TREATMENT OF OBESITY IN CHILDREN AND ADOLESCENTS
Obesity should be detected and treated with precaution to avoid complications and persistence in adult life. The success of the treatment of obesity is based on a decrease of ingested calories in relation to the burning of energy, keeping in mind that eating guidelines must instill eating habits and a appropriate lifestyle that, on the long term, promote a loss in weight in relation to height, age, and that an ideal weight is maintained without affecting the growth and development of the child.
The three basic pillars of treatment of obesity are the modification of ingestion, an increase in physical activity and a change in eating habits..
The treatment of obesity in children is usually done in three phases:
a) FInitial phase of treatment: they should not expect to simply lose weight, but to establish and instill eating habits and a healthy life style. This requires a change in conduct of the entire family environment.
b) Adhering to treatment phase: The comprehension, acceptance and realization of the proposed treatment must be agreed upon and they must start to make objectives for losing weight. A close observation of the child's progress is necessary to evaluate their capacity to adhere to the treatment and continue to advance in the same manner.
c) Maintenance phase: during this stage eating habits and regular physical activity must continue to be supervised.
Modification Of Energy Ingestion
Nutritional counseling is essential and must always be accompanied by a change in attitude as much by the family as by the child. Education on the composition of foods and stressing the importance of distribution is as vital as daily eating, to construct the base for which treatment is successful.
Customs, way of life, clinical history, possible additional complications of obesity and the possible presence of eating disorders in the child and the family must be known. Eating should be personalized according to tastes, hours, socioeconomic level, and possible complications of obesity.
Strict diets are only indicated in severe cases of obesity. It is important to avoid absolute prohibitions of certain foods because it makes it difficult to follow a diet and can create problems of anxiety.
A change in nutrition does not only require collaboration of the parents, but also grandparents or people who look after the children. Nutritional modifications have to be specific, easily managed, ending in the child following the diet and maintaining motivation without damaging their growth. Preference is given to hypocaloric cooking and that which conserves the real flavor of the food, like steamed, grilled, papillot, etc.
The child should eat five meals at regular hours: breakfast, mid-morning, lunch, mid-afternoon and dinner, dividing the amount of total energy/calories in the following manner: breakfast 20%, mid-morning 15%, lunch 30%, mid-afternoon 15% and dinner 20%.
En las niñas es frecuente la aparición de trastornos menstruales, con mayor incidencia de síndrome de ovario poliquístico.
a) Energy/Calories: must be a function of the spontaneous ingestion of the child, appropriate reduction being 20-25% of their habitual intake (presumed to be around 500 Kcal). The amount of energy will readjust during the course of treatment and due to the loss in weight, there is a decrease in the basal metabolism:
b) Carbohydrates: should make up 55-60% of the total calories. It is helpful to exclude sweets.
c) Proteins: make up 15% of the total daily calories. This should include lactic proteins (fundamentally low-fat or fat-free) at breakfast and mid-morning meals to assure a source of sufficient calcium. The rest of the protein comes from lunch and dinner.
d) Lipids: their consumption should not surpass 30% of the total energy ingested, according to the proportion: 10% saturated fat, 10% monosaturated and 10% polysaturated. Avoidance of fatty meats, sausages, chocolate and related sauces, is necessary. The use of vegetable oils is preferable (olive, sunflower, corn, etc)
e) Vitamins and minerals: the recommended necessities for each age group should be respected.
f) Fiber: 20-30 g/day is recommended
g) Drinks: water, mineral water with or without gas, tisane and infusions can be consumed liberally.
Exercise
In general, physical exercise programs are structured with aerobic activities associated with a change in lifestyle. They must promote exercise in team sports while at the same time decreasing the hours of playing on computers or watching television.
Physical activity should be done at least three times per week, initially for 15 minutes, progressing to a level of 30-40 minutes. The intensity should reach a heart rate of no higher that 50-60% of the maximum heart rate.
Patients with severe obesity should not do intense physical exercise, as the excess of weight can damage the limbs. In addition, they may not have the capacity to carry it out because of the development of feelings of frustration and rejection of this activity. In these cases, finding opportunities to increase their physical activity (helping at home, walks, not lying down after meals, etc) is necessary.
Psychological Treatment And Support
The methods for decreasing the grade of obesity is a function of changes in behavior that must, at first, analyze the behavior centered around actions related to eating (type and frequency of foods consumed), as well as previous behavior and the consumption of food.
A method must be directed through the family as a base. The family can learn a series of skills to make appropriate changes. Parents must be conscious of bad eating habits and activities of their child (or the family in general), and the behavior of the parents themselves in the face of the problem.
They should change their behavior in a slow and progressive, but permanent manner, making small changes only when they have achieved previous goals.
Emotional support is extremely important during adolescence, a time when emotional problems of children with obesity and their family can worsen. It is recommended that work in support groups help with the impact on the family.
Pharmaceuticals And Surgery
Currently there are no approved pharmaceuticals for the treatment of child obesity; however there are clinical studies being done with the two approved drugs for adults and the treatment of obesity - orlistat and sibutramine.
The techniques of bariatric surgery for adults are only done in exceptional cases of severe obesity and only when the child has finished growing and gone through pubertal development.