Intensive approaches advised for obese youth

Children and adolescents who are obese are able to lose weight through concentrated behavioral modification programs, according to a pair of recent reports.

But experts say these programs can be hard to access because of the money and time required. Evidence does not support any particular lower-intensity intervention, but experts also say efforts that can be effective in a primary care setting must be found to make a real impact on the pediatric obesity epidemic.

"Accessibility of these kinds of programs is a real issue. The cost is extremely high, but the public health impact is pretty limited," said Dr. Goutham Rao, director of the weight management and wellness center at Children's Hospital of Pittsburgh. "Unless we find a practical and financially sound solution for primary care, we're never going to solve the problem of childhood obesity."

Some 17% of children ages 2-19 are defined as obese, and this statistic has been the focus of significant medical society and public health initiatives. For instance, the American Medical Association, in collaboration with the Health Resources and Services Administration and the Centers for Disease Control and Prevention, convened representatives from 15 health organizations to form the Expert Committee on the Assessment, Prevention and Treatment of Child and Adolescent Overweight and Obesity. Its recommendations were published in the December 2007 Pediatrics.

"The challenge is how to help families actually make changes," said Sarah Barlow, MD, MPH, lead author on that paper and associate professor of pediatrics at Baylor College of Medicine in Houston.

In September, the Agency for Healthcare Research and Quality issued a data review. Increasing acknowledgement of this problem has led to more research on the subject, and the authors believe that more evidence proving which approaches work will translate to more patients being able to access these services.

"The literature has burgeoned as people recognize this public health problem," said Evelyn Whitlock, MD, MPH, lead author and a senior investigator at the Kaiser Permanente Center for Health Research in Portland, Ore. "And we're hoping that this kind of evidence will allow insurers and health care organizations to make effective programs more available."

Researchers found that children and teens would weigh an average of three to 23 pounds less after a medium- to high-intensity weight-loss program that involved meeting for at least 25 hours over six to 12 months compared with those who did not take part. The more intensive the program, and the more overweight the child, the greater the weight loss. These changes were maintained for at least a year.

"It's such a difficult condition that you need consistent therapy," said Dr. Sonia Caprio, professor of pediatrics at Yale University School of Medicine in Connecticut, who studies this topic.

These programs also boosted physical fitness and improved markers of cardiovascular and diabetes risk. Efforts in health care settings worked better than those at schools. They all included organized physical activity, parental involvement for younger children and behavioral management principles. Prescription medications or bariatric surgery were found useful for extremely obese teens.

"Effective prevention is the best way to stem the childhood obesity epidemic, but we also have to find effective and healthy ways of helping our children and teens who already are obese get to a healthier weight," said AHRQ Director Carolyn M. Clancy, MD. "AHRQ's new evidence report helps identify possible solutions."

Accenting prevention

This report also reaffirmed the importance of prevention, and much of it was in line with new guidelines to be published by the Endocrine Society in December issue of the Journal of Clinical Endocrinology & Metabolism.

"The most important take-home message is prevention," said Gilbert P. August, MD, lead author and professor emeritus of pediatrics at George Washington University School of Medicine in Washington, D.C. "We want to introduce lifestyle changes before the patient is obese. Once the patient becomes obese, it's much more difficult to do these things. Bad habits become ingrained, and patients become frustrated by the slow pace of healthy weight loss."

The Endocrine Society document recommended evaluating possible comorbidities in any child with a body mass index over the 85th percentile, although routine evaluation for endocrine causes of excess weight was unnecessary. Physicians also should attempt to prevent obesity by advocating that schools allow for an hour of physical activity a day for all students. Mothers also should be encouraged to breastfeed infants.

In a related development, the U.S. Preventive Services Task Force published an evidence review in the Oct. 21 Annals of Internal Medicine. It found that primary care interventions before and during pregnancy and after a woman gives birth are effective at increasing breastfeeding, which has a range of health benefits, including preventing obesity.