et al.
      Health care providers’ weight management practices for adolescent obesity and alignment with clinical practice guidelines: a multi-centre, qualitative study.
      Primary care providers have the unique position to advocate inside and outside of the health care setting in an attempt to combat the current obesity epidemic.
      • Taylor S.A.
      • Borzutzky C.
      • Jasik C.B.
      • et al.
      Society for Adolescent Health and Medicine
      Preventing and treating adolescent obesity: a position paper of the Society for Adolescent Health and Medicine.
      The World Health Organization
      World Health Organization
      Report of the Commission on Ending Childhood Obesity. [eBook edition]. World Health Organization, 2016.
      recognized childhood obesity as an issue requiring a large-scale change on many different levels and provided a list of recommendations for health care providers, governments, and all stakeholders to end childhood and adolescent obesity, which are listed in Table 2.

      Conclusion

      Adolescent obesity is a serious international health condition that continues to increase at alarming rates.
      • Quek Y.-H.
      • Tam W.W.S.
      • Zhang M.W.B.
      • Ho R.C.M.
      Exploring the association between childhood and adolescent obesity and depression: a meta-analysis.
      Very little progress has been made toward slowing the rate of childhood and adolescent obesity; therefore, educating providers and families of the importance of prevention and early treatment is essential.
      World Health Organization
      Report of the Commission on Ending Childhood Obesity. [eBook edition]. World Health Organization, 2016.
      According to the World Health Organization, obesity during adolescence can affect their immediate health, future health, educational accomplishments, and quality of life.
      World Health Organization
      Report of the Commission on Ending Childhood Obesity. [eBook edition]. World Health Organization, 2016.
      Owing to the metabolic, physiological, and psychologic effects obesity has on the adolescent population today, it is crucial providers have resources readily available to care for this population and their families.
      • Daniels S.R.
      • Hassink S.G.
      Committee on Nutrition
      The role of the pediatrician in primary prevention of obesity.
      Primary care providers are diligent with screening to ensure a patient’s BMI is not deviating too far from the expected values to prevent further progression and complications.
      • Daniels S.R.
      • Hassink S.G.
      Committee on Nutrition
      The role of the pediatrician in primary prevention of obesity.
      Providers also screen for nutrition and physical activity issues using recommended guidelines to educate parents and adolescents.
      • Kebbe M.
      • Perez A.
      • Buchholz A.
      • et al.
      Health care providers’ weight management practices for adolescent obesity and alignment with clinical practice guidelines: a multi-centre, qualitative study.
      Goal setting with the inclusion of the family is important to ensure the patient is successful.
      • Kebbe M.
      • Perez A.
      • Buchholz A.
      • et al.
      Health care providers’ weight management practices for adolescent obesity and alignment with clinical practice guidelines: a multi-centre, qualitative study.
      Slowing the progression of the obesity epidemic may be possible with additional screening, prevention, and early treatment of this disease in adolescence, which can improve the health of future generations.
      • Daniels S.R.
      • Hassink S.G.
      Committee on Nutrition
      The role of the pediatrician in primary prevention of obesity.

      Supplementary Data

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      Biography

      Kayla McManus, RN, is a student in the MSN FNP program at Clemson University School of Nursing, Clemson, SC, and can be contacted at [email protected] .
      Heide Temples, PhD, APRN, PPCNP-BC, IBCLC, is an associate professor in the School of Nursing, Clemson University, Clemson, SC.