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Recommendations Summary

Pediatric Weight Management (PWM) Energy Restricted Diets

Click here to see the explanation of recommendation ratings (Strong, Fair, Weak, Consensus, Insufficient Evidence) and labels (Imperative or Conditional). To see more detail on the evidence from which the following recommendations were drawn, use the hyperlinks in the Supporting Evidence Section below.


  • Recommendation(s)

    PWM: Energy Restricted Diets - Children Six to 12 Years Old

    If energy-restriction is appropriate, based on the registered dietitian's professional judgment, then a balanced macro-nutrient diet that contains no fewer than 900kcal per day is recommended to improve weight status within a multi-component pediatric weight management program in children ages six to 12, who are medically monitored. Research indicates that balanced macro-nutrient diets at 900kcal to 1, 200kcal per day are associated with both short-term and longer-term (more than one year) improved weight status and body composition among six- to 12-year-old children.

    Rating: Strong
    Conditional

    PWM: Energy Restricted Diets - Adolescents

    If energy-restriction is appropriate, based on the registered dietitian's professional judgment, then a balanced macro-nutrient diet that contains no fewer than 1, 200kcal per day is recommended to improve weight status within a multi-component pediatric weight-management program in adolescents (ages 13 to 18), who are medically monitored. Research indicates that energy-restricted balanced macro-nutrient diets no lower than 1, 200kcal per day are associated with both short-term and longer-term (more than one year) improved weight status and body composition among 13- to 18-year-old adolescents.

    Rating: Strong
    Conditional

    Note: A balanced macro-nutrient diet for children is defined by the DRI in terms of the following percentage of daily energy intake: Carbohydrates (45% to 65%), protein (10% to 35%), fat (20% to 35%).

    • Risks/Harms of Implementing This Recommendation

      Children and adolescents on energy-restricted diets should be monitored for adequate micro-nutrient intake as well as adequate growth and development.

    • Conditions of Application

      Patient, family and caregiver goals should be considered in determining treatment goals.

    • Potential Costs Associated with Application

      • Longer-term (more than one year) participation in a weight-management program may be necessary to sustain improvement in weight status and body composition. However, longer-term participation increases costs both for the program and to the patient.
      • If organizational and program costs are passed on to participants, this could limit program access. Additionally, parent commitment to program participation is required.
      • The absence of health insurance coverage for weight management could limit program access.

    • Recommendation Narrative

      While balanced macro-nutrient, reduced-calorie diets (over 1, 200kcal to the recommended kcal-per-day level, per DRI) were inconsistent in their results (Grade III) in children (ages six to 12), using a balanced macro-nutrient, low-calorie diet (900kcal to 1, 200kcal per day), as part of a multi-component weight-management program, showed consistent reduction in adiposity measures, both short-term and longer-term (Grade I).

      In adolescents, if stabilization of weight is taken as the minimum measure of effectiveness, then eight of the nine treatment arms examined indicate that a balanced macro-nutrient, calorie-deficit diet (more than 1, 200kcal to recommended kcal-per-day level, per DRI) is effective in the short-term for treatment of adolescent obesity (Grade I). However, in all cases where follow-up occurred, adolescents had gained some if not all of their weight back.

      In 2007, an Expert Committee (appointed by the American Medical Association, in collaboration with the Health Resources and Service Administration and the Centers for Disease Control and Prevention) produced a report on the Recommendations Regarding the Prevention, Assessment, and Treatment of Child and Adolescent Overweight and Obesity (Sarah E. Barlow and and the Expert Committee. Expert Committee Recommendations Regarding the Prevention, Assessment, and Treatment of Child and Adolescent Overweight and Obesity: Summary Report. Pediatrics 2007;120;S164-S192).

      The ADA Evidence Analysis Work Group on Pediatric Weight Management (focused on the treatment of childhood obesity) completed the evidence analysis on a series of childhood obesity topics (ADA Pediatric Weight Management Evidence Analysis Project) and released their Evidence-Based Pediatric Weight Management Nutrition Practice Guideline in Summer 2007. The Work Group determined, at the time of the ADA guidelines were created, that recommendations of the Expert Committee would be used to supplement the ADA Pediatric Weight Management Guideline, as there were a few topical areas where there was insufficient research to make strong evidence-based recommendations.

      In cases where there was a paucity of research, the ADA Work Group followed the Expert Committee's recommendations. In only one case did the Expert Committee's recommendation differ from the ADA Work Group's recommendation. This is with regard to energy intake recommendations for treatment of pediatric obesity within a medically-supervised, multi-component pediatric weight-management program.

      Different Energy Intake Recommendations

      Even though the ADA Work Group and the Expert Committee examined the same body of research, the Expert Committee decided to exclude a body of research by Epstein, et al. This influenced their recommendation for energy intake in treating obesity in children (ages six to 12). The Expert Committee treated this body of research separately from the research used to formulate their major recommendation and did not include the results of this research as part of their final recommendation. In the Expert Committee's words:

      “Because the research by Epstein et al focused primarily on white, middle-class, intact families with younger children (6–12 years of age), it is...unclear how well results may be generalized beyond this population.” (p.261).

      The ADA Work Group also treated the Epstein et al research separately (using the Traffic Light Diet). However, the ADA Work Group determined that challenges to generalizability for this research were no more serious than much of the other research on this topic. Thus, the ADA Work Group included the research on the Traffic Light Diet as part of the basis for formulating its recommendation for energy intake in children (ages six to 12 years).

      Comparison of the Two Groups' Recommendations

      • ADA
        • PWM: Energy-restricted diets; children six to 12 years old
          • If energy restriction is appropriate, based on the registered dietitian's professional judgment, then a balanced macro-nutrient diet that contains no fewer than 900kcal per day is recommended to improve weight status within a multi-component pediatric weight-management program in children ages six to 12 who are medically monitored
          • Research indicates that balanced macro-nutrient diets at 900kcal to 1, 200kcal per day are associated with both short-term and longer-term (over one year) improved weight status and body composition among six- to 12-year-old children
          • Grade: Strong
          • Conditional.
      • Expert Committee
        • Although the outcomes are mixed, evidence does suggest that, in both the short term and the long term, a reduced-energy diet [less energy than required to maintain weight, but not less than 1, 200kcal (5, 040kJ per day)] may be an effective part of a multi-component weight-management program in children six to 12 years of age. (Spear BA, Barlow SE, Ervin C, Ludwig DS, Saelens BE, Schetzina KE, Taveras EM. Recommendations for treatment of child and adolescent overweight and obesity. Pediatrics. 2007, Dec; 120 Suppl 4: S254-288. p.260).

    • Recommendation Strength Rationale

      • The evidence for short- and longer-term (more than one year) improvement in adiposity status for children (ages six to 12) was given a Grade I, according to ADA evidence standards
      • The evidence for short-term (under one year) improvement in adiposity status for adolescents (ages 13 to 18) was given a Grade I, according to ADA evidence standards.

    • Minority Opinions

      None.