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Clinical Crossroads |

Weight Loss Strategies for Adolescents:  A 14-Year-Old Struggling to Lose Weight

David S. Ludwig, MD, PhD, Discussant
JAMA. 2012;307(5):498-508. doi:10.1001/jama.2011.2011.
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With prevalence approaching 20% in the United States, adolescent obesity has become a common problem for patients, parents, and clinicians. Obese adolescents may experience physical and psychosocial complications, as illustrated by the case of Ms K, a 14-year-old girl with a body mass index of 40. Unfortunately, the effectiveness of pediatric obesity treatment is modest in younger children and declines in older children and adolescents, and few interventions involving adolescents have produced significant long-term weight loss. Nevertheless, novel strategies to alter energy balance have shown preliminary evidence of benefit in clinical trials, including a diet focused on food quality rather than fat restriction and a lifestyle approach to encourage enjoyable physical activity throughout the day rather than intermittent exercise. Parents can have an important influence on weight-related behaviors in adolescents despite typically complicated emotional dynamics at this age, especially through the use of noncoercive methods. A key parenting practice applicable to children of all ages is to create a protective environment in the home, substituting nutritious foods for unhealthful ones and facilitating physical activities instead of sedentary pursuits. Other behaviors that may promote successful long-term weight management include good sleep hygiene, stress reduction, and mindfulness. Ultimately, the obesity epidemic can be attributed to changes in the social environment that hinder healthful lifestyle habits, and prevention will require a comprehensive public health strategy.

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Figure 1. Patient's Growth Chart
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Ms K's height and weight throughout childhood on growth curves from the Centers for Disease Control and Prevention.

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Figure 2. Conceptual Model of Cycle of Childhood and Adult Obesity
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Childhood obesity may lead to adult obesity because of greater duration of excessive weight gain; the tendency for obesity-promoting diet and physical activity habits to track into adulthood8; persistence of biological changes that promote obesity involving, for example, fat cell size, number, or distribution9; and psychosocial issues that cause weight gain and/or antagonize weight loss, including poverty and depression.10 Adult obesity, in turn, may cause childhood obesity through in utero metabolic programming as discussed in the text; parental modeling of obesity-promoting diet and physical activity habits11; normalized perception of excess weight, wherein obesity in a child may be unrecognized or encouraged12; and parental psychosocial issues. Medical and economic costs for society will likely escalate unless this cycle can be arrested.

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Diet is a four letter word!
Posted on January 5, 2012
Brian E. Hunt, PhD
Wheaton College
Conflict of Interest: None Declared
While extreme, Ms K's presentation is typical, both for children and adults. The focus on short-term weight management, the use of meal skipping in an attempt to reduce caloric intake, the added family and social stress related to her obesity, and lack of sustained physical activity. But how should Ms K. and her parents be advised?
First, the term diet, that is strageties aimed at rapid, short-term weight loss, should be eliminated from the discussion. Significant, rapid weight loss leads to psychological and biological adaptations intended to minimize the loss of energy stores. Perhaps the most famous study was performed by Ancel Keys during WWII which demonstrated increased fixation on food, reduced satiety upon eating, increased anxiety and symptoms of depression, and disordered eating behaviors among men who under went substantial caloric restriction[1]. Other studies have shown that rapid weight loss leads to sustained changes in homrones related to satiety, making it difficult to sustain the caloric intake necessary to sustain the weight loss[2].
As for the obesity per se., she should be advised to start eating a nutrient rich breakfast. Several studies have shown that meal skipping leads to increased caloric intake upon the next meal. K.S. Stote and colleagues reported that meal skipping leads to increased hunger before meals, increased desire to eat, fixation on food, reduced satiety upon eating[3]. Not only should Ms K eat more, but she and her parents should slow down at meal time. Several years ago Andrade reported that increased extended mealtime led to increased satiety and lower caloric intake[4]. Peptide YY and GLP-1, hormones related to satiety, are increased in people who consume a meal in 30 minutes compared to 10 minutes[5]. So sit down and enjoy breakfast and dinner together, and mom and dad should be encouraged to stop focusing on their daughter's body weight.
While childhood obesity is an independent risk factor for adult obesity, diabetes, heart disease and some forms of cancer, the abject failure of weight loss programs to produce long-term weight loss has nudged clinicians, dietitians, and physiologists to focus more on healthy behaviors that will improve metabolic and cardiovascular health independent of body mass. At the most recent meeting of the American College of Sports Medicine a symposium was held addressing this issue titled "Does Weight Loss as a Primary Outcome Undermine Obesity Treatment Programs?". The consensus recommendation was to focus on over-all health outcomes - reduced cholesterol, sympathetic activity, blood glucose and increased aerobic capacity, arterial compliance, and skeletal muscle mass. All these factors can be improved with little change in body mass while improving the overall risk of cardiovascular and metabolic disease as an adult.
While not mentioned, sleep may be an important factor to consider. There are substantial increases in human growth hormone, important for maintaining lean body mass and decreases in cortisol, important for the storage of energy as adipose. As much as we would like to increase her physical activity, adequate sleep is an important factor in weight management.
Lastly, we need to applaud and encourage Ms K for her attempts to be physically active - walking home from school and playing field hockey. These types of activities need to be encouraged. Not so much to lose weight, but to improve her psychological function (reduced symptoms of depression from which she likely suffers) and her cardiovascular and metabolic health. While exercise has not been shown to be a successful strategy for long-term weight loss, it is an important part of a broad- based weight management plan as stated in the ACSM position stand on the "Appropriate Physical Activity Intervention Strategies for Weight Loss and Prevention of Weight Regain for Adults"[6].
In summary, Ms K and her family should be encouraged to stop thinking about short-term weight loss. In fact, Ms K. should be encouraged to eat appetizing, nutrient dense foods more regularly, and to slow down and enjoy the experience. Emphasis should be placed on improved cardiovascular and metabolic fitness rather than body weight. Physical activity should be included as part of her plan, but not to lose weight. More social forms of physical activity/play might be preferable as often times social support plays a key role in compliance.
1. Kalm LM, Semba RD. They starved so that others be better fed: remembering Ancel Keys and the Minnesota experiment. J Nutr. Jun 2005;135(6):1347-1352. 2. Sumithran P, Prendergast LA, Delbridge E, et al. Long-term persistence of hormonal adaptations to weight loss. N Engl J Med. Oct 27;365(17):1597- 1604. 3. Stote KS, Baer DJ, Spears K, et al. A controlled trial of reduced meal frequency without caloric restriction in healthy, normal-weight, middle- aged adults. Am J Clin Nutr. Apr 2007;85(4):981-988. 4. Andrade AM, Greene GW, Melanson KJ. Eating slowly led to decreases in energy intake within meals in healthy women. J Am Diet Assoc. Jul 2008;108(7):1186-1191. 5. Kokkinos A, le Roux CW, Alexiadou K, et al. Eating slowly increases the postprandial response of the anorexigenic gut hormones, peptide YY and glucagon-like peptide-1. J Clin Endocrinol Metab. Jan;95(1):333-337. 6. Donnelly JE, Blair SN, Jakicic JM, Manore MM, Rankin JW, Smith BK. American College of Sports Medicine Position Stand. Appropriate physical activity intervention strategies for weight loss and prevention of weight regain for adults. Med Sci Sports Exerc. Feb 2009;41(2):459-471.
Treatment of pediatric obesity
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Conflict of Interest: None Declared

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