What are the latest guidelines for managing obesity in teenagers?

Latest Guidelines for Managing Teenagers with Obesity

The current guidelines recommend a comprehensive, multidisciplinary approach to managing obesity in teenagers, with family-centered behavioral interventions as first-line treatment, followed by consideration of pharmacotherapy and bariatric surgery in severe cases with comorbidities. 1, 2

Assessment and Diagnosis

• BMI percentiles or standardized BMI scores should be used to determine whether adolescents have overweight (BMI 85th-95th percentile) or obesity (BMI ≥95th percentile) 3, 2
• Specific assessment for obesity-related comorbidities including dyslipidemia, hypertension, insulin resistance, and liver abnormalities should be conducted for teenagers with BMI ≥95th percentile 3, 2
• Waist circumference should be measured to assess abdominal adiposity as part of the comprehensive evaluation 4

First-Line Treatment: Lifestyle Modification

Dietary Interventions

• Implement an energy-balanced diet with appropriate caloric restriction (typically 500 kcal/day deficit) while ensuring adequate nutrition for growth and development 1, 4
• Eliminate sugar-sweetened beverages to reduce daily caloric intake 1
• Focus on healthful nutrition with increased consumption of whole grains and reduced intake of fast food and energy-dense items 1
• Avoid highly restrictive diets in younger adolescents as rapid weight loss can lead to delay in linear growth 1

Physical Activity Recommendations

• Promote 60 minutes of moderate to vigorous physical activity daily for teenagers 1, 2
• Reduce sedentary behaviors such as watching TV and playing computer/video games 1, 2
• For older adolescents, encourage participation in sports teams or non-competitive activities such as dance or martial arts 1

Behavioral Therapy Components

• Implement self-monitoring, stimulus control techniques, goal setting, positive reinforcement, problem solving, and relapse prevention strategies 1
• For adolescents aged 12-21 years, implement office-based weight loss plans with the adolescent as the change agent for behavior modification 3, 2
• Set small and gradual behavior change goals rather than focusing on rapid weight loss 1
• Help families monitor eating and physical activity behaviors 1

Treatment Intensity and Follow-up

• For adolescents with BMI 85th-95th percentile: Implement excess weight-gain prevention with the adolescent as change agent for energy-balanced diet and reinforced physical activity recommendations for 6 months 3
• For adolescents with BMI ≥95th percentile without comorbidities: Implement office-based weight-loss plan with family-centered approach and adolescent as change agent for 6 months 3
• For adolescents with BMI ≥95th percentile with comorbidities or BMI ≥35: Refer to comprehensive lifestyle weight-loss program for intensive management for 6-12 months 3
• If no improvement in BMI percentile after initial intervention, refer to comprehensive multidisciplinary weight-loss program 3, 2

Second-Line Treatments

Pharmacotherapy

• Consider pharmacotherapy as an adjunct to lifestyle modification for adolescents with more severe obesity and inadequate weight loss 3, 5
• For adolescents with BMI ≥95th percentile who show no improvement with lifestyle intervention, consider initiation of medication (orlistat) under care of experienced clinician for 6-12 months 3
• Newer antiobesity medications such as liraglutide, semaglutide, and phentermine/topiramate, when combined with lifestyle modification therapy, can reduce mean BMI by approximately 5% to 17% at 1 year 5
• Metformin may be considered for adolescents with severe obesity at high risk for developing type 2 diabetes 1

Bariatric Surgery

• For adolescents with BMI far above 35 and comorbidities unresponsive to lifestyle therapy for 1 year, consider bariatric surgery or referral to center with expertise in procedures 3
• Bariatric surgery (Roux-en-Y gastric bypass and vertical sleeve gastrectomy) for severe adolescent obesity reduces mean BMI by approximately 30% at 1 year 5
• Individuals considering bariatric surgery should be counseled regarding risks, benefits, and outcomes, and should be monitored for nutrient deficiency 3

Expected Outcomes and Challenges

• Realistic weight management goals should focus on weight maintenance rather than weight loss in growing teenagers, allowing BMI to gradually decrease as height increases 2
• Family-based behavioral weight management programs typically achieve modest results, with BMI reduction of 1-3 units 1, 2
• More intensive lifestyle modification therapy requires more than 26 contact hours over 1 year to elicit approximately 3% mean BMI reduction 5
• High attrition rates are common in behavioral weight management programs 1
• Benefits of treatment on weight may be promising during intensive intervention but may not persist long-term without continued support 1

Important Considerations

• Weight regain is common after weight loss, including after bariatric surgery; long-term support is essential 3
• Younger adolescents tend to respond better to lifestyle interventions than older adolescents with severe obesity 1
• Use respectful, non-stigmatizing language in all patient interactions 4
• Avoid approaches that might induce unhealthy slimming practices or lead to eating disorders 2
• Energy restriction must be carefully monitored to avoid compromising normal growth and development 2

The latest guidelines emphasize that obesity management in teenagers requires a staged approach, starting with lifestyle modifications and progressing to more intensive interventions based on response and severity. Family involvement and addressing the psychological aspects of obesity are crucial components of successful treatment programs.