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Rev Endocr Metab Disord DOI 10.


Effective dietary therapies for pediatric obesity treatment
Angela Fitch & Jenny Bock

# Springer Science + Business Media, LLC 2009

Abstract Dietary changes combined with behavioral management techniques, such as short term attainable goal setting, is effective for treating pediatric obesity. Dietary interventions combined with increasing physical activity are essential for weight loss. We review the basic nutrition concepts that should be employed to treat pediatric obesity and summarize the available literature on effective dietary interventions that have been studied to date. Keywords Dietary interventions . Obesity . Pediatric weight management

interventions such as increasing exercise and decreasing screen time [2]. Dietary changes should not be considered as temporary but rather a component of a more permanent transition to a healthier lifestyle. The goal is to induce incremental dietary changes that can be successfully incorporated into a global lifestyle change during childhood and maintained into adulthood. Contrary to many popular plans and advertisements, there are no temporary solutions or quick fixes. Here, we review the current literature on dietary management of pediatric obesity and discuss fundamental practical lifestyle interventions that are the basis for pediatric obesity treatment.

1 Introduction Obesity is a complex, multi-factorial, chronic medical condition that is on the rise in the pediatric population [1]. Obesity, whether it occurs in the adult or pediatric population, still amounts to an imbalance of caloric intake vs. expenditure for most individuals. Dietary changes are important but should not be separated from other lifestyle
A. Fitch Internal Medicine and Pediatrics, Pediatric Weight Management Program, University of Minnesota, Minneapolis, MN, USA J. Bock Fairview/University of Minnesota Medical Center, Department of Nutrition, Pediatric Weight Management Program, University of Minnesota, Minneapolis, MN, USA A. Fitch (*) Fairview Eagan Clinic, 1440 Duckwood Drive, Eagan, MN 55122, USA e-mail:

2 Key components to obesity treatment There are several core principles to begin treating pediatric obesity effectively from a dietary standpoint (Table 1). 2.1 Individualization Although the core principles remain the same for all patients, dietary interventions to treat pediatric obesity must be individualized to meet each patient’s social, ethnic and individual needs [3, 4]. A single approach is unlikely to fit the needs for the population as a whole. Several basic and effective lifestyle recommendations should be instituted at the beginning of therapy which should form the foundation on which to begin the individualization process for each patient. 2.2 Food journaling A food journal is an important tool in obtaining further insight as to what the obese pediatric patient is potentially

Giving parents this table can aid in preparation of these snacks ahead of time and also encourage appropriate portion sizes for snacking. Slow and Whoa” or Stoplight food concept for children and parents. A limitation in journaling is under reporting caloric consumption. particularly fast food Choose appropriate portion sizes Encourage the switch to skim milk and increase consumption of calcium . Thus. Practical examples of the portion size for 100 calories of a given food are listed in Table 4. This journal will help guide treatment and also serves to hold patients and parents accountable for what they are eating. Setting short term attainable goals for incremental changes Eat family meals together as much as possible Limit eating out at restaurants. Such situations can sabotage a treatment plan and make long term success difficult. Compelling evidence now strongly supports the elimination of sugar sweetened beverages as a simple way to reduce calorie intake that is effective at decreasing BMI. Many times there may be family members who are thin and the concept of weight loss is something they have trouble comprehending.3 Family involvement Multiple studies have shown that successful pediatric weight loss strategies require support and understanding from the child’s family [1. The food journal can be a fun process (kids can decorate their journal) and records can be kept online using resources such as www. especially for those with the highest BMI range [13. Family members may wish to have certain foods available in the home that are not a part of the healthy weight loss plan making it more difficult for children to make healthy food choices. we strive to have children and/or their parents continue to journal what they are eating each are for 9 servings a day.thedailyplate. This also encourages snacking with healthier. An example of a practical. it can serve as a useful behavioral therapy as a child or parent may be less likely to eat certain foods if they are responsible for writing it down in a journal.mypyramid. 7–10]. providers give families a chart of “go or green light” foods that they can consume freely. This can be difficult especially when not all the family members are obese and may resist adoption of similar dietary changes. 2.Rev Endocr Metab Disord Table 1 Core principles of dietary treatment program Individualization of treatment Food journaling Family involvement and support Short term. Utilization of these plans has been shown to be effective in controlling caloric consumption [11.4 Goal setting using dietary interventions The evidenced based lifestyle interventions as recently reviewed by the American Academy of Pediatrics Expert Committee from 2007 are shown in Table 2 [2]. 12]. relatively simple goals to strive towards in attempting to eliminate excess calories in the diet but should be tailored to particular problem areas for the individual patient. General recommendations for encouraging children to reduce calorie consumption are listed in Table 3. 2. Similar studies have not been performed in the adolescent population but it can be assumed that similar misrepresentation may well occur in this population. The current recommendations for the US Department of Agriculture (www. • • • • • Elimination of sugar sweetened beverages Increased intake of water or skim milk Eating a healthy breakfast daily Pack lunch for school as much as possible Strive for 5 total fruits and vegetables daily at a 14]. This includes extended family members and caretakers who Table 2 Evidenced based initial lifestyle interventions to treat pediatric obesity • • • • • might encourage poor eating habits if they are unaware of the need for the patient to lose weight. “slow or yellow light” foods that they can consume only in moderation. We frequently recommend limiting snacks to a 100 calorie portion. These are practical. In this plan. journaling is an example of a general principle that can be individualized for each patient’s needs. attainable goal setting eating on a daily basis. In this regard. Adolescent patients may be more likely to be compliant with a food journal if they text message their diets using a smart phone rather than traditional recording tools [6]. general lifestyle modification diet is the “Go. and “whoa or red light” foods that they should only be consuming on occasion. Women taking part in the Women Health Initiative underreported caloric intake by 25% in their food journaling [5]. 2. In our practice.

these two studies highlight the importance of calorie reduction rather Table 4 100 Calorie snack ideas Apple ( 1 medium) Banana ( 1 medium) Blueberries ( 1 cup) Carrots ( 6 baby) with 3 Tbsp hummus or 2 Tbsp cream cheese Celery ( 1 stalk) with 1 Tbsp peanut butter Cashews (11 whole) Cherries. nutrient poor items that are frequently marketed to children. Areas to incorporate should include food journaling. and the importance of long term behavior change. No one dietary treatment can be recommended at this time though each approach used in the studies included has some HealthyEating_calculator. One tool available to estimate pediatric needs is The Healthy Eating Plan Calculator (found at http://www. This on-line calculator will estimate needs for weight maintenance using the 2005 Dietary Guidelines for Americans and The Institute of Medicine’s nutritional recommendations for ages 4 and above. Each macronutrient strategy resulted in a similar degree of weight loss [ 18]. and high fiber (5 g plus year of age/day) energy deficient diet is the general recommendation until additional data becomes available in pediatrics. 16].bcm. exercise and reduced screen time) are most likely to be successful on a long-term basis. high protein (25%). light (1/2 cup) Edamame. and for those who do not have any underlying metabolic disorder that predisposes them to excess weight gain such as Prader-Willi. the emphasis is typically placed on guiding healthy food choices and appropriate portion sizes. boiled (1/3 cup) Granola bar Popcorn low fat microwave (3 cups) Strawberries (2 cups) . calculating estimated needs for weight maintenance or mild weight loss can be beneficial in providing and planning appropriate meal and snack plans for the patient/parents to use as a guiding reference. Organized. However. it will. height and weight calculations are based solely on 50th percentile for age specific height and weight to calculate requirements. comprehensive treatment programs that focus on multiple facets of obesity (diet.1 Estimating caloric needs for weight loss In pediatric weight management. 3 Going beyond the basics: specialized dietary treatment approaches The above initial interventions can work well as a weight maintenance guide for children who are still growing in height. Sample meal plans that estimate the caloric intake needed for weight loss are a critical component of a more aggressive approach. For patients with these types of genetic disorders or for adolescents that have reached their adult heights or are morbidly obese (BMI >99th percentile). high carbohydrate (55%). raw (20) Frozen yogurt. thereby still lowering their BMI. 3. based on a child’s age. Another useful tool is the MyPyramid Plan feature of the USDA’s website (www. it is important to note that for ages 2–8 years old. gender. and general activity level. Recent studies in adults compared the effectiveness of a number of popular diets with various macronutrient compositions on short term weight loss. weight.htm) designed by the Baylor College of Medicine’s Children’s Nutrition Research Center. However. Upon entering the same information. again. A low fat (< 30%). or Down syndrome. goal setting. once other basic lifestyle interventions have been discussed. and a reduction in the caloric intake while maintaining a required nutrient intake. and not focused on achieving a certain caloric goal. a more sophisticated approach is often required. This can prove a useful guideline to gingerly reduce calories in lower calorie foods instead of caloric dense.Two recent metaanalyses evaluated a variety of dietary strategies for weight loss studies in pediatric patients (Table 5) [17. recommending one strategy over another or a more restrictive diet can be medically supervised [7]. Perhaps as important as the macronutrients in the diet are the behavioral changes that accompany a change in lifestyle. adhering to one’s plan. height.mypyramid. Although similar trials have not been performed in for macronutrient composition but in a reduced calorie format. The current recommendation is to create a meal plan that follows the recommendations from the United States Department of Agriculture (www. assessment of caloric intake. Turner. A registered dietician skilled in weight management is a necessary component of this specific dietary intervention and can guide specific goals to set for the individual patient. give a caloric goal based on the 2005 Dietary Guidelines.Rev Endocr Metab Disord Table 3 Techniques to encourage less calorie consumption Drink several ounces of water before the meal Use smaller plates Wait 20 minutes prior to second helpings Use the child’s size of their fist to estimate portion for most foods Fill ½ the plate with fruits and vegetables Use fruit as a dessert than composition.

52 kg .6 kg in the intervention group compared to a mean weight gain of 2.44 kg .77 kg Length of treatment 13 weeks 13 weeks 1 day 10 days 10 weeks 12 weeks 12 weeks 8 weeks Figueroa-Colon et al. 1985 [19] Hills and Parker 1988 [20] Israel et al.67 kg + 2. calculating estimated needs for an individual should be an ongoing process. 3) is no fewer than 900 kcals in ages 6–12 and 1200 kcals in ages 13–18. . If a caloric goal is used.84 kg .2.0.13. The control group had no specific intervention. In every case.0.8. Both groups were followed for 6 months.14.3 kg + 0.2. and weight changes.9. 2) balanced in macronutrient composition.They studied 12 children in the study group and 7 children in the control group who were “super obese” (140–195% of ideal body weight) for 6 months in a school based setting. and 4)) is medically supervised. it is very important to ensure the plan still remains nutritionally complete.2 kg .1 kg + 0. This dietary intervention was studied most intensively in 1996 by Figueroa-Colon et al [9].1.4.3 kg . it is only appropriate if it is: 1) based off the professional judgment of a medical professional.32 kg + 0. and reevaluated and adjusted each visit based on patient compliance. At 6 months.08 kg .5. This is typically performed under the guise of an experienced medical provider using specially formulated liquid meal replacements. food records.7 kg . Initially the study group was placed on a protein sparing modified fast diet for 9 weeks (600 –800 calories) and then maintained on a structured hypocaloric diet (1200 calories) for 12 weeks.5.83 kg + 2. 1984 [22] 9 weeks Senediak and Spence 1985 [23] 4 weeks 15 weeks the case of a very obese younger child where using their actual weight would result in caloric intake recommendations that would exceed their actual needs. The MyPyramid Plan will also provide a picture representation of the appropriate servings from each food group that will add up to this caloric goal. It may be an ongoing area of research to be utilized in specialized medically supervised circumstances or in conjunction with bariatric surgery programs.Rev Endocr Metab Disord Table 5 Summary of pediatric weight loss studies Study Braet et al.1.6 kg . This can provide parents with a clearer picture of where these calories should be coming from in their daily intake.8 kg in the 7 control children.56 kg .15 kg +1. 1997 [8] Treatment program Group Individual Advice Camp Control Protein sparing modified fast Control Peer counseling and lunch box monitoring Control Exercise treatment only Control Weight reduction treatment program Weight reduction program plus parent program Control Parent/child treatment Child only treatment Control Rapid behavioral treatment Gradual procedural treatment Non specific control Waiting list control Mean weight change .42 kg . 1996 [9] Foster et al. There is not enough long-term data on the health consequences of this type of diet to recommend its use in routine clinical practice at this time but it can be effective in controlled settings.69 kg . The Pediatric Weight Management Guidelines from the 2007 ADA Evidence Analysis Library state that if energy restriction in pediatrics is used.6.2 Protein sparing modified fast diet A protein sparing modified fast diet is a low calorie diet that maintains protein balance and limits carbohydrates to induce a relative state of ketogenesis.84 kg . 1985 [21] Kirschenbaum et al. there was a statistically significant mean weight loss of 5. 3.5 kg + 2.2 kg .

JAMA. In a larger. controlled 12-week trial of a low carbohydrate diet in obese adolescents. Initial dietary interventions should focus on developing a nutritionally balanced. portion controlled eating plan that is age appropriate. the Stoplight diet is designed for younger children ages 6–12 but can also be used as a basic starting point for older patients as well [11. Low carbohydrate diets are not currently recommended for long-term weight loss in children. This work is instrumental in promoting the idea that one diet does not fit all and why some dietary changes may help people with certain body types and not others. At 1 year. Ogden CL. This is best accomplished in a clinical setting in collaboration with a pediatric dietician trained in weight management. 4 Summary Evidence has shown that education alone is not enough to effect lifestyle changes.05) and had improvement in non-HDL cholesterol levels (P<. 27].295:1549–55. 2. Examples include: non starchy vegetables. P <. French fries.9 kg. However. Diet composition and weight were monitored and recorded every 2 weeks.3 kg vs.4. 4. The concept of “glycemic load” takes into account the amount of carbohydrate consumed as well as the food’s ability to contribute glucose to the bloodstream after ingestion. most fresh fruits. There are no long-term studies on low carbohydrate diets in children. There was improvement in LDL cholesterol levels (P<. that followed the low GI diet experienced a greater degree of weight loss. The control group (n= 14) was instructed to consume <30% of energy from fat. assessment. should be eaten away from the home or not at all. Examples include: bananas. There were no adverse effects on the lipid profiles of participants in either group. high fiber foods. reinforced with daily tracking of the desired behavioral changes and use of incentives. lower calorie diet. Larger randomized studies need to be conducted on low carbohydrate and low glycemic index diets [25. which is referred to as the glycemic index. eliminating sugar sweetened beverages and emphasizing intake of lower calorie. 2006.Rev Endocr Metab Disord 3. skim milk. yellow and green light foods.05) in the low fat control group but not in the low carbohydrate group. Barlow SE. soda pop The energy goals for Epstein’s Stoplight diet range from 900–1300 calories/day (ages 6–12) and daily recording/ journaling of all food and drink consumed is an integral component of this intervention. lean meats. [26] no difference was seen in weight loss between groups following a low GI diet and low fat diet. The reduced glycemic load diet imposed no specific calorie restriction but encouraged the intake of low glycemic index foods such as fruits. These types of foods can also be referred to as “Go. 1999–2004. sugar added yogurt. whole grain no sugar added cereal Yellow light foods: viewed as essential to a healthful diet but due to higher nutrient density should be eaten in moderation. Green light foods: low calorie. pasta and rice Red light foods: high in fat or simple sugars. high fiber foods such as fruits. low fat group. 12].1 The stoplight diet Developed in the 1970’s by Leonard Epstein. the low GI group had greater reduction in BMI compared to the conventional. Obese younger children who do not respond to the above interventions and adolescents who are no longer growing require a more in depth analysis of their dietary intake and a more specific meal plan that reduces caloric intake while maintaining nutritional balance. Recommendations to eat more low glycemic index foods can certainly be incorporated as part of a safe. other than food. then <40 g/day for 10 weeks. Serum lipid profiles were obtained at the start of the study and after 12 weeks. global approach which may hold promise for longer term success [28]. It focuses on red.05). limited to no more than 1 servings per week. with no restrictions placed on intake. Prevalence of overweight and obesity in the United States. raisins. References 1. and to eat low carbohydrate foods according to hunger. green leafy vegetables and low fat dairy products. The study group (n=16) was instructed to consume <20 g of carbohydrate per day for 2 weeks. candy. Sondike et al [24] conducted a randomized. vegetables and whole grains. Examples include: ice cream. The low carbohydrate group lost more weight (mean. to help in sustaining motivation. sour cream.4 Lifestyle-modification diets 3. dried fruits. In 2003 Ebbeling et al [25] randomized 16 adolescents (2 drop-outs) to a reduced glycemic load diet compared to a low fat. 3. Dietary habit changes need to be presented within the setting of concrete and measurable goals.9±9. Slow and Whoa” foods. adolescents and limited data in adults as well.1±4. 9.3 Low carbohydrate and low glycemic index diets In 2003. high simple sugar foods. and treatment of child and adolescent . follow-up study. those participants with baseline increased markers of insulin resistance. Expert committee recommendations regarding the prevention. This is generally accomplished by reducing high fat.

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