This chapter addresses the science of childhood and adolescent obesity and the approach to treatment. Although the principles and tools discussed in other chapters are applied to this population, that does not mean that children and adolescents are little adults and do not have unique needs. It does mean that people of all ages physiologically respond in the same way to excess caloric intake. People of all ages also experience the same comorbidities of obesity. The incidence of chronic conditions like hypertension and diabetes has dramatically increased among obese children and adolescents; when present these conditions need to be aggressively treated with the same seriousness in young people as in adults. The long-term health impact for the young obese patient with early onset of these diseases is not known. The potential morbidity and mortality from either hypertension or diabetes after 20 to 30 years may begin to occur during young adulthood. With an early age of onset for these diseases, the young person's life expectancy could be reduced. This premise is consistent with the findings of the Bogalusa Heart Study, which shows that the onset of cardiovascular disease and the effects of hypertension can begin early in life .
Children and adolescents are different from adults and from each other. In this chapter a patient is considered to be a child or pre-adolescent up to 13 years of age and an adolescent from age 13 to 18. This age distinction is important in treatment; the physician should present the weight management program differently to the two age groups.
When treating a young overweight or obese patient, the primary care physician must consider the growth and development of both genders at all ages. One way this is done is through use of the body mass index (BMI) charts for children and adolescents produced by the Centers for Disease Control and Prevention (CDC), which are gender specific for ages 2 to 20. These charts, coupled with the principles and tools presented in this book, can guide the physician in helping the patient progress through a healthy weight maintenance or weight reduction program.
Helping children and adolescents in weight maintenance or weight loss in the primary care setting is more complex and challenging than helping adults lose weight. Growth and development variables within the child and external variables outside the child's control, coupled with the lack of an evidence-based clinical practice guideline for the primary care setting, make helping such patients difficult and long-term weight loss success uncertain at best. As a result of these barriers, it is tempting for the physician to refer such patients to a specialty pediatric obesity treatment clinic. Unfortunately, such clinics typically are not located nearby or are not financially feasible, especially for patients with limited income. Another option is for the physician to offer obese patients and families sound-bite type recommendations like "don't make the child clean his or her plate," "simply reduce TV viewing time," or "play outside until it gets dark." Such an approach may or may not be effective with temporary weight loss. However, this process does not involve a logical method of appropriate patient selection, or implementation of sound dietary, behavioral, and physical activity components of a program tailored to the individual child or adolescent. Finally, the least appealing option for the physician is to ignore the patient's weight condition, hoping the child or youth will hit a growth spurt and grow into their weight. This is not likely to happen when a 9-year-old boy weighs almost 150lb or a 13-year-old girl tips the scale at 200lb. Ignoring the patient's obesity or handing the patient or parent an information brochure with bulleted suggestions for weight loss is not a medically sound option.
The final section in this chapter will discuss three case presentations. Sometimes the patient is successful with weight maintenance or weight loss and sometimes not. Whatever the short-term weight management outcome, the physician can gain some professional satisfaction knowing that unlike commercial products or programs that promise quick weight loss or the misinformation shared by the patient's parents or peers, the physician is treating the patient for a chronic disease with the best information available at this time.
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