Four Stage Treatment Recommendations
"Primary goal in obesity treatment is improvement of long-term physical health through permanent healthy lifestyle habits."
Barlow and the Expert Committee have recommended a four stage treatment plan for patients and families, with increasing intensity at each stage (Barlow, 2007).
Patients should be given a trial of 3-6 months at one stage before advancing to the next stage of treatment. Outcome measure is weight or BMI percentile.
Stage 1 - Prevention Plus
Families focus on basic healthy lifestyle eating and activity habits with improved BMI status
- Consume > 5 servings of fruits and vegetables every day. Use mypyramid.gov to identify specific servings for each fruit and vegetable according to age
- Minimize sugar-sweetened beverages - soda, sports drinks, and punches. These should be completely eliminated if possible although a reduction to 1 serving per day is okay.
- Decrease television viewing (and all screen time) to < 2 hours per day. (<2 years of age = no television). Do not have a television in the patient's bedroom.
- Be physically active > 1 hour each day.
- Prepare more meals at home rather than purchasing restaurant food
- Eat at the table as a family at least 5-6 times per week
- Consume a healthy breakfast every day
- Involve the whole family in lifestyle changes
Allow the child to self-regulate his or her meals.
Help families tailor behavior recommendations to their cultural values.
Target specific behaviors.
Account for financial situation.
Identify and account for cultural beliefs and living conditions.
Implement changes in accordance with the family's schedule.
This stage can be initiated by any health care provider - physician, nurse practitioner, physician assistant, nursing staff
Stage 2 Structured Weight Management
- A planned diet or daily eating plan with balanced macronutrients, in proportions consistent with Dietary Reference Intake recommendations, emphasizing foods low in energy density.
- Structured daily meals and planned snacks (breakfast, lunch, dinner, and 1-2 snacks) with no food or calorie-containing beverages at other times
- Additional reduction of television and other screen time to < 1 hour per day
- Planned, supervised, physical activity or active play for 60 minutes per day
- Monitoring of these behaviors through use of logs
- Planned reinforcement for achieving targeted behaviors
Dietitian
To help develop a structured eating plan and outline appropriate food choices.
Counseling
To help with parenting skills, conflict resolution or motivation.
Physical therapist or exercise therapist referral
To develop physical activity habits.
Patients should be seen at least monthly in the office
Stage 3 - Comprehensive Multidisciplinary Intervention
Structured program in behavior modification
Includes food monitoring, short-term diet and physical activity goal setting, and contingency management.
- Negative energy balance (calories out > calories in) resulting from structured dietary and physical activity changes is planned.
- Parental participation in behavior modification techniques is needed for children < 12 years of age.
- Parents should be trained regarding improvement of the home environment.
- Systematic evaluation of body measurements, diet, and physical activity should be performed at baseline and at specified intervals throughout the program.
- A multidisciplinary team with experience in childhood obesity, including a behavioral counselor, registered dietitian, exercise specialist, and primary care provider who continues to monitor medical issues and maintains a supportive alliance with the families should be involved.
- Frequent office visits should be scheduled; weekly visits for 8-12 weeks and subsequently once monthly.
- Group visits may be more cost-effective and have therapeutic benefit.
- An established pediatric weight management program may be best suited to provide this type of intervention, although such programs are sparse and often not covered by insurance plans.
- Commercial weight management programs can be considered, but the PCP's office needs to screen the programs to ensure that the approach is healthy and appropriate for the age of the child.
Stage 4 - Tertiary Care Intervention
This is not currently available at UTMB in Galveston.
Medications
Sibutramine (SSNRI) - can increase weight loss in adolescents participating in a diet and exercise program (trade names Reductil and Meridia, by Abbott )
Orlistat (trade name Xenical, by Roche )- causes fat malabsorption through inhibition of enteric lipase.
Sibutramine is approved in patients > 16 years and orlistat in patients > 12 years of age
The following medications are NOT approved for use in children:
- Phentermine
- Diethylpropion
- Ephedrine
- Ephedra alkaloids
Very Low-Calorie Diet
Long term outcome data are not available for this intervention
