Clinical Pearls & Morning Reports
Published July 19, 2023
The prevalence of obesity in adolescents has increased since the 1980s, most markedly in low-income communities and communities of color, a difference that is at least in part attributable to structural racism and stigma (with negative attitudes creating social and economic obstacles to health). Read the NEJM Clinical Practice Article here.
Q: Name the adverse health consequences associated with obesity during adolescence.
A: Obesity during adolescence (10 to 19 years of age) is associated with health consequences that include prediabetes and type 2 diabetes, nonalcoholic fatty liver disease, dyslipidemia, polycystic ovary syndrome, obstructive sleep apnea, and mental health disorders and social stigma. In addition, obesity during adolescence is a risk factor for complications and death from coronary heart disease as well as for death from any cause in adulthood, including early adulthood.
Q: Can the potential harms of obesity during adolescence be mitigated?
A: Combined data from four prospective cohort studies showed that an elevated body-mass index (BMI) in both childhood and adulthood were associated with increased relative risks for type 2 diabetes (relative risk, 5.4), hypertension (relative risk, 2.7), elevated LDL cholesterol levels (relative risk, 1.8), and carotid artery atherosclerosis (relative risk, 1.7), whereas persons with elevated childhood BMI and normal adult BMI had risks for these conditions that were similar to those among persons with normal childhood and adult BMIs. These studies support the importance of diagnosis and treatment of obesity during childhood and adolescence, as well as in adulthood, to reduce adverse health consequences.
A: Supervised marked caloric restriction (very-low-calorie diets) for weight loss in adolescents is not recommended. Studies have shown mixed results with the use of these diets; weight regain is typical, and there are concerns regarding long-term acceptability and safety, including risks of eating disorders, electrolyte or other metabolic disturbances, vitamin and mineral deficiencies, and adverse psychological effect. Although social emphasis on patient-imposed restrictive dieting behaviors is associated with a risk of disordered eating, supervised multidisciplinary weight management and treatment of obesity with ongoing support from a pediatrician, pediatric dietician, and mental health professional are not associated with an increased risk of eating disorders.
A: Management of obesity in adolescents should use a multidisciplinary long-term care model that includes attention to lifestyle modification and consideration of pharmacologic and bariatric surgical therapies. Communication should be considerate of the stigma associated with the term “obesity,” and the use of person-first language (i.e., “person with obesity” rather than “obese person”) is important. Intensive treatment with regard to health behavior and lifestyle, with at least 26 hours of face-to-face treatment over a period of at least 3 months, is a foundational aspect of the comprehensive treatment of obesity. Sugar-sweetened beverages should be eliminated from the diet. The addition of approved weight-loss medications has improved the outcomes of multidisciplinary weight-loss programs in clinical trials. Randomized, placebo-controlled trials have shown the effectiveness of two glucagon-like peptide 1 receptor agonists - liraglutide and semaglutide - in adolescents when combined with lifestyle therapy. The use of antiobesity medications or bariatric surgery (or both) along with intensive treatment with regard to health behavior and lifestyle results in a greater reduction in BMI than lifestyle treatment alone and should be discussed with families, along with the caveats that weight regain is common, data regarding long-term outcomes are lacking, and these treatments are expensive.