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. In summary, Collins et al. ((19)), in an analysis of all studies including an adequate dietary intervention (in addition to other components) and an appropriate control intervention, suggest that dietary interventions achieve a 10–20% weight loss in overweight children and adolescents in the short run. Unfortunately, with the exception of one study ((20)), all other studies assessing dietary interventions in pediatric overweight have not provided information about long-term weight control. Whereas most studies use dieting as a core part of lifestyle modification in the management of pediatric overweight, some researchers question not only the effectiveness of food restriction, but also warn against the risks associated with dieting in this population ((21)). Thus, it can be difficult for children to comply with dieting behavior for prolonged periods, leading to negative self-perception and reduced self-esteem ((21)). Using a structured restricting meal plan may in some cases actually lead to an increase in overweight in children who are already treated for overweight as a result of denial of hunger cues, discontinuation of eating while still hungry, and skipping meals ((22),(23)). Moreover, dieting may result in developing binge eating once food is available, and in psychological disturbances such as increased preoccupation with food ((24)). These reservations have led in recent years to the development of nondieting approaches which recommend adaptive food choices and meal size changes, without change in the physiological meal pattern of the individual, as the appropriate treatment strategy for the treatment of overweight youngsters. In contrast to dieting programs that require restriction of energy-intake (food) as an essential component, nondieting approaches recommend “healthier eating” strategies that can be maintained throughout childhood and into adulthood. This approach has the additional advantage of removing the stigma of “being on a diet” and increasing the opportunity of the overweight youngster to feel empowered and able to make choices, in contrast to feelings of incompetence that may arise if the youngster fails to stick to his or her diet. Savoye et al. ((25)) compared the efficacy of a dieting and a nondieting weight management approach, albeit in a descriptive non-RCT design, both procedures used in combination with nutritional education, physical exercise, and behavioral modification. At 1-year follow-up, both groups demonstrated a significant decrease in BMI, compared to baseline. The dieting group tended to show at that time greater weight reduction compared to the nondieting group (16.4% decrease in BMI standard deviation score (SDS) vs. 4.7%, respectively), although the differences were not significant. At 2 years follow-up, the dieting group reverted toward baseline (5.1% decrease in BMI SDS from baseline), whereas the nondieting group demonstrated a further reduction of weight (9.1% decrease in BMI SDS from baseline); again the differences between the two groups were not significant. The findings of this study caution against the risk of long-term weight rebound in overweight youngsters treated with dieting approaches, but not in those treated with nondieting weight management strategies. Similar findings were shown in a few controlled studies ((26)). Nevertheless, the research on nondieting weight management approaches and on the risks of dieting in pediatric overweight is still scarce; at this stage there is no evidence that nondieting approaches provide better long-term outcomes, or that restricting approaches should be abandoned. Any approach that emphasizes health promotion should consider a change in lifestyle a necessary adjunct to the treatment of overweight youngsters ((27)). Several RCTs using classroom and family-based interventions in children and adolescents have shown that a reduction in sedentary behaviors, particularly television use, sometimes but not always in combination with increased physical activity and adequate dieting, may be associated with a significant decrease in BMI ((16),(28),(29)), body fat, and cholesterol, and with improved aerobic fitness ((29),(30),(31)). Two studies carried out by Epstein and his colleagues, one assessing the influence of reduction of sedentary behaviors and promotion of physical activity on weight as the sole intervention ((32)), and the other assessing their influence when combined with family-based behavioral weight-control program ((33)), have both found a reduction of 10–20% in weight percentage at 12–24 months' follow-up assessment, compared to baseline. Whereas there is yet no firm evidence to establish recommendations for optimal physical activity interventions, it may be more informative to evaluate the amount and intensity of physical activity required to reduce fat mass than to assess the extent of energy expended in physical activity ((34)). Some RCTs have shown that moderate but continuous physical exercising for several months may reduce body fat, fasting insulin, and triglyceride concentrations, even in the absence of dietary intervention ((35)). Overweight youngsters will be more involved in physical activity if they experience it as fun and noncompetitive, select activities that they enjoy, go at their own pace, and share this activity with others ((1),(6)). Programmed aerobic exercises are usually less effective, and often considerably less enjoyable than routine lifestyle exercise ((20)). Most studies reviewed have assessed only short-term improvement with lifestyle modifications, some showing that reduction in weight and body fat, and increase in leisure-time physical activity may persist at 1-year follow-up ((29),(36)). The long-term influence of enhanced physical activity and reduction of sedentary behaviors on weight reduction in overweight children has not been adequately assessed, yet. Nevertheless, Kirk et al. ((6)) recommend that adequate management of overweight children ought to include the reduction of energy intake while maintaining adequate nutrient intake to protect growth and development, combined with increase of energy expenditure by promoting physical activity and reducing sedentary behaviors. Similarly, the American Academy of Pediatrics ((37)) recommends that lifestyle changes should be geared toward healthy eating and activity habits, for example limiting the television or computer time to no >2 h daily, rather than aiming for the achievement of an ideal body weight. Residential summer camps represent another popular multimodal lifestyle modification strategy. Several recent studies, either open ((38),(39)), or RCTs ((40)), have shown that a 4–8 week structured residential program consisting of moderate dietary restriction, fun-based skill-learning physical activity, and educational and psychological interventions, results in a significant decrease in BMI, waist circumference measurement, fat mass and blood pressure, and improvement in aerobic fitness and self-esteem. In a follow-up study of those campers staying for two consecutive summers, mean BMI at 1 year, namely before the second intervention, has been found to be lower than at the start of the intervention ((38)). Specifically, 4.4% of the children continue to reduce their BMI despite growth, 56.5% maintain their BMI at less than the initial baseline evaluation, and 39.1% increase their BMI to values greater than baseline ((39)). These findings suggest that in the short run, residential weight-loss programs can represent an effective, although expensive, treatment option for pediatric overweight. The long-term maintenance of weight reduction in these programs is still inconclusive. Additionally, as highly structured weight reduction programs might carry the risk of developing disordered eating ((25),(41),(42)), this should be taken into consideration. Although the reviewed studies of residential camp interventions have not reported of such an adversity, we still suggest that overweight children and adolescents should be screened by trained pediatricians, dietitians, and mental health professionals before attending these programs. Analysis of the findings of the reviewed studies on lifestyle modification in childhood overweight demonstrates a lack of consensus to their efficacy. This is likely related to the inconsistencies in the treatment approaches used (e.g., change of lifestyle as a sole intervention or as part of a multimodal approach) and the methodological limitations found in many studies that limit the ability to draw consistent conclusions as to their outcome. Summerbell et al. ((36)), reviewed 18 randomized controlled trials that assessed the efficacy of lifestyle interventions (changes in physical activity and sedentary behaviors) and different types of behavioral treatment or cognitive behavioral treatment in the treatment of childhood overweight, most of the studies including family involvement and lasting for a minimum of 6 months' duration. The authors did not find any intervention that demonstrated definitive favorable results, or that was significantly superior to other interventions. Other authors have reached different conclusions. Whitlock et al. ((3)), who investigated all treatment trials for childhood overweight since 1985 in Western industrialized countries (22 trials, all including various combinations of dieting, behavioral treatment and family interventions in addition to lifestyle modifications) and Kirk et al. ((6)), who recommended to apply a multimodal treatment strategy in which lifestyle modification was one part, suggested that the improvement associated with lifestyle modifications has the most validated empirical support, at least in the short term. One important conclusion shared consistently by many researchers (e.g., refs. (43),(44)) is that the engagement of parents and the promotion of a supportive family environment may improve the outcome of lifestyle modification in pediatric overweight above and beyond the effect of the intervention itself. Currently there is a unanimous agreement that psychodynamic psychotherapeutic interventions are ineffective in the management of pediatric overweight. As in the case of adult obesity, the most studied intervention in pediatric overweight is behavioral therapy (BT) ((3)). Several types of BT are used in the treatment of overweight children and adolescents, including goal-setting, self-monitoring, stimulus control, mastery, contingent reinforcement, problem solving, and group interventions ((3),(6),(45),(46),(47)). Similar to dieting and lifestyle modification, the interpretation of the findings of BT studies is limited, owing to the inclusion of other treatment modalities in these studies ((3)). Analysis of the BT studies in overweight children and adolescents shows that most followed-up their participants from 6 to 24 months ((9),(16),(46),(47)). Whereas in all reviewed BT studies, most being a part of a multimodal program rather than the sole treatment offered, treated youngsters have fared better than controls, the decrease in overweight percentage has been modest, ranging from 10 to 20% after 1 year. In addition to weight reduction, some of the BT studies found improvement in dieting, sedentary behaviors and physical activity ((9),(16)), and obesity-related physiological indices ((9),(46),(48)). Unfortunately, almost none of the reviewed studies reported findings on long-term outcome of BT in pediatric overweight. One exception is the research conducted by Epstein and his colleagues ((20)) who combined BT with dieting, physical exercise, and family-based interventions, and found that weight reduction persisted in a considerable proportion of the children at 10 years follow-up. Children and adolescents might benefit from BT particularly if it is combined with other treatment modalities such as adjunctive family-based treatment ((11)), adaptive changes in the child's lifestyle and in the family environment ((6)), and adequate dietary and physical activity interventions ((29)). Additionally, whereas cognitive BT (CBT) is an accepted intervention in obese adults ((49)), only a few studies have employed CBT in childhood overweight, with some reporting encouraging results ((50)). Duffy and Spence ((51)) have found no superiority of CBT over BT in overweight children aged 7–13, with both treatments being effective at 3 and 6 months' follow-up. Braet et al. ((42)), treating 7–17 years old youngsters in an in-patient setting, have compared a standard CBT program to extended programs that add to the standard regimen exposure sessions with relevant food cues and specific cognitive techniques. Both programs have been similarly associated with a significant reduction in weight and concomitant improvement in psychological well-being at 14 months follow-up compared to baseline. One of the key roles of parents is to provide the child's contextual environment. Parenting style and feeding style are crucial factors in fostering a healthy lifestyle, an awareness of internal hunger and satiety cues, as well as in de-emphasizing thinness ((52)). Therefore, parents should be considered key players in any intervention aimed at treating overweight-related problems in children and adolescents ((6),(36),(44),(53),(54)). For the most part, treatment of childhood overweight has been focused mainly on reducing the child's weight, with the parents serving as promoters of this goal ((36),(54),(55),(56)). Nevertheless, in recent years there is a growing evidence that changes ought to occur in the entire family system, not just in the child per se ((54),(57),(58),(59),(60),(61),(62)). Parenting skills are considered to be of utmost importance for successful weight reduction interventions in overweight children. The effects of these interventions are likely enhanced if targeted reductions in high-fat, high-calorie foods, and gradual targeted increases in physical activity occur not only in the overweight child but also in the entire family ((44),(53),(63)). Some family-based interventions, whether being the sole treatment ((64)), or part of a comprehensive multimodal intervention ((43)), have reduced not only the child's weight, but also physiological parameters such as blood pressure, and cholesterol and triglycerides concentrations. Family-based intervention is implemented on the premise that parental support and modeling, family functioning, and the home environment are important determinants of treatment outcome ((65)). RCTs performed by Epstein et al. ((20)) provide evidence that behaviorally oriented treatment programs designed to target and reinforce a change in eating habits and weight loss in both the parents and their overweight child have shown better results after a follow-up period of 10 years when compared to treatments that focus solely on changing the child's eating habits and weight. Specifically, these authors have shown that 34% of the participants who have entered family-based behavioral treatment at the age of 6–12 have reduced their overweight by ≥20%, with a third of this group being no longer overweight after 10 years. Still, in ∼50%, long-term weight reduction has not been maintained. Family-based programs are also superior to control treatments that target and reinforce the family members for attendance only, without requiring family changes ((20)). Whereas it is currently accepted that parents should be involved in the treatment of their overweight children, there is no consensus yet as to the way this should be performed, and whether the child's presence and responsibility is necessary. Findings suggest that parents who impose control on their children's eating (strict authoritarian parenting behavior) may interfere with the child's ability to regulate food intake. This may potentially result in increasing the risk for the later development of binge eating and overweight ((66)). By contrast, parenting strategies which engage in the use of some authoritative strategies in conjunction with facilitating appropriate child autonomy, enable the child to regulate his or her own eating behavior, while at the same time fostering parental control over the quality and pattern of the food environment. These moderated authoritative parenting strategies, which enable the child to decide how much he or she wishes to eat, have been found to be more effective in fostering adequate changes in the child's eating patterns as compared to strict parental authoritarian behaviors ((67),(68),(69),(70),(71)). In most current family-based behavioral pediatric weight-loss programs, although parental involvement and change are necessary, the overweight child is still considered the main agent of change ((36)). To our knowledge, Golan et al. ((53),(58),(65),(72)) have been the first to suggest that parents, rather than their children, should be the main agent of change. Targeting parents only with a family health-centered approach has been associated with greater weight loss and higher consumption of healthy foods in overweight children compared to treatment strategies focusing on the child. Parents may serve both as a source of authority and as role models for their children, thus providing an environment designed to reduce maladaptive eating-related attitudes and behaviors and improve self-regulation and healthy behavior practices. Moreover, in a recent RCT ((73)) assessing weight reduction and improvement of eating-related behaviors in a health-centered family-based program, 32 families have been randomized to a parents alone condition vs. a child and parent condition. The intervention aimed at parents only has resulted in a significantly greater reduction in the child's percent of overweight at the end of the program as well as at 1-year follow-up, compared with the child and parent condition. A greater reduction in food stimuli in the home environment has also been noted in the parents-only group. In both groups, the parents' own weight status has not changed. Among the factors potentially contributing to weight reduction, the level of attendance in the sessions explained 28% of the variability in the child's weight status change, the treatment group explained another 10%, and the improvement in the obesogenic load explained 11% of the variability. Pharmacological interventions for childhood overweight should be implemented in the case of imminent major comorbid medical complications, or as adjuvants, to supervised lifestyle intervention and behavioral and family-based intervention, if these have failed ((1),(6)). Current pharmacological interventions are designed to: (i) increase energy expenditure (stimulants); (ii) suppress caloric intake (anorectic agents); and/or (iii) limit nutrient absorption ((74)). Stimulants. The use of metabolic stimulants for the treatment of overweight has consistently drawn considerable criticism. Many such medications, although considered potentially effective (for example, thyroid hormones, dinitrophenol, amphetamines, fenfluramine, dexfenfluramine, phenylpropanolamine, and ephedra) are currently absolutely contraindicated in children and adolescents. Rejection of these drugs stems from the risk of addiction, as well as from these medications' frequent association with severe and in some cases life-threatening medical and psychiatric complications ((1)). Anorectic agents. The only anorectic agent currently approved for use in overweight adolescents (only in those older than 16 years of age) is sibutramine, a nonselective inhibitor of neuronal reuptake of serotonin, norepinephrine, and dopamine, thus promoting satiety. Additionally, sibutramine-induced sympathetic enhancement may reduce food intake by stimulation of thermogenesis and reduction of energy expenditure associated with weight loss ((6)). Several recent RCTs have by now assessed the efficacy of sibutramine in comparison to placebo in combination with caloric restriction, physical activity, BT, and/or family-based interventions in over 700 adolescents ((48),(75),(76),(77)). These studies have followed their subjects for 6–12 months, all showing a superiority of the active drug to placebo in reducing weight, BMI, waist circumference, high-density lipoprotein-cholesterol, triglycerides, glucose, insulin levels, and insulin resistance. This improvement occurs in both genders and regardless of ethnic origin. One study ((76)) has found a significant improvement in quality of life in the sibutramine vs. the placebo treated group. Potentially serious adverse effects associated with the use of sibutramine include mild hypertension and tachycardia, insomnia, anxiety, headache, and depression. In the earlier of these studies ((48)), 44% of the adolescents receiving sibutramine have developed mild hypertension and tachycardia necessitating a reduction in drug dose, and ∼12% have developed sustained elevations in blood pressure requiring the discontinuation of the medication. By contrast, the more recent studies have not found elevated blood pressure in the sibutramine group, and tachycardia was only mild, not necessitating discontinuation of the medication ((75),(76),(77)). These differences in adverse effects are not clear, as in all studies the participants have received similar sibutramine dosage (15 mg daily), and titration has not been markedly different. Anorectic agents should complement, not replace, a diet and exercise program. In general, sibutramine has modest effects on total body weight (typically an additional 2–10 kg weight reduction) and responses vary considerably among individuals. Most of the weight loss occurs within the first 4–6 months of treatment, due to the achievement of a negative plateau, and the long-term effect of sibutramine is inconclusive. Regain of weight is the norm if the medication is discontinued. Administration of sibutramine is not recommended for >2 years' duration ((1)). Topiramate is a sulfamate derivative of fructose approved as an add-on therapy in seizure disorders in adults and children over the age of two ((44)). Topiramate is currently not approved by the Food and Drug Administration as an anorectic agent in the treatment of overweight adults and children, and it is associated with a number of neurological and cognitive adverse effects ((78)). To date one RCT ((79)), one open study ((80)), and several case reports ((81),(82)) have shown significant weight reduction with topiramate in adult patients with binge eating disorder (BED). Topiramate has been administered very infrequently to overweight youngsters, and as reported in the few case reports reviewed, it has been used only in specific at risk populations with considerable overweight and additional obesity-related physical disturbances. These include children with neurologic disorders ((83)), Prader-Willi syndrome ((84)), autistic spectrum disorders ((85)), and neuroleptic-induced weight gain ((86)). In all these cases topiramate has induced significant and sometimes persisting weight loss. Although adversely affecting cognitive functioning, dose reduction may significantly ameliorate this dysfunction ((83)). Given the adverse effects associated with topiramate use and the paucity and limitations of current research, the use of topiramate in overweight children should be restricted to those involved in institutional review board-approved clinical trials. Drugs that limit nutrient absorption. These drugs, aside from sibutramine, are the only medications currently approved for use in younger populations. The drug orlistat inhibits pancreatic lipase and thereby increases fecal losses of triglycerides. Orlistat decreases body weight and total and low-density lipoprotein-cholesterol levels and reduces the risk of T2 diabetes mellitus in adults with impaired glucose tolerance. In the United States, orlistat is currently Food and Drug Administration approved in children older than 12 years. Whereas one open study ((87)) and three RCTs ((88),(89),(90)) have found significant reduction in BMI and several physiological parameters with orlistat combined with dieting, exercise, and/or BT, one study ((91)) has found no difference between the active drug and placebo. In two studies of overweight adolescents, the combination of orlistat with lifestyle intervention has reduced weight (−4.4 ± 4.6 kg), BMI (−1.9 ± 2.5 kg/m2), total cholesterol (−21.3 ± 24.7 mg/dl), low-density lipoprotein (−17.3 ± 15.8 mg/dl), f