Obesity in Children & Teens

Obesity is one of the most common chronic diseases of childhood. In 1998, the National Institutes of Health defined it as a chronic disease. This designation was an attempt to destigmatize obesity and recognize its causes, which include genetic, environmental, psychological, and socioeconomic factors. Since the environment is obesogenic, and obesity is a risk factor for significant comorbidity, it is essential to diagnose and treat obesity in a non-stigmatizing and evidence-based manner.

Other Names

  • Adolescent obesity
  • Childhood obesity
  • Overweight

Key Points

Multifactorial considerations
Obesity is multifactorial and not a result of personal or familial failure. Racism, poverty, and other social determinants of health are important risk factors to consider.

Diagnosing obesity
Body mass index (BMI) is the most straight-forward and commonly available tool for diagnosis of obesity.

Screen for comorbidities
Obesity is both a chronic disease as well as a risk- factor for other chronic diseases. The more severe the obesity, the higher the risk for comorbidities. [Skinner: 2015] Screening for comorbidities is a cornerstone of obesity management (see below for screening guidelines).

Management
Treatment includes nutrition support, physical activity treatment, behavioral therapy, bariatric surgery, and pharmacotherapy. There is no evidence to support watchful waiting.

Weighing treatment risks
Risks of treatment include weight fluctuations and disordered eating. Multiple studies have shown a decrease in disordered eating when children are enrolled in structured weight management programs. Current guidelines stress that the risks of obesity and comorbid conditions outweigh the risks of treatment.

Role of primary care
The medical home is pivotal in diagnosing, treating, and preventing childhood obesity. [Daniels: 2015] Primary prevention includes efforts to influence, in healthy directions, the eating and activity behavior of all children. Secondary prevention efforts are those thrisk at are directed toward children who, for whatever reason, are at greater than average risk of becoming obese. Tertiary prevention is designed to prevent the consequences of obesity and would be considered treatment. Treatment details can be found below. [Daniels: 2015]

Practice Guidelines

In 2023, the American Academy of Pediatrics (AAP) released a new Clinical Practice Guideline for the Evaluation and Treatment of Children with Obesity. The full report and executive executive summary are listed below:

  • Hampl SE, Hassink SG, Skinner AC, Armstrong SC, Barlow SE, Bolling CF, Avila Edwards KC, Eneli I, Hamre R, Joseph MM, Lunsford D, Mendonca E, Michalsky MP, Mirza N, Ochoa ER, Sharifi M, Staiano AE, Weedn AE, Flinn SK, Lindros J, Okechukwu K.
    Clinical Practice Guideline for the Evaluation and Treatment of Children and Adolescents With Obesity.
    Pediatrics. 2023;151(2). PubMed abstract / Full Text

  • Hampl SE, Hassink SG, Skinner AC, Armstrong SC, Barlow SE, Bolling CF, Avila Edwards KC, Eneli I, Hamre R, Joseph MM, Lunsford D, Mendonca E, Michalsky MP, Mirza N, Ochoa ER, Sharifi M, Staiano AE, Weedn AE, Flinn SK, Lindros J, Okechukwu K.
    Executive Summary: Clinical Practice Guideline for the Evaluation and Treatment of Children and Adolescents With Obesity.
    Pediatrics. 2023;151(2). PubMed abstract / Full Text

Screening for Risk Factors

Screening children for risk factors associated with obesity is the principal method for determining which children are candidates for secondary prevention efforts. Screening involves assessing factors from the history and observing an infant or child’s growth pattern. In the 2023 guideline, the American Academy of Pediatrics places increased focus on how social determinants of health and systemic factors increase risks for individuals. The presence of risk factors should prompt the provider to provide early anticipatory guidance for overweight and obesity prevention.

The AAP consensus recommendation is to “perform initial and longitudinal assessment of individual, structural, and contextual risk factors to provide individualized and tailored treatment of the child or adolescent with overweight or obesity." [Gaikwad: 2023]

Risk Factors

Family History of Overweight and Obesity
Studies have consistently shown that overweight and obesity are influenced by genetics. However, the degree to which individuals are affected varies. A 2012 meta-analysis with 115 studies found that BMI heritability ranged from 47-90% and 24-81% in twin and family studies, respectively. [Elks: 2012] Parental obesity more than doubles the risk of adult obesity among children under 10 years of age. [Whitaker: 1997] Furthermore, it is important to note that it is not just genetics that affects risk. Genetic, environmental, and behavioral factors modulate this risk and result in intergenerational transmission of adiposity. [Gaikwad: 2023]

Epigenetic and Prenatal Factors
Although mechanisms are poorly understood, the intra-uterine environment in which an infant develops can alter the way genes are expressed.

  1. Maternal BMI and gestational weight gain are both associated with increased rates of childhood overweight and obesity. [Larqué: 2019]
  2. Infants and children born to mothers with gestational diabetes have greater adiposity at birth and risk of overweight and obesity in childhood. [Logan: 2017]
  3. Both environmental tobacco smoke and maternal smoking during pregnancy are associated with increased risk of overweight and obesity. [Qureshi: 2018]
Birthweight
Low (<2500 g) and high (>4000 g) birthweight are associated with higher risks of overweight and obesity. [Larqué: 2019]
Early Breastfeeding Cessation
Evidence is inconclusive; however, some studies have suggested that early breastfeeding cessation is associated with childhood overweight and obesity. [Larqué: 2019]
Rapid Early Weight Gain
Children with rapid early weight gain, defined as crossing 1 or more percentile lines on growth charts in their first two years of life are up to 3.6 times more likely to have overweight and obesity as children and adults. [Zheng: 2018]
Environmental
The environment in which a child grows has the potential to negatively or positively affect the risk of developing overweight or obesity. For example, studies have shown that children of lower socioeconomic status (SES) are at higher risk of developing obesity. [Hales: 2017] This association is multifactorial and is impacted by public policy factors, how unhealthy food is marketed, school environment, education, access to fresh food or food insecurity, and access to safe physical activity. [Gaikwad: 2023]
Adverse childhood experiences (ACE) and toxic stress have also been associated with higher risk. A 2011 study found that exposure to 4 or greater ACE categories was linked to higher prevalence of obesity.
The home environment also plays a large role in risk. Studies have shown that specific parenting feeding styles can impact weight. Specifically, a meta-analysis found that an authoritative feeding style is protective against obesity. [Sokol: 2017] Family routines and limit setting within the home were also inversely related to obesity. [Bates: 2018] Access to sugar-sweetened beverages, screen time, and dining out increase the risk of obesity. [Luger: 2017]
Children and Youth with Special Health Care Needs (CYSHCN)
CYSHCN are 27% to 59% more at risk than typically developing children to become overweight or obese. [Bandini: 2015] For example, CYSHCN may have less healthy dietary and physical activity patterns because of medical conditions (e.g., spina bifida or cerebral palsy) that limit or restrict opportunities to be physically active. m[Minihan: 2011] They may be taking medications such as atypical antipsychotics (e.g., risperidone), antidepressants, mood stabilizers, and anticonvulsants that increase their risk of excess weight gain. [Vanina: 2002] It is important to carefully monitor the growth patterns of CYSHCN to recognize which of them may be showing a trajectory that may lead to obesity.

Screening for Obesity

The American Academy of Pediatrics (AAP) recommends that pediatricians and other primary health care providers annually screen all children ages 2-18 years old for overweight (BMI ≥ 85th percentile to <95th percentile), obesity (BMI ≥ 95th percentile), and severe obesity (BMI ≥ 120% of the 95th percentile for age and sex) using age- and sex-specific CDC growth charts. Furthermore, due to its ease of use, reproducibility, and sensitivity/specificity, the AAP recommends using body mass index (BMI) as the primary screening and diagnostic tool. [Gaikwad: 2023]

Body Mass Index (BMI)

Obtaining accurate measures of height and weight and calculating and plotting the BMI is the most practical method of screening for obesity. For most individuals, BMI correlates well with direct measures of body fat, and most electronic health records calculate BMI automatically[JM2]. Other methods, such as waist circumference, dual-energy absorptiometry, body-fat composition estimates, and visual assessment, tend to be more expensive, invasive, and less accurate. Also, a variety of charts ((BMI Males 2-20 Years (CDC) (PDF Document 62 KB) BMI Females 2-20 Years (CDC) (PDF Document 68 KB)), websites (BMI Percentile Calculator for Children and Teens (CDC)), and apps are available to assist with calculating the BMI and assessing the percentile.
Most health risks associated with obesity are related to the presence of excessive amounts of adipose tissue as well as its distribution. An elevated BMI strongly correlates with excess adiposity, but the correlation is imperfect. Moreover, BMI does not provide information regarding whether the distribution of the excess adipose tissue is central (visceral) or not. Central or visceral obesity correlates more highly with insulin resistance, type 2 diabetes, and increased cardiovascular disease risk. Clinical judgment and longitudinal patterns of BMI must be used, particularly for children and adolescents who appear to be muscular and whose BMI is minimally elevated.  [Morgan: 2010] [Simmonds: 2016]

Screening for Comorbidities

Children and adolescents with overweight and obesity are at increased risk of associated comorbidities, such as hypertension (HTN), dyslipidemia, non-alcoholic fatty liver disease (NAFLD), obstructive sleep apnea (OSA), depression, abnormal glucose metabolism and diabetes, slipped capital femoral epiphysis, and polycystic ovarian disease. Although the risk of certain comorbidities is greater among certain racial and ethnic groups, it is important to note that the etiology is multifactorial and is related to the impact of genetic, environmental, and social factors. [Divers: 2020] Screening for these comorbidities should form part of the evaluation of the overweight and obese child, given that weight loss interventions can improve many of these conditions. [Rajjo: 2017] As with any other condition, this begins by obtaining a thorough history, which should include the patient’s trends regarding diet, lifestyle, activity, a family and social history that focuses on obesity-related comorbidities and risk factors, and medications that increase obesity risk.

The review of systems and physical exam should be used to assess for comorbidities. For example, a patient with obesity reporting polyuria coupled with acanthosis nigricans found on exam may have diabetes. The AAP Clinical Practice Guideline for the Evaluation and Treatment of Children and Adolescents provides comprehensive tables with common system complaints and physical exam findings along with their associated obesity-related causes.

Evaluation

Further testing for obesity-related comorbidities is an important step in appropriate patients. Identifying abnormalities is important because cardiovascular risk factors present in childhood often carry on into adulthood. Furthermore, studies show that lifestyle modifications and pharmacologic treatment, if appropriate, can improve outcomes. [Juonala: 2011]. The AAP made important updates in evaluation and screening recommendations in their 2023 obesity clinical practice guideline. Identifying candidates for further workup. [Ayer: 2015] is based on BMI classification, history, physical findings, and patient preference.
Dyslipidemia:
The prevalence of abnormal lipids is 3x higher in children with obesity compared to those with a healthy BMI. [Nguyen: 2015] The AAP recommends screening for dyslipidemia with a fasting lipid profile in children 10 years and older with obesity (BMI ≥ 95th percentile) and overweight (BMI ≥ 85th percentile to <95th percentile). In children 2-9 years of age with obesity (BMI ≥ 95th percentile), providers may choose to screen for dyslipidemia. [Gaikwad: 2023].
Abnormal glucose metabolism
The prevalence of type 2 diabetes is increasing in the pediatric population, and overweight/obesity is a strong predictor. [Mayer-Davis: 2017] The AAP recommends screening for abnormal glucose metabolism in children 10 years and older with obesity (BMI ≥ 95th percentile) with fasting plasma glucose, oral glucose tolerance test, or glycosylated hemoglobin. In addition, screening is recommended in children 10 years and older with overweight (BMI ≥ 85th percentile to <95th percentile in the presence of additional risk factors (maternal history of diabetes/gestational diabetes, family history of diabetes in 1st or 2nd degree relative, signs of insulin resistance, and use of obesogenic medications. [Gaikwad: 2023] [Andes: 2020] See Pediatric Type 2 Diabetes Screening & Management Care Process Model.
Non-alcoholic fatty liver disease (NAFLD)
Children with overweight and obesity have increased risk of NAFLD, and some studies have reported rates as high as 34% in children with obesity. [Anderson: 2015] The AAP and the North American Society of Pediatric Gastroenterology, Hepatology, and Nutrition (NASPGHAN) recommend screening for NAFLD using aspartate transaminase in children 10 years and older with obesity (BMI ≥ 95th percentile). Additionally, children 10 years and older with overweight (BMI ≥ 85th percentile to <95th percentile. [Gaikwad: 2023] should be screened in the presence of additional risk factors (family history of NAFLD, central adiposity, signs of insulin resistance, pre-diabetes, diabetes mellitus, dyslipidemia, and sleep apnea. [Gaikwad: 2023]
Hypertension (HTN)
HTN in childhood increases the risk of HTN in adulthood, and its prevalence is directly related to BMI percentile. [Chen: 2008] The AAP recommends measuring blood pressure at every visit starting at 3 years in children and adolescents with overweight and obesity. [Gaikwad: 2023]
In addition to these above-listed comorbidities, providers should evaluate for other conditions such as polycystic ovarian disease, Depression, obstructive sleep apnea, and slipped capital femoral epiphysis as appropriate.
For more information, click the image for full view:
Special Considerations in the Review of Systems for the Patient With Overweight or Obesity [Hampl: 2023]
Review of Systems - Children with Overweight or Obesity
Physical Examination Findings in Children and Adolescents With Obesity [Hampl: 2023]
Exam FInding in Children with Obesity

Risks of Screening

Consideration must be given to the risk of performing unnecessary testing and its accompanying cost. However, given the large impact of the morbidity associated with obesity-related conditions, it is likely that the benefits outweigh the risks. Furthermore, there seems to be a higher likelihood of severe disease or progression in pediatric patients with obesity compared to adult counterparts. [Harlow: 2018] [Newton: 2016] [Holterman: 2013] This highlights the importance of identifying and treating these conditions sooner rather than later.

Treating and Preventing Obesity

Treatment

Treatment should occur through the medical home and can include nutrition and physical activity support, behavioral therapy, pharmacotherapy, and surgery.
Intensive health behavior and lifestyle treatment (IHBLT) has been shown to be an effective behavioral treatment for childhood obesity, but it is challenging to deliver and not widely available. Children age 6 and older can be referred if these programs exist in their community. The more hours of treatment, the higher the efficacy. The most effective treatments included at least 26 hours of face-to-face time. [Grossman: 2017] In places where these programs are not available, the medical home can help connect families to nutrition support, programs to aid in food insecurity, local parks and recreation, and other community services in place of Intensive Health Behavior and Lifestyle Treatment.
Intensive Health Behavior and Lifestyle Treatment [Hampl: 2023]
Intensive Behavior and Lifestyle Changes Related to Obesity
American Academy of Pediatrics
Strategies include:
  • Reducing sugar-sweetened beverages (see MyPlate (USDA)
  • Encouraging 60 minutes of daily activity
  • Reducing sedentary behavior – largely by decreasing screen time. [Daniels: 2015]
Pharmacotherapy can be offered as an adjunct treatment to patients 12 years and older. The FDA has approved semaglutide and several other GLP-1 agonists for the treatment of obesity in children 12 years and older. A weekly subcutaneous semaglutide dose of 2.4mg was shown to decrease BMI by about 16% compared to placebo in adolescents with obesity. Although gastrointestinal side effects are common with GLP-1 agonists (nausea, abdominal pain, reflux, constipation, diarrhea), these are generally mild and do not typically lead to treatment discontinuation. [Malozowski: 2023] At a cost of over $1300 a month at the time of this writing, it is also financially unfeasible for most. Other pharmacotherapy options include metformin, orlistat, phentermine, and topiramate; however, their side effect profile and lower efficacy make them less favorable. [Gaikwad: 2023]
There is evidence to support the referral of patients 13 years and older with severe obesity to metabolic and bariatric surgery (there is no lower age limit, but data is limited under age 13). Unfortunately, these resources do not exist in all communities.

Prevention

Some additional strategies used for treatment can, in theory, be used for prevention. The following have moderately convincing evidence or expert consensus to support their role in prevention, and they likely have health benefits beyond obesity treatment and prevention. Many of these are shown to improve outcomes even without weight loss or reduction in BMI. [Lumeng: 2015] [Davis: 2007]

5-2-1-0 A DAY
The 5-2-1-0 message is widely disseminated and supported by a number of groups and organizations. It is a simple message that clinicians can deliver to parents and children:

  • Five servings of fruits and vegetables
  • Less than two hours of screen time
  • More than one hour of exercise
  • Zero sweetened beverages

Consistent with the AAP approval of a serving of 100% juice, some have modified this to “5-2-1-almost none per day.

Limit Screen Time
Most studies regarding screen time have focused on television. Some, but not all, studies have shown a correlation between hours of TV watched and risk of increased adiposity. Given this correlation, the AAP recommends no screen time for children under 18 months and 1 hour or less per day for children aged 2-5 years. [Healthy: 2023] For children over age 5, the AAP suggests families have a plan to limit excessive use but without an official upper limit. [Council: 2022]

60 Minutes of Daily Exercise
Aerobic exercise is associated with multiple benefits in pediatric patients, including improved bone health, decreased BMI, cardiorespiratory fitness, improved cognition, and reduced risk of depression. The United States Department of Health and Human Services recommends 60 minutes daily or more of moderate to vigorous aerobic exercise. [Piercy: 2018]

No (or almost no) Sweetened Beverages
Strong evidence associates the intake of sweetened beverages with obesity or excess adiposity. [Luger: 2017] Sweetened beverages include soda, sports beverages, and sweetened fruit drinks. Current evidence does not support an association between 100% fruit juice and obesity unless consumed in “large quantities.” The AAP currently recommends that consumption of 100% fruit juice be limited to 1 serving (4-6 oz.) per day for children between 1 and 6 years old and no more than 8 oz for children ages 7-14 years old. [Korioth: 2019] Some pediatricians have questioned the benefits of juice and have recommended that its consumption be even more limited—perhaps to “none.”

Breakfast
Skipping breakfast has been associated with more metabolic dysfunction, including greater waist circumference, higher fasting insulin, higher total cholesterol, and higher LDL, even after adjusting for other potential confounders. [Odegaard: 2013] [Szajewska: 2010] Overweight and obese adolescents are more likely than those of normal weight to skip breakfast. When they do eat breakfast, it is smaller and of a lower nutritional quality. Although no evidence demonstrates that eating breakfast will prevent obesity, no evidence suggests that such a strategy would be harmful.

Appropriate Sleep
There is an association between higher BMI and shorter sleep duration. It may be that decreased sleep increases the hormone ghrelin and decreases leptin, which leads to hunger. Insufficient sleep is associated with increased calorie consumption and decreased physical activity due to fatigue. Encouraging healthy sleep patterns is recommended. [Ruan: 2015]

Nutrition and Children with Complex Health Care Needs

Parents of CYSHCN are often concerned about whether their child’s nutritional needs are being met. Some of these children may have difficulty achieving adequate calories to support appropriate growth, and parents may offer foods that are higher in “empty” calories in the hope that their child will gain weight. Achieving the recommended 5 servings a day of fruits and vegetables may be particularly challenging. It is important to individualize recommendations for calories and dietary constituents based on the child’s condition and potential for physical activity. Careful monitoring of growth trajectories to ensure that the child’s growth is consistent and that weight gain is not excessive for the child’s height is probably the best way of knowing whether more specific recommendations regarding the child’s diet are necessary. It may be appropriate to refer the family to a registered dietician for specific advice regarding the child’s unique needs.

Services & Referrals

Behavioral Therapies (see RI providers [32])
Families with children <10 years old may benefit from a behavioral program that offers child and family counseling focusing on learning new skills, problem-solving, and managing feelings.

Food & Nutrition > … (see RI providers [31])
Refer at onset (or during the first appointment with a patient with obesity) to receive counseling regarding diet and assist with diagnosing eating disorders. Refer to assist in treating eating disorders and teaching healthy living habits.

Weight Loss Programs (see RI providers [0])
Referral may be helpful to reach weight goals.

Resources

Information & Support

For Professionals

Obesity & Children with Special Needs (AbilityPath.org) (PDF Document 1.7 MB)
Excellent presentation detailing the particular risks for CYSCHN and obesity. Includes practical approaches for parents and health care professionals.

Disability and Obesity (CDC)
Summarizes the factors that contribute to some individuals with disabilities being at higher risk for obesity and provides guidance on possible interventions; Centers for Disease Control and Prevention.

For Parents and Patients

Live Well (Intermountain Healthcare)
Education for families about healthy lifestyles; Intermountain Healthcare.

MyPlate (USDA)
Offers personalized eating plans and interactive tools to help plan and assess food choices; US Department of Agriculture.

Let's Move! (obamawhitehousearchives.gov)
Resources for families, parents, children, communities, and health care providers for providing healthy food in schools, improving access to healthy, affordable foods, and increasing physical activity; First Lady Michelle Obama’s initiative for healthy families.

Nutrition & Fitness (KidsHealth)
Nutrition, fitness, and overall health information for parents, kids, teens, and educators. Includes recipes, safety tips, and discussion of feelings; sponsored by the Nemours Foundation.

Tools

BMI Males 2-20 Years (CDC) (PDF Document 62 KB)
Body mass index for age percentiles; Centers for Disease Control.

BMI Females 2-20 Years (CDC) (PDF Document 68 KB)
Body mass index for age percentiles; Centers for Disease Control.

BMI Percentile Calculator for Children and Teens (CDC)
The calculator provides BMI, BMI-for-age percentile, and an easy-to-read interpretation. Results can also be viewed on a CDC BMI-for-age growth chart; Centers for Disease Control & Prevention.

Clinical Growth Charts (CDC & WHO)
Provides links to 2 comprehensive sets of growth charts: the CDC Clinical Growth Charts (preferred for use with children 24 months and older) and the World Health Organization (WHO) Charts (preferred for children under 24 months); Centers for Disease Control and Prevention.

Services for Patients & Families in Rhode Island (RI)

For services not listed above, browse our Services categories or search our database.

* number of provider listings may vary by how states categorize services, whether providers are listed by organization or individual, how services are organized in the state, and other factors; Nationwide (NW) providers are generally limited to web-based services, provider locator services, and organizations that serve children from across the nation.

Helpful Articles

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Authors & Reviewers

Initial publication: January 2024
Current Authors and Reviewers:
Authors: Rachel Tanz, MD
Jose Morales Moreno, MD

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