The obesity rate for children and adolescents is increasing dramatically and presenting health risks that are frequently overlooked by parents and health care professionals. 15% of teenagers were obese in 1980 and 20% were obese in the 1990s. The response of the overweight teen to the discrimination and pressure to be thin often results in disordered eating patterns and harmful practices used to reduce. Culturally, there is an urgent need for adults to become familiar with the problem and help children deal with it in a responsible manner. The new approach to childhood obesity requires that participation of parents and teens. It forfeits the “control” model of food restrictions and dieting for healthier solutions that emphasize positive self-concepts, family relations and addresses weight management by solving its underlying causes. Families must be concerned about the problem but do their best to insure that self-esteem is based on more than appearances.

Frances M. Berg reviewed the issues and the solutions regarding obesity in Children and Teens in Weight Crisis that was published in the Healthy Weight Journal and are included in this overview. The article notes that pressure from the media, fashion industry and the tendency of television to stereotype females as passive has created an unrelenting pressure to be thin. Children and adolescents often respond to this pressure by adopting harmful weight practices in an attempt to lose weight.

THE PROBLEM/UNHEALTHY SOLUTIONS

The centers for Disease Control and Prevention (CDC) in Atlanta announced that 61% of girls and 28% of boys had dieted to lose weight in the past year. Inappropriate and unhealthy methods such as semi-starvation, vomiting and use of diet pills, laxatives and diuretics were all common weight loss methods used by these young people. Statistics showed that athletes were at high risk for dangerous weight control behavior with nearly 53% of gymnasts reporting the use of vomiting to lose weight, whereas wrestlers tended to “make weight” through fluid restriction/dehydration techniques and food deprivation. African-American females were most likely to use laxatives and diuretics while Caucasians generally used vomiting to control weight. These practices are being reported in girls as young as nine years old and are increasing among males.

Taking over the counter diet pills containing phenylpropanalamine (PPA) is a common practice. In a study of 1,368 female and 1,062 male students of Michigan State University (MSU), it was reported that nearly 50% of the females and 6% of the young males had taken PPA in the last year. Pharmacologically, this appetite suppressant, related to amphetamines and ephedrine, does not work without diet and exercise and can be dangerous. Side effects from PPA include: fatigue, hyperphagia, insomnia, mood changes, irritability and, in large doses, psychosis. This is alarming since many of the students in the MSU study took more than the recommended does.

Herbal products such as MaHung (ephedrine and psuedoephedrine) which claims to increase metabolism, and HCA acid, which claims to prevent fat production are popular products – and equally or more dangerous than PPA.

Purging and laxative abuse can cause both acute and chronic problems, including electrolyte imbalance which can lead to cardiac arrhythmias, laxative tolerance which necessitates larger and larger doses and causes sluggish bowel function, iron deficiency anemia, and other problems like cramping, bloating, nausea, constipation and diarrhea.

Most alarming is that smoking is often used as a weight control aid, especially among female smokers. Taken up as a habit to control weight, when attempts are made to quit and weight is gained, the tendency is to return to smoking.

Besides the physical harm involved in unhealthy weight control practices, mental and emotional problems include apathy, moodiness, low self-esteem, perfectionist behavior, social withdrawal, inability to concentrate and binge eating. Dieting and disordered eating habits is common at very young ages and can become an entire way of life. In one study of 494 girls in California, 30% to 46% of nine year olds and 46% to 81% of ten year olds had disordered eating behavior.

Even with all the effort to control weight, obesity is on the rise among our teenagers. According to the Third National Health and Nutrition Examination Survey, in the US, 21% of teenagers between 12 and 19 are overweight, with the percentage of overweight girls being slightly higher than boys. The highest rates of obesity are noted in Hispanic and American Indian children.

THE CAUSE/IMPACT OF OBESITY

The impact of early obesity is controversial. Some researchers, like Jules Hirsch, claim the number of fat cells is fixed during childhood. Other studies indicate that obesity is more complicated and involves genetic and environmental factors. Claude Bouchard says about 50% of adult obesity can be traced to family origin, with children form obese parents can be traced to family origin, with children from obese parents having about 80% chance of becoming obese. Most adolescents continue to be overweight. The more sever the obesity is as a child or teenager, the worse the problem is as an adult. Consequently, there is an increase risk of heart disease at an earlier age.

Family dynamics are considered important by Laurel Mellin, who says that genetics are only part of the problem, but a larger problem may be related to the isolation of children. Mellin’s studies show that the tendency for obesity increased, as families were less engaged and suggests that teaching family interaction skills may be more effective than targeting diet and exercise alone.

A sedentary lifestyle is repeatedly cited as one of the causes for increased obesity among our youth. Girls are particularly prone to be sedentary, with television contributing to the problem in two ways: 1) by stereotyping females as passive and 2) being a sedentary pastime. More lip service is paid to exercise in both the home and the school that real activity. Physical education classes in school are often humiliating for the overweight child or completely neglect the needs of this population, little time is actually spent in physical activity. One study found the average 40 minute physical education class provided about 3 minutes of vigorous activity. At home, many children are almost entirely sedentary, with television being the common culprit. Overweight adolescents watch two times as much television or use computers twice as much as normal weight adolescents. Dr. Epstein, an outstanding researcher in the treatment of adolescent obesity, has shown that decreasing these sedentary activities is as – or more – effective and takes less effort than attempting to have the adolescent participate in an exercise program.

THE TREATMENT OF ADOLESCENT OBESITY

Traditional treatment programs for children and adolescents teach dieting and recommended exercise, behavioral change and gradual weight loss. Dieting, whether very low calorie (liquid) diets or diets to maintain body weight to allow for future growth to normalize the body weight, is traditionally the foundation of adolescent treatment programs. However, there is little evidence that long-term success is achieved from restrictive dieting. Consistent exercise is associated with better long-term weight loss results.

The new approach to solving a weight problem in adolescents involves helping them to become healthy and happy at whatever size they are. Encouraging this helps them to manage their energy balances by establishing habits they can maintain over a lifetime. This is consistent with what Dr. John Foreyt from Baylor College of Medicine presents in Living Without Dieting. This approach contrasts with the traditional “control” paradigm of food restriction and dieting. The importance of training teachers is being noted, since studies show that the wrong kind of intervention is worse than excess weight, and healthy solutions that proceed in a natural manner, are preferred. Such healthy solutions included emphasizing exercise and teaching parents and adolescents to trust each other. Parents should be responsible for providing wholesome and appealing food at predictable and pleasant times and children should be trusted to decide how much and what they want to eat of what is available.

Recent research indicates that mothers who are more controlling of their children’s food intake have children who show less ability to self-regulate. Children get too fat when parents systematically overfeed them, restrain food intake or are preoccupied with keeping them from being fat.

The new focus is to identify and deal with the underlying causes of being overweight, such as stress in the family, suing food demands as a manner of attracting attention or under activity caused from depression. Promoting aerobic activity in exercise classes at school and becoming more preoccupied with reducing television time by providing opportunities for activity are encouraged. Parental involvement is necessary to success in the new approach to treating obesity. The reasoning is that it is unrealistic to expect a diet to cure what a whole family system is promoting. And parental support is vital to having the child feel loved and accepted, which is essential to successful weight management.

The best predictor of adolescent weight loss is for the parent to be a good role model and lose weight if he or she is overweight. Stress or conflict is adversely related to weight loss. Thus, parents need to resolve those problems or their problems as they attempt to help their teenager with his/her problem.

Guidelines and responsibilities for teens and families in contemporary, successful adolescent weight-loss programs include:

For Family/Parents:

• Respect individual food preferences.
• Offer a variety of foods.
• Understand physical differences in the need for food.
• Convey non-judgmental attitudes.
• Demonstrate unreserved acceptance of the teen.
• Maintain structured meals and snacks.
• Help the teen to detect and trust hunger, appetite and satiety.
• Don’t reward with food.
• Cut down on feeding cues (reminders) by putting food out of sight, confining eating to the table and turning off the TV at eating time.
• Keep the caloric density of food moderate and avoid use of high fat, high sugar foods.
• Don’t deprive your child of treat foods.
• Think of your child as normal when making food decisions.

For the Teen:

• Take responsibility for your own appetite and tastes within the family setting.
• Understand the signals in your body for hunger.
• Use consistent physical activity as a source of energy.
• Eat for energy and health.
• Appreciate genetic and growth factors in personal appearance changes.
• Try to achieve a healthy body image.
• Express yourself assertively.
• Take a critical look at media message about health/body image.
• Measure health as a state of energetic and confident well being as opposed to a number on the scale.

For Both Teens and Family

• Be realistic about the outcome.
• Shore responsibility for eating.
• Support and enhance social functioning.

MEDICAL AND SURGICAL TREATMENT

Very low calorie diets (VLCDs) are controversial and have been shown to be ineffective long term. These programs (usually referred to as liquid diets) use protein-sparing, modified fast providing less than 1000 calories per day and should be under the supervision of a physician. In England, they are not recommended for use by children under 13 though in the US no consensus exists on what represents appropriate indications for its use by children. There has been, however, in view of 20 years use, phentermine and fenfluramine can be considered in the context of a comprehensive program which involves nutrition education and management, exercise counseling and/or a structures exercise program, peer support and family support. The success is greater when both parents participate. For teenagers under 16 years old, medication should not be used without a trial of nutrition counseling and development of a regular exercise program for three months. Best results come from committing to a professionally supervised program for 12 to 24 months. This is reasonable even though research shows the medications fenflueamine and phentermine do not produce dependency. Just as when treating adolescents and children with medications for attention deficit disorder and hyperactivity, physicians treating obesity with medications are concerned about the abuse of medications.

Consequently, teenagers should only be placed on medications if they agree to and are committed to a comprehensive program with intense supervision. Adolescents with drug or emotional problems should not begin medications unless they have been drug-free for a year, have approval and cooperation from their therapist and stress and family issues are being addresses by a mental health professional.

Teenagers with over 100 pounds to lose and a family history of obesity should consider surgery if medications fail. There is limited experience with surgery in adolescents, however, in one study at the University of Florida Department of Surgery showed a higher level of complications than in adults.

Dr. Borrell is a board certified physician with graduate certification in child, adolescent and adult psychiatry. He is an Assistant Clinical Professor at Baylor College of Medicine and The University of Texas Medical School at Houston and Consultant to the Adolescent Medicine Clinic at Baylor. He has practiced in Houston for 15 years with children, adolescents and adults, specializing in eating, compulsive and additive disorders. He has treated over 2000 patients at M.D. Managed Weight Care, a Houston company, which is affiliated with Comprehensive Weight Management, a national company for the treatment of sever obesity through surgery. Dr. John Foreyt, with the Baylor College of Medicine and Dr. Salvadore Maddi, with the University of California at Irvine, consult to determine the outcome of treatment and to develop treatment strategies.