Topic 2 Management guidelines

What recommendations should a health professional give to the parents of a child with increased weight?

As part of its response to the global epidemic of obesity, WHO has issued guidelines to support primary healthcare workers to identify and manage children who are overweight or obese.

  • All infants and children aged less than 5 years presenting to primary health-care facilities should have both weight and height measured in order to determine their weight-for-height and their nutritional status according to WHO child growth standards.
  • Where infants and children are identified as overweight, WHO recommends providing counselling to parents and caregivers on nutrition and physical activity, including promotion and support for exclusive breastfeeding in the first 6 months and continued breastfeeding until 24 months or beyond.
  • If children are obese, they should be further assessed and an appropriate management plan should be developed. This can be done by a health worker at primary health-care level if adequately trained, or at a referral clinic or local hospital.

Acquiring healthy eating behaviors that will endure is important for children and adolescents: lifelong healthy eating habits help prevent non-communicable diseases (NCDs) as well as conditions that may occur due to malnutrition.

Nutrition management has been applied to numerous childhood obesity intervention studies.

Diverse forms of nutrition education and counseling, key messages, a Mediterranean-style hypocaloric diet, and nutritional food selection have been implemented as dietary interventions.

The modification of dietary risk in terms of nutrients, foods, dietary patterns, and dietary behaviors has been applied to changing problematic dietary factors.

Dietary interventions with a multidisciplinary approach have had positive outcomes in modifying obesity-related dietary risk factors for obese children and adolescents:  a reduction in high-fat food and sugary beverages, increased intake of fruits and vegetables, reduction in snacks, and maintenance of a balanced diet.

However, unfavorable outcomes were reported after long-term follow-up in terms of weight fluctuation, increased energy intake, macronutrient intake, and unhealthy dietary behaviors.

Behavioral modification and motivational interviewing on the health and diet of children and adolescents, to improve their self-control and mindful eating for sustainable healthy weight and nutritional status, are required to provide nutritional education and management.

It is necessary to considerate behavioral and environmental risk factors in a diet and to provide tailored nutritional therapy according to the stages of change among children and adolescents.

For this reason, individual, familial, social, and political-level involvement are recommended for effective and sustainable nutritional management of childhood obesity.

In addition, practical key messages for health and diet may be helpful in establishing healthful habits and lifestyles in this public health crisis.

  • BMI should be calculated and plotted at least annually, and integrated with other information such as growth pattern, familial obesity and medical risks to assess the child’s obesity risk.
  • For prevention, the recommendations include both specific eating and physical activity behaviors, but also the use of patient-centered counseling techniques such as motivational interviewing, which helps families identify their own motivation for making change.
  • For assessment, the recommendations include methods to screen for current medical conditions and for future risks, and methods to assess diet and physical activity behaviors.
  • For treatment, overweight children could be approached with a staged method based on the child’s age, BMI, related comorbidities, parents’ weight status and progress in treatment; the first stage is a brief counseling that can be delivered in a health care office, and subsequent stages require more time and resources.
Source: Barlow SE; Expert Committee. Expert committee recommendations regarding the prevention, assessment, and treatment of child and adolescent overweight and obesity: summary report. Pediatrics. 2007 Dec;120 Suppl 4:S164-92. doi: 10.1542/peds.2007-2329C. PMID: 18055651.
  • Limiting consumption of sugar-sweetened beverages
  • Encouraging consumption of diets with recommended quantities of fruits and vegetables
  • Limiting television and other screen time (no television viewing before 2 years of age and thereafter no more than 2 hours of television viewing per day, by allowing a maximum of 2 hours of screen time per day and removing televisions and other screens from children’s primary sleeping area)
  • Eating breakfast daily
  • Limiting eating out at restaurants, particularly fast food restaurants
  • Encouraging family meals in which parents and children eat together
  • Limiting portion size
Source: Barlow SE; Expert Committee. Expert committee recommendations regarding the prevention, assessment, and treatment of child and adolescent overweight and obesity: summary report. Pediatrics. 2007 Dec;120 Suppl 4:S164-92. doi: 10.1542/peds.2007-2329C. PMID: 18055651.

Given the difficulty of behavior-based weight loss and subsequent weight maintenance and the expense and potential harm of medication and surgery, obesity prevention should be a public health focus.

Efforts must begin early in life, because obesity in childhood is likely to persist into adulthood.

TREATMENT: The primary goal of obesity treatment is improvement of long-term physical health through permanent healthy lifestyle habits.

To achieve these goals, providers could present a staged approach with 4 treatment stages of increasing intensity. Patients can begin at the least-intensive stage and advance depending on responses to treatment, age, degree of obesity, health risks, and motivation:

  1. Prevention Plus (healthy lifestyle changes)
  2. Structured weight management
  3. Comprehensive multidisciplinary intervention
  4. Tertiary care intervention

Stages of Obesity Treatment

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