Managing Childhood Overweight: Behavior, Family, Pharmacology, and Bariatric Surgery Interventions

A dramatic rise in overweight has been recently shown to occur among male and female adolescents in many countries, reaching epidemic proportions in Western industrialized countries ((1)). This increase in childhood obesity places a significant burden on physical, psychological, and social health and calls for an urgent implementation of diverse treatment strategies. It is currently accepted, and probably even required, for professionals to relate to childhood overweight, which signifies a physiological construct, rather than to childhood obesity, which bears considerable derogatory connotation ((1)). Accordingly, the US Centers for Disease Control and Prevention defines overweight among individuals 2–19 years old as the 95th percentile or greater of BMI-for-age (BMI = weight/height2), and risk for overweight as the 85th to 95th percentile of BMI-for-age ((2)). In this review we will use the term overweight, unless the use of obesity is required. Treating overweight children is of extreme importance, not only because it affects their physical and psychological well-being and development, but because a considerable proportion of overweight children are at risk to become obese adults ((3)). Thus, although the indications for medical interventions in overweight children are still not well defined, it is suggested, in accordance with this risk-related definition, that treatment is required in almost all overweight children, and in at risk for overweight children with related medical complications ((1)). All the authors of the present review article took part in an international multiprofessional consensus meeting dedicated to the issue of pediatric obesity held at the Dead Sea in Israel, in March 2004. The result of this meeting was a comprehensive consensus document where the evidence was summarized, and recommendations developed ((1)). The present review incorporates the findings of this consensus meeting with respect to currently available treatment options in pediatric obesity with an updated comprehensive systematic literature search of the Cochrane, PUBMED, PSYCHLIT, PSYCHINFO, and ERIC databases. Originally, we aimed to carry out a literature search for the decade before the consensus meeting (1994–2003), but subsequently added comprehensive updated information, including data published between 2004 and 2007. This time period has envisioned the most dramatic increase in the rates of pediatric obesity ever to occur ((1)). This suggests the presence of a very different treatment environment than before ((3)), calling for a critical appraisal of currently adequate treatments, promotion of new strategies, and enhancing the conditions for improving treatment outcome. The review is based on a total of 80 articles published between the years 1994 and 2007. The following interventions will be discussed: dieting and nondieting weight reduction programs (15 articles), change in lifestyle (18 articles), behavioral treatment (12 articles), family interventions (18 articles), pharmacotherapy (18 articles), surgical interventions (9 articles), and multidisciplinary in-patient interventions (7 articles) (quite a few articles relate to more than one treatment strategy). The study relates mostly to the findings of randomized control trials (RCTs), or controlled trials, unless otherwise specified. Dieting and food intake modifications are key elements in the treatment of pediatric overweight. The term dieting implies a structured planned change in the established physiological meal pattern of the individual with specific guidelines advised for macronutrient composition (e.g., carbohydrate, fat and/or protein) and energy intake (which is often, but not necessarily, restriction of energy intake) geared toward reaching desired weight and physiological status. For overweight adults, a low-fat energy-intake restricting diet is considered the accepted treatment ((4)). In the case of overweight children, although a low-fat diet regiment is the conventional intervention ((5)), low-carbohydrate high-protein diet ((6)), and low-glycemic-load diet ((7)) have also been used successfully. Nevertheless, RCTs measuring the effects of different diets on weight reduction in overweight children and adolescents have not found a superiority of one of these three diets over another for short-term weight loss ((8),(9),(10),(11),(12)). These studies and other RCTs ((13),(14),(15),(16),(17),(18)) aimed to assess the overall effectiveness of dietary interventions in overweight youngsters. The interpretation of their findings is however limited, as additional interventions, e.g., lifestyle (physical activity and/or sedentary behavior) modifications, behavioral treatment and/or parental counseling and family interventions, were included in most of these studies, and only a few disentangled the effect of dieting from that of other interventions ((10),(17),(18)). Duration of dieting was usually between 3 and 6 months, and of follow-up between 3 and 12 months (only a few of these studies followed their patients for up to 24 months). A wide range of variability, reflecting considerable methodological inconsistencies, was found among these studies, in that 25–90% of the participants who completed the different food restricting interventions showed relative weight loss at follow-up compared to baseline. This decrease was less remarkable in comparison to the immediate postintervention assessment, suggesting that the effect of the intervention may diminish over time. 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