PWM: Executive Summary of Recommendations (2007)
Pediatric Weight Management Evidence-Based Nutrition Practice Guideline
Executive Summary of Recommendations
Below are the major recommendations, and ratings for the Pediatric Weight Management (2007) Evidence-Based Nutrition Practice Guideline. More detail (including the evidence analysis supporting these recommendations) is available on this website to Academy members and subscribers under Major Recommendations.
To see a description of the Academy Recommendation Rating Scheme (Strong, Fair, Weak, Consensus, Insufficient Evidence) click here.
Pediatric Weight Management (PWM) Comprehensive, Multicomponent Weight Management Program for Treating Childhood Obesity
PWM: Multicomponent Program
Interventions to reduce pediatric obesity should be multi-component and include diet, physical activity, nutrition counseling and parent or caregiver participation. A large body of strong research indicates that clinically supervised, multi-component weight-management programs are more successful than single component programs for short-term and longer-term (more than one year) improvement in child and adolescent obesity.
Strong, Imperative
Pediatric Weight Management (PWM) Obesity in Children Ages Two to Five
PWM: Children Two to Five Years Old
Weight maintenance is generally recommended in overweight children two to five years old, within a multi-component weight-management intervention with active participation of a parent or caregiver. Weight loss may be recommended when the child has serious medical complications. Research was not identified on the efficacy and safety of weight-loss interventions among children ages two to five years old. The practitioner should refer to the Expert Committee Recommendations (Pediatrics Dec 2007, Vol 120 / Issue Supp4) for weight goals (Table 8) for children two to five years old.
Consensus, Imperative
Pediatric Weight Management (PWM) Assessing Foods and Pediatric Overweight
PWM: Foods Associated with an Increased Risk of Overweight
Dietary factors that may be associated with an increase in the risk of overweight and should be included in Nutrition Assessment are: increased total dietary fat intake and increased calorically sweetened beverages. ADA Evidence Analysis has shown that these factors are positively associated with childhood overweight.
Strong, ImperativePWM: Foods Associated with an Decreased Risk of Overweight
Dietary factors that may be associated with a decrease in the risk of overweight and should be included in Nutrition Assessment are: increased fruit and vegetable intake. ADA Evidence Analysis has shown that these factors may be negatively associated with childhood overweight
Strong, ImperativePWM: Assessment - Total Energy Intake and 100% Fruit Juice
Dietitians should be aware of the research on the following dietary factors when carrying out their Nutrition Assessment: reported total energy intake and 100% fruit juice intake. ADA Evidence Analysis has found that these factors may or may not be related to pediatric overweight, but the research is still unclear on the relationship.
Fair, ImperativePWM: Assessment - Dairy and Calcium
Dietitians should be aware of the observational research that indicates an inadequate intake of dairy and calcium may be related to an increase in the risk of pediatric overweight. Consideration should be given to including dairy and calcium intake as part of the nutrition assessment.
Fair, Imperative
Pediatric Weight Management (PWM) Assessing Child and Family Diet Behaviors in Pediatric Obesity
PWM: Family Diet Behaviors - Increased Risk of Obesity
Child and family diet behavior factors that may be associated with an increase in the risk of pediatric obesity and should be included in Nutrition Assessment are: Parental restriction of highly-palatable foods, consumption of food away from home, increased portion size of meals and breakfast-skipping. ADA Evidence Analysis has shown that these factors are positively associated with childhood overweight or obesity.
Fair, ImperativePWM: Family Diet Behaviors - Relationship Unclear
Dietitians should be aware of the research on the following child and family diet behavior factors when carrying out their Nutrition Assessment: Parental encouragement or pressure to eat, parental control over child’s dietary intake, meal frequency, snacking frequency or snack food intake and using food as a reward. ADA Evidence Analysis has found that these factors may not be related to pediatric overweight or obesity or that the research is still unclear on the relationship.
Fair, Imperative
Pediatric Weight Management (PWM) Assessing Physical Activity and Sedentary Behaviors
PWM: Sedentary Behaviors that Increase the Risk of Pediatric Overweight and Obesity
Sedentary behaviors that may be associated with an increase in the risk of pediatric overweight and pediatric obesity and that should be included in Nutrition Assessment are: Excessive television viewing and excessive use of video games. ADA Evidence Analysis has shown that these factors are positively associated with childhood overweight and obesity.
Fair, ImperativePWM: Physical Activity Behaviors that Decrease the Risk of Pediatric Overweight and Obesity
Physical activity behaviors that may be associated with a decrease in the risk of pediatric overweight and pediatric obesity and that should be included in Nutrition Assessment are: Regular physical activity and sports participation. ADA Evidence Analysis has shown that these factors may be negatively associated with childhood overweight and obesity.
Fair, Imperative
Pediatric Weight Management (PWM) Determination of Total Energy Expenditure
PWM: Option for Determining Energy Expenditure
If possible, RMR should be measured (e.g., indirect calorimetry). If RMR cannot be measured, then the equations for estimating total energy expenditure in overweight youth provided in the 2005 US Institutes of Medicine "Dietary Reference Intakes for Energy, Carbohydrate, Fiber, Fat, Fatty Acids, Cholesterol, Protein, and Amino Acids (Macronutrients), " may be used. Estimated energy needs should be based on Total Energy Expenditure (TEE--see below for TEE calculation).
Consensus, Conditional
Pediatric Weight Management (PWM) Assessing Family Climate Factors
PWM: Family Climate - Increased Risk of Overweight or Obesity
Family climate factors that may be associated with an increase in the risk of pediatric obesity and should be included in Nutrition Assessment are: Parental dietary disinhibition and restraint, negative aspects of family functioning (such as lack of parental support or over-possessiveness) and parental concern about child’s weight status. ADA Evidence Analysis has shown that these factors are positively associated with childhood overweight or obesity.
Fair, ImperativePWM: Family Climate - Decreased Risk of Overweight or Obesity
Family climate factors that may be associated with a decrease in the risk of pediatric obesity and should be included in Nutrition Assessment are: Positive aspects of family functioning (such as family cohesion, expressiveness, democratic style, parental support and cognitive stimulation at home). ADA Evidence Analysis has shown that these factors may be negatively associated with childhood overweight or obesity.
Fair, ImperativePWM: Family Climate - Relationship Unclear
Dietitians should be aware of the research on the following family climate factor when carrying out their Nutrition Assessment: Household food insecurity. ADA Evidence Analysis has found that this factor may not be related to pediatric overweight or obesity or that the research is still unclear on the relationship.
Fair, Imperative
Nutrition Prescription
Pediatric Weight Management (PWM) Nutrition Prescription in the Treatment of Pediatric Obesity
PWM: Nutrition Prescription
A nutrition prescription should be formulated as part of the dietary intervention in a multi-component pediatric weight-management program. The exact specification of nutrients and energy is often translated into a specific eating plan. Nutrition interventions are selected based on the nutrition prescription. Research shows that when an individualized nutrition prescription is included, improvements in weight status in children and adolescents are consistent. When an individualized nutrition prescription is not included, results are less consistent.
Strong, Imperative
Energy Restriction
Pediatric Weight Management (PWM) Energy Restricted Diets
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.
Strong, ConditionalPWM: 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.
Strong, Conditional
Altered Macronutrient Diets
Pediatric Weight Management (PWM) Reduced Glycemic Load Diet
PWM: Reduced Glycemic Load Diet - Children Six to 12 Years
If an ad libitum, reduced glycemic load diet is selected for use in children (ages six to 12), then this diet could be used to produce modest short-term improvement in weight status. Limited research shows that an ad libitum reduced glycemic load diet results in short-term improvement in weight status in this age group.
Weak, ConditionalPWM: Reduced Glycemic Load Diet - Adolescents
If an ad libitum reduced glycemic load diet is selected for use in adolescents (ages 13 to 18), then this diet could be used to produce modest short-term and longer-term improvement in weight status and body composition. Limited research shows that an ad libitum reduced glycemic load diet results in short-term improvement in weight status and body composition in this age group. One study shows weight status improvement at one year.
Fair, Conditional
Pediatric Weight Management (PWM) Very Low Carbohydrate Diet
PWM: Very Low Carbohydrate Diet - Adolescents
If a low-carbohydrate diet is selected for use in adolescents, then it is recommended for short-term (up to 12 weeks) use. The use of an ad libitum very-low-carbohydrate diet, which is defined as a diet containing 20g to 60g of carbohydrates to treat obese adolescents has shown short-term improvement in weight status. However, due to the lack of evidence, it is not recommended for long-term treatment of pediatric obesity.
Weak, Conditional
Pediatric Weight Management (PWM) Using Protein Sparing Modified Fast Diets for Pediatric Weight Loss
PWM: Protein Sparing Modified Fast Diets: Short-term Treatment
If children and adolescents are >120% of ideal body weight, have serious medical complications and would benefit from rapid weight loss, then a Protein Sparing Modified Fast Diet (PSMF) could be utilized in a short-term intervention (typically 10 weeks) under the supervision of a multidisciplinary team of healthcare providers who specialize in pediatric obesity. Research shows that short term use of a PSMF brings about short term and longer term improvement in weight status and body composition when part of a medically supervised, multicomponent program.
Weak, ConditionalPWM: Protein Sparing Modified Fast Diets: Long-term Treatment
The Protein Sparing Modified Fast Diet is not recommended for long-term weight management for obesity in children or adolescents. There are few well designed studies to support the use of this intervention for longer than 10 weeks.
Weak, Imperative
Pediatric Weight Management (PWM) Very Low Fat Diet (Less than 20% Daily Energy Intake from Fat)
PWM: Very Low Fat Diet
Use of a very-low-fat diet (less than 20% of total daily energy) is not recommended for use in pediatric weight management. The efficacy of a very-low-fat diet, defined as less than 20% of total daily energy intake from fat in the treatment of pediatric obesity, has not been studied.
Insufficient Evidence, Imperative
Nutrition Education
Pediatric Weight Management (PWM) Nutrition Education in the Treatment of Pediatric Obesity
PWM: Tailor Nutrition Education to Nutrition Prescription
In a multi-component program, if there is a Nutrition Diagnosis for food and nutrition-related knowledge deficit, then Nutrition Education should be tailored to the Nutrition Prescription. Research shows that if nutrition education is not tailored to nutrition prescription, improvement in weight status is not consistent.
Fair, Conditional
Nutrition Counseling
Pediatric Weight Management (PWM) Nutrition Counseling and Behavior Therapy Strategies in the Treatment of Obesity in Children and Adolescents
PWM: Nutrition Counseling
Nutrition counseling, delivered by an RD (which is inclusive of goal-setting, self-monitoring, stimulus control, problem-solving, contingency management, cognitive restructuring, use of incentives and rewards and social supports), should be a part of the behavior therapy component of a multi-component pediatric weight-management program.
Consensus, ImperativePWM: Behavioral Therapy
Behavior therapy strategies should be included as part of a multi-component pediatric weight-management program. Research shows that when behavior therapy strategies are included within the context of a multi-disciplinary team, weight status and body composition improve.
Strong, ImperativePWM: Family-Based Counseling
Family-based counseling that includes parent training or modeling should be included as part of a multi-component weight-management program that targets children ages six to 12 years. During the development of a multi-component treatment program for children ages 12 years and younger, the registered dietitian should advise the health-care team on the advantages of incorporating parent training or modeling as part of the treatment program. Research studies that including parent training or modeling as part of a multi-component weight-management program for children 12 years and younger showed positive changes in a child’s weight status and adiposity.
Strong, Imperative
Pediatric Weight Management (PWM) Family Participation in Treating Pediatric Obesity in Children and Adolescent Obesity Treatment
PWM: Family Participation - Children Six to 12 Years Old
Parent or caregiver should be included in multi-component pediatric weight-management programs as an agent of change when treating children ages six to 12. A strong body of research indicates that including parents and caregivers as agents of change in the treatment of their child's obesity is associated with both short-term and longer-term (more than one year) improvements in weight status. A more limited body of research indicates that treating six- to 12-year-old children without parental participation is not effective.
Strong, ImperativePWM: Family Participation - Adolescents
Parent or caregiver may be included in multi-component pediatric weight-management programs when treating adolescents. A limited body of research indicates that programs with or without parent or caregiver participation may be effective for improvements in weight status and adiposity in adolescents.
Fair, ConditionalPWM: Family Participation - Treatment Format
If parent or caregiver participation is included in child and adolescent weight-management programs, health professionals should tailor the format (e.g., group vs. individual format, parent or caregiver with child vs. parent or caregiver and child separate, etc.) to meet individual, family and program needs. Research does not show a clear superiority of one format vs. another for parent or caregiver participation.
Consensus, Conditional
Pediatric Weight Management (PWM) Nutrition Counseling: Setting Weight Goals with Patient and Family
PWM: Weight Goals
Weight goals should be individualized for the child. Because of growth occurring within children and adolescents, the goal of pediatric weight-management programs may be weight stabilization rather than weight loss. Research indicates that weight stabilization in children and adolescents may be associated with improvements in BMI and other measures of adiposity.
Consensus, Imperative
Coordination of Nutrition Care
Pediatric Weight Management (PWM) Coordination of Care in Pediatric Weight Management
PWM: Coordination of Care
The dietitian should collaborate with members of the health-care team (as available) in planning and implementing behavior, physical activity and adjunct therapy strategies. Effective multi-component pediatric weight management interventions benefit from the diverse expertise of different health-care professionals.
Consensus, Imperative
Physical Activity and Inactivity
Pediatric Weight Management (PWM) Decreasing Sedentary Behaviors in Children and Adolescents
PWM: Decreasing Sedentary Behaviors - Children
Children should be counseled to reduce or limit sedentary activities (e.g., television, video games, "screen time"). Intervention research indicates that reducing sedentary activities may have both short-term and longer-term benefits in terms of pediatric obesity. Observational research also indicates that television time may also be associated with increased consumption of energy-dense foods.
Fair, ImperativePWM: Decreasing Sedentary Behaviors - Adolescents
Adolescents should be counseled to reduce or limit sedentary activities (e.g., TV, video games, "screen time"). Limited intervention research indicates that reducing sedentary activities may have both short term benefits in terms of pediatric obesity.
Weak, Imperative
Pediatric Weight Management (PWM) Physical Activity in the Treatment of Childhood and Adolescent Obesity
PWM: Physical Activity
Physical activity should be included as part of a multi-component pediatric weight-management program. Research indicates that increasing physical activity as part of a multi-component program results in significant improvements in weight status and body composition in children and adolescents.
Strong, Imperative
Adjunct Therapies
Pediatric Weight Management (PWM) Adjunct Therapies: Use of Weight Loss Medications in Treating Obesity in Adolescents
PWM: Collaboration with Health Care Team
The dietitian should collaborate with the health-care team regarding the use of weight-loss medications as an adjunct therapy within a multi-component pediatric weight-management program for adolescents. Clinical outcomes are likely to be enhanced with the participation of a dietitian.
Consensus, ImperativePWM: Weight Loss Medication
If a weight-loss medication is selected as an adjunct therapy, then an over-the-counter or prescription gastrointestinal lipase inhibitor (e.g., orlistat), approved by the FDA for use in adolescents, may be recommended to treat obese adolescents participating in a multi-component pediatric weight-management program. Research indicates that a gastrointestinal lipase-inhibitor further improves weight status and body composition in some individuals within a multi-component adolescent weight-management program. However, the FDA has not studied or approved the use of this class of medication for children under the age of 12.
Fair, Conditional
Pediatric Weight Management (PWM) Adjunct Therapies: Weight Loss Surgery and Adolescent Obesity
PWM: Weight Loss Surgery
Dietitians should collaborate with other members of the health-care team regarding the appropriateness of weight-loss surgery for severely obese adolescents who have not achieved weight-loss goals with less-invasive weight-loss methods and who meet specified criteria (see Conditions of Application below). Research indicates that for a subset of adolescents who meet the recommended criteria, weight-loss surgery may be effective in bringing about significant short-term and long-term weight loss. Obese children (under 13 years of age) are generally not considered to be appropriate candidates for weight-loss surgery.
Consensus, Imperative
Treatment Format Options
Pediatric Weight Management (PWM) Treatment Format Options: Group vs. Individual Intervention
PWM: Group vs. Individual Interventions
Either group or individual nutrition intervention may be used as part of a multi-component pediatric weight-management program. Limited research that compares individual vs. group format does not indicate differences in overall pediatric weight status. However, two studies suggest that some dietary outcome measures may be improved with an individual counseling format.
Weak, Imperative
Pediatric Weight Management (PWM) Optimal Length of Weight Management Therapy in Children and Adolescents
PWM: Optimal Length of Treatment
During the intensive treatment phase, Medical Nutrition Therapy for pediatric obesity should last at least three months or until initial weight-management goals are achieved. Because overweight and obesity are chronic, often life-long, conditions, it is critical that a weight-management plan be implemented after the intensive phase of treatment. A greater frequency of contacts between the patient and practitioner may lead to more successful weight loss and maintenance.
Consensus, Imperative