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Pediatric Weight Management

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.

Overview

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

Nutrition Assessment and Treatment

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, Imperative

PWM: 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, Imperative

PWM: 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, Imperative

PWM: 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, Imperative

PWM: 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, Imperative

PWM: 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, Imperative

PWM: 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, Imperative

PWM: 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

Intervention

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, 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.

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, Conditional

PWM: 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, Conditional

PWM: 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, Imperative

PWM: 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, Imperative

PWM: 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, Imperative

PWM: 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, Conditional

PWM: 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, Imperative

PWM: 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, Imperative

PWM: 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

Monitoring and Evaluation

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