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Obesity is recognized by the World Health Organization as an emerging epidemic with significant health risks. This paper outlines the issues for overweight and obese adolescents in Canada, and provides guidelines for providing practical, office-based management in the community. The focus is upon promoting healthy approaches to weight, eating and activity.
L’Organisation mondiale de la santé définit l’obésité comme une épidémie en émergence comportant des risques importants pour la santé. Cet article souligne les enjeux pour les adolescents gras ou obèses au Canada et fournit des directives afin d’offrir un traitement pratique en cabinet privé dans nos collectivités. On se concentre sur la promotion d’une démarche saine face au poids, à l’alimentation et à l’activité.
The World Health Organization (WHO) has drawn attention to the “escalating epidemic of overweight and obesity” (1). In June 1997, they released the results of the WHO Consultation on Obesity. The results focused attention on the attendant risks of obesity in adulthood, but included important references to the issues of children and adolescents (2–4). In July 1997, the Canadian Medical Association Journal (CMAJ) issued a special supplement titled Obesity: A risk factor for cardiovascular disease (5). This supplement summarizes the adolescent-specific components of these documents and offers physicians some practical, clinical guidelines about their important role in the management of adolescents with obesity.
The definition of obesity in most adolescents is unclear. Developmentally prepubertal adolescents gain in percentage body fat. As they progress through puberty to full adult physique, males reduce the percentage of body weight as fat, while females increase their percentage (6). As noted in the WHO and CMAJ documents, the body mass index (BMI) is probably a less than adequate measure to use to classify obesity in adolescence scientifically (3,5). The combination of BMI and waist circumference may have the best predictive value for risk of cardiovascular disease in adulthood (5).
For practical, clinical purposes, the BMI ([weight in kg divided by height in m] squared) is the preferred measure, with scores between 25 and 27 considered as overweight and above 27 as obese. In some countries, BMI scores of 30 or greater are used to define obesity. An alternative is to refer to weight for height charts (eg, United States National Center for Health Statistics), and any value that is 120% above the median can be considered as signifying obesity.
In Canada, the prevalence of obesity among the general population has changed little in the past 15 years. About 27% of adult females and 35% of adult males are obese and at significant risk for chronic disease. While the prevalence of obesity in the general population increases substantially after adolescence, it is clear that the presence of obesity during adolesence increases the individual risks in adulthood (7).
In a 1992 survey of almost 16,000 adolescents (grades 7 to 12) in British Columbia, 13% reported heights and weights that, when calculated as BMI, classified them as overweight or obese (8). More important is what individual adolescents think, feel and do about their weight and shape. For example, 32% of students felt that they were overweight, and 56% reported wanting to lose weight. These perceptions were more common in females and increased with progression through the grade levels. Among females 42% of grade 7 and 59% of grade 12 students reported exercising to lose weight, and a discouraging number of students reported using other weight control techniques such as dieting, purging and consuming diet pills.
Dietary and activity patterns established in childhood and adolescence have significant impacts on pubertal development and on health in later life. For example, some normal weight adolescents will join their overweight peers to form the population of obese adults at risk for cardiovascular disease and hypertension. These behaviours may set the stage for the variety of social, educational and employment difficulties experienced by many obese adults (and some adolescents) (4). The potential health consequences of obesity during childhood or adolescence are listed in Table 1.
Appearance has important social and emotional meaning for adolescents. The British Columbia survey indicated that weight- and appearance-related concerns among adolescents were exceedingly common, and were not limited to adolescents who are clinically defined as overweight or obese. The social and cultural milieu within which weight-preoccupied or obese adolescents must function may foster distorted thinking and behaviour about their appearance. Such distortions, if combined with an early adolescent preoccupation with fat or ‘fatness’, or early engagement in disordered eating and weight control practices, may contribute to a lifetime of struggle with anorexia nervosa and/or bulimia.
Early adolescents generally seek help at the insistence of a concerned parent, school teacher or public health nurse. Mid to late adolescents usually present as self-referrals or after having been caught engaging in disordered eating patterns. Most will have already tried commercial diet programs or one of the many weight loss regimens described in popular teen magazines. Many will have experienced the classical ‘yo-yo’ pattern of loss, regain, loss, etc. At presentation, most adolescents will deny being teased or even being worried about their weight, but, as clinical rapport builds, a different story will emerge.
History is the most important component of a clinical assessment. It should include a thorough family history of obesity and attendant risks of obesity. Age of onset of obesity in family members and presence of diabetes, cholesterol concerns, hypertension and other cardiovascular disease, as well as breast cancer and other newly identified risks should be elicited. It is also important to find out about family members’ attitudes towards food, weight and shape, and develop an understanding of the mother’s own struggles with these issues. While genetic and other familial or lifestyle factors are the most common causes of obesity in adolescents, the assessment should rule out organic and psychiatric causes.
The clinical history should cover the weight and growth history of the adolescent with special reference to eating and activity patterns. The nature of foods consumed (fibre, fat and salt content), the timing of meals and snacks and where consumed, evidence of binge behaviours and solo eating, and use of diet products (diet pills, diet drinks and over-the-counter remedies) are important to explore with the adolescent alone and with his or her parents. The extent and nature of physical activity (hours in front of television or video games, after school habits and type of sports played) plus evidence of limitations in activity due to the obesity (pain, shortness of breath and physical bulk) should be explored and observed firsthand.
Clinical examination should include height, weight, and girths (including waist). It is not necessary to perform skinfold measurements. If skinfold measurements are completed, they should be performed in a consistent, standardized manner by a skilled nurse, physician or nutritionist. Aside from seeking evidence of organic etiology of the weight problem, the examination should determine general body build, main distribution sites of adiposity and problems with personal hygiene (body odour, skin creases and self-care). Blood pressure, pulse, evidence of joint problems and presence of bulimic stigmata should be recorded. A brief evaluation of intelligence, obsessive or depressive symptoms, and motivation should complete the assessment.
The adolescent with obesity faces a number of present and future risks, including physical and emotional problems in adolescence, a complex mix of social, educational, recreational and employment challenges in the young adult years, and the longer term prospect of increased morbidity and mortality. The adolescent with obesity, who at an early age is exposed to rigorous dieting, may negatively affect growth and bone metabolism, and is at risk for the complications of anorexia nervosa and bulimia. The task of the clinician is to help the adolescent steer clear of the risks, while promoting the positive self-image and coping skills that will equip him or her to deal with the complex mix of challenges in young adulthood.
The goal of successful management is size acceptance within a healthy eating, healthy activity framework. The adolescent may present with the desire to loose substantial amounts of weight, but this is often an illusory, self-defeating objective. In managing obese adolescents, it is important to establish realistic goals based on small incremental losses to a total of about 10% of presenting weight. With the rapidly growing adolescent it is preferable to offer to help them not to gain more, while with the adolescent who has achieved maximum height it may be preferable to focus on stopping the yo-yo. Essentially, this involves a three-step approach to weight: stop gaining, start losing, and learn to level off and maintain.
An obese adolescent should be asked to keep a record of all intake and activity in a single week. This is not a popular or consistently performed exercise, so a little parental supervision helps. The physician should stress that this information will be used to help understand the adolescent’s situation and guide the advice given. Remind them that it is not helpful to leave things out or fake the record. Some clinicians prefer to avoid this step and simply refer the adolescent to a dietician. However, the dietician will want to have the same information, and it is suggested that the doctor review the diet/activity/feelings record before making a referral. As with any other referral of an adolescent patient, it is wise to ensure that the person to whom the adolescent is referred is someone who likes working with adolescents and works in an adolescent-friendly program.
Some clinicians prescribe a diet or meal plan. If done, this should start slowly at about 300 kcals less than what the adolescent is currently consuming. This can be accomplished by suggesting small dietary changes such as switching to skim milk, using low fat milk products, and reducing butter, margarine and cheese consumption. Further decrements can follow as the weight gets under control. Avoid very low calorie regimens or fad diets, and encourage adolescents to learn and follow Canada’s Food Guide To Healthy Eating’s guidelines.
Many methods and programs are available to assist clinicians in this process. There are self-help books, peer support groups, adolescent-oriented weight loss clinics, acupuncturists and naturopaths, fitness groups and medical clinics that specialize in obesity treatment. They all promise much but in the long run they may only deliver disappointment. A word of caution; none of these approaches will work if the family and the adolescent are just looking for a quick fix and are not motivated for the long haul. For this reason, it is important that the primary physician participate in the management process. There is much that even the busiest of physicians can do (Table 2).
Careful monitoring, a listening attitude and judicious anticipatory guidance are the key elements in medical management. Office visits should include weigh-ins, and dietary and activity reviews; visits should be scheduled for every two to three weeks and provide sufficient time to talk. This is a prime chance to have the entire family on side and supportive of the adolescent’s new eating and activity plan. This support includes family members paying more attention to their own words and actions about needing to lose weight, their excessive preoccupation with diet books and recipes, worries about fitting into last year’s bathing suit, telling fat jokes, etc. Work with the family to get them to choose low fat, high fibre food for meals and snacks for the entire family.
The obese adolescent wishes to be seen as a person, not as an obese person. Obese adolescents need help to develop strategies to cope with high risk times of the year such as birthdays, Valentine’s Day, Easter and Christmas. In the summer months, they lack the routine of school and the interaction with friends. It helps to see them more regularly over the holidays. They need help and encouragement to be more physically active – suggest brisk walking and swimming – and doctors’ help to address the pain and injuries complaints that may interfere with activities. Provide practical suggestions about such things as shoes, clothing and personal hygiene. Selecting a graduation outfit can be a challenge to the obese adolescent. Work on techniques to help the adolescent reduce snacking and binging, and to learn how to substitute tasty low calorie snack foods for the usual adolescent ‘junk food’. Above all, help the adolescent to understand that working with a doctor is the beginning of a lifelong process. It is a process that should develop a commitment to developing positive coping skills, to avoid retreating into negative eating patterns when under stress or unhappy, and to learning to meet the challenge of size and shape in healthier ways.
Adolescents who are overweight or obese may seek medical help for their disorder. The physician has a clear and positive role to play in the management of this troublesome worldwide problem. The potential for early intervention and prevention by physicians is significant. In addition, advances in our understanding of the biology of obesity, such as the role of leptins or the significance of newer genetic models, requires doctors to be mindful of the required changes in the management of these adolescents. The benefits to obese children and adolescents include lower morbidity and mortality in adulthood, optimal adolescent growth and development, and the opportunity to experience a positive relationship with a caring physician. Physicians are encouraged to accept the challenges that adolescent obesity can present.