Treatment algorithm

Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups: see disclaimer

ONGOING

body mass index (BMI) ≥85th to 94th percentile (overweight)

1st line – lifestyle modification and treatment of comorbidities

Back
ONGOING
|
body mass index (BMI) ≥85th to 94th percentile (overweight)
1st line – 

lifestyle modification and treatment of comorbidities

Lifestyle modification is one of the cornerstone treatments for all children with a body mass index (BMI) ≥85th percentile. [ Cochrane Clinical Answers logo ]

In children <6 years the goal of treatment is weight maintenance or to slow weight gain. In children 6-12 years the goal is weight maintenance, and in children 12-18 years the goal is weight maintenance or gradual weight loss.[64]

Lifestyle modification includes education around diet and physical activity, plus behavioral therapy, so that children and their families can make and sustain changes.[3][57][84]​​​​​​​ Lifestyle interventions lead to significant weight loss and improved cardiometabolic parameters, compared with no treatment: BMI (-1.25 kg/m², 95% confidence interval [CI] -2.18 to -0.32) and BMI z score (-0.10, 95% CI -0.18 to -0.02).[87]

Intensity of lifestyle modification treatment is variable but the main factor found to contribute to effectiveness is the intensity (or dose) of the intervention, measured in hours of face-to-face contact. The number of hours delivered is directly proportional to the likelihood that a child will experience a reduction in BMI.[3]​ For example, the US Preventive Services Task Force found that ≥52 hours per year was associated with a difference in change in BMI z-score from baseline of -0.31, while 26 to 51 hours was associated with a difference in change in BMI z-score from baseline of -0.17 (this was 0.01 for 6 to 25 hours and -0.09 for 1 to 5 hours, respectively).[82]​ It may be delivered through regularly scheduled visits in primary care, with assistance from dieticians and clinicians with experience in behavior change/motivational interviewing, or through weekly visits to a dedicated pediatric weight management team, or as an in-hospital/residential program.​​ Escalation to more intensive weight management programs depends on the child's age, response to treatment, risk factors, and motivation, among others.​[3]​ In-hospital lifestyle modification programs may be effective for children with obesity susceptibility gene loci, indicating the importance of addressing environmental, social, and behavioral factors.[91]

It is imperative that the parents and family also adopt healthy lifestyle habits and shared decision making for the child to have success with weight maintenance or weight loss.[92]

Diet: children should be encouraged to eliminate sugar-sweetened beverages, decrease portion sizes, and limit both energy-dense and fast foods.[59][93]​​[95][96][97]​​​​ Eliminating sugar-sweetened beverages from the diet has been shown to significantly reduce caloric intake and obesity.​[3][95]​​ Diets rich in fruits and vegetables should be suggested, and healthy food choices should be offered in the school. Family meals should be encouraged. More frequent family meals are associated with a higher intake of fruits and vegetables, and a lower intake of fast food and takeout food, in US adolescents.[98] If possible, unhealthy foods should be removed from the home.

US nutritional guidelines encourage all children to consume nutrient-dense foods, including fruits, vegetables, wholegrains, beans, peas, lentils, eggs, seafood, unsalted nuts and seeds, fat-free and low-fat dairy products, and lean meats (prepared without added sugar, salt, and saturated fats).[97]

Advise regular meals to avoid grazing and snacking, and provide education on portion control.[84]

Physical activity: children should be encouraged to get at least 60 minutes of physical activity per day.[93]​[97]​​[99]​ The activity should be age appropriate and fun for the child, to encourage compliance. Play activities such as climbing or playing catch or tag are encouraged.[58]​ Family involvement in promoting physical activity is encouraged. Parents and caregivers have an essential role in modeling healthy behaviors and setting realistic goals.[58] Television viewing and other discretionary screen time (e.g., computer and video games, internet) should be limited. The American Academy of Pediatrics recommends no media use in children under the age of 18 months, a 1 hour limit for ages 2-5 years old and a parent-monitored plan for media use in older children.[3]​ The American Heart Association recommends: removing screens from bedrooms and during meals; encouraging daily, device-free social interactions and outdoor play; and supporting parents to enforce limitations on screen time, and set an example of healthy screen-based behavior.[100]​ Children with obesity often experience personal barriers to movement and exercise, including mobility barriers. Therefore, tailoring and adapting pediatric exercise interventions will often be necessary, particularly for those that report musculoskeletal pain, high rates of fatigue, urinary incontinence, skin chafing, or have impaired motor skills or other conditions (e.g., muscular dystrophy, immobility, etc).[8]

Comorbidities should be treated concurrently.[85]​ Associated psychosocial problems (e.g., bullying, teasing, low self-esteem) or psychiatric conditions (e.g., anxiety, depression) should be sought and treated.[84]

Plus – motivational interviewing

Back
ONGOING
|
body mass index (BMI) ≥85th to 94th percentile (overweight)
Plus – 

motivational interviewing

Treatment recommended for ALL patients in selected patient group

A patient-centered counseling style which focuses on shared decision making and the patients’ self identified motivations for change, in contrast with a more traditional healthcare professional led approach. It aims to result in a particular behavior change, such as reducing intake of a particular food or having more meals together as a family.

Motivational interviewing consists of four processes: (1) engaging - establishing a relationship and collaborative role; understanding patient issues; (2) focussing - identifying appropriate strategies to change weight; (3) evoking - highlighting motivations for change; (4) empowering patients to make change; planning - completing effective plans for change; appropriately managing relapse.

Consider – intensive health behavior and lifestyle treatment

Back
ONGOING
|
body mass index (BMI) ≥85th to 94th percentile (overweight)
Consider – 

intensive health behavior and lifestyle treatment

Treatment recommended for SOME patients in selected patient group

Intensive health behavior and lifestyle treatment should be considered in children <6 years of age, and is recommended in children 6 years of age and older. It is most effective with at least 26 hours of face-to-face, family-based, multicomponent treatment over 3-12 months.[85]

body mass index (BMI) ≥95th percentile (obesity) or BMI ≥120% of 95th percentile (severe obesity)

1st line – lifestyle modification and treatment of comorbidities

Back
ONGOING
|
body mass index (BMI) ≥95th percentile (obesity) or BMI ≥120% of 95th percentile (severe obesity)
|
age 2-11 years
1st line – 

lifestyle modification and treatment of comorbidities

Lifestyle modification is one of the cornerstone treatments for all children with obesity. [ Cochrane Clinical Answers logo ]

In children <6 years the goal of treatment is weight maintenance (weight loss of up to 1 lb/month or 0.5 kg/month may be acceptable if BMI is 21 or 22 kg/m²). In children 6-12 years the goal is gradual weight loss (1 lb/month or 0.5 kg/month).[64]

Lifestyle modification includes education around diet and physical activity, plus behavioral therapy, so that children and their families can make and sustain changes.[3][57][84]​ Lifestyle interventions lead to significant weight loss and improved cardiometabolic parameters, compared with no treatment.[87]

Intensity of lifestyle modification treatment is variable but the main factor found to contribute to effectiveness is the intensity (or dose) of the intervention, measured in hours of face-to-face contact. The number of hours delivered is directly proportional to the likelihood that a child will experience a reduction in BMI.[3]​ For example, the US Preventive Services Task Force found that ≥52 hours per year was associated with a difference in change in BMI z-score from baseline of -0.31, while 26 to 51 hours was associated with a difference in change in BMI z-score from baseline of -0.17 (this was 0.01 for 6 to 25 hours and -0.09 for 1 to 5 hours, respectively).[82]​ It may be delivered through regularly scheduled visits in primary care, with assistance from dieticians and clinicians with experience in behavior change/motivational interviewing, or through weekly visits to a dedicated pediatric weight management team, or as an in-hospital/residential program. Escalation to more intensive weight management programs depends on the child's age, response to treatment, risk factors, and motivation among others.[3]​​

In-hospital lifestyle modification programs may be effective for children with obesity susceptibility gene loci, indicating the importance of addressing environmental, social, and behavioral factors.[91]

It is imperative that the parents and family also adopt healthy lifestyle habits and shared decision making for the child to have success with weight maintenance or weight loss.[92]​

Diet: children should be encouraged to eliminate sugar-sweetened beverages, decrease portion sizes, and limit both energy-dense and fast foods.[59][93]​​[95][96][97]​​​​ Eliminating sugar-sweetened beverages from the diet has been shown to significantly reduce caloric intake and obesity.​[3][95]​​ Diets rich in fruits and vegetables should be suggested, and healthy food choices should be offered in the school. Family meals should be encouraged. More frequent family meals are associated with a higher intake of fruits and vegetables, and a lower intake of fast food and takeout food, in US adolescents.[98] If possible, unhealthy foods should be removed from the home.

US nutritional guidelines encourage all children to consume nutrient-dense foods, including fruits, vegetables, wholegrains, beans, peas, lentils, eggs, seafood, unsalted nuts and seeds, fat-free and low-fat dairy products, and lean meats (prepared without added sugar, salt, and saturated fats).[97]

Advise regular meals to avoid grazing and snacking, and provide education on portion control.[84]

Physical activity: children should be encouraged to get at least 60 minutes of physical activity per day.[93]​[97]​​[99]​​ The activity should be age appropriate and fun for the child, to encourage compliance. Play activities such as climbing or playing catch or tag are encouraged.[58]​ Family involvement in promoting physical activity is encouraged. Parents and caregivers have an essential role in modeling healthy behaviors and setting realistic goals.[58] Television viewing and other discretionary screen time (e.g., computer and video games, internet) should be limited. The American Academy of Pediatrics recommends no media use in children under the age of 18 months, a one hour limit for ages 2 to 5 years old and a parent-monitored plan for media use in older children.[3]​ The American Heart Association recommends: removing screens from bedrooms and during meals; encouraging daily, device-free social interactions and outdoor play; and supporting parents to enforce limitations on screen time, and set an example of healthy screen-based behavior.[100]​ Children with obesity often experience personal barriers to movement and exercise, including mobility barriers. Therefore, tailoring and adapting pediatric exercise interventions will often be necessary, particularly for those that report musculoskeletal pain, high rates of fatigue, urinary incontinence, skin chafing, or have impaired motor skills or other conditions (e.g., muscular dystrophy, immobility, etc).[8]

Comorbidities should be treated concurrently.[85]​ Associated psychosocial problems (e.g., bullying, teasing, low self-esteem) or psychiatric conditions (e.g., anxiety, depression) should be sought and treated.[84]

Plus – motivational interviewing

Back
ONGOING
|
body mass index (BMI) ≥95th percentile (obesity) or BMI ≥120% of 95th percentile (severe obesity)
|
age 2-11 years
Plus – 

motivational interviewing

Treatment recommended for ALL patients in selected patient group

A patient-centered counseling style which focuses on shared decision making and the patients’ self identified motivations for change, in contrast with a more traditional healthcare professional led approach. The objective is not to set and achieve a particular goal. Rather, it aims to result in a particular behavior change, such as reducing intake of a particular food or having more meals together as a family.

Motivational interviewing consists of four processes: (1) engaging - establishing a relationship and collaborative role; understanding patient issues; (2) focussing - identifying appropriate strategies to change weight; (3) evoking - highlighting motivations for change; (4) empowering patients to make change; planning - completing effective plans for change; appropriately managing relapse.

Consider – intensive health behavior and lifestyle treatment

Back
ONGOING
|
body mass index (BMI) ≥95th percentile (obesity) or BMI ≥120% of 95th percentile (severe obesity)
|
age 2-11 years
Consider – 

intensive health behavior and lifestyle treatment

Treatment recommended for SOME patients in selected patient group

Intensive health behavior and lifestyle treatment should be considered in children <6 years of age, and is recommended in children 6 years of age and older. It is most effective with at least 26 hours of face-to-face, family-based, multicomponent treatment over 3-12 months.[85]

1st line – lifestyle modification and treatment of comorbidities

Back
ONGOING
|
body mass index (BMI) ≥95th percentile (obesity) or BMI ≥120% of 95th percentile (severe obesity)
|
age 12-18 years
1st line – 

lifestyle modification and treatment of comorbidities

Lifestyle modification is one of the cornerstone treatments for all children with obesity. [ Cochrane Clinical Answers logo ] ​

In children 12-18 years the goal of treatment is weight loss not to exceed 2 lb (0.9 kg) per week.[64]

Lifestyle modification includes education around diet and physical activity, plus behavioral therapy, so that children and their families can make and sustain changes.[3][57][84]​ ​​​​Lifestyle interventions lead to significant weight loss and improved cardiometabolic parameters, compared with no treatment: BMI (-1.25 kg/m², 95% confidence interval [CI] -2.18 to -0.32) and BMI z score (-0.10, 95% CI -0.18 to -0.02).[87]

Intensity of lifestyle modification treatment is variable but the main factor found to contribute to effectiveness is the intensity (or dose) of the intervention, measured in hours of face-to-face contact. The number of hours delivered is directly proportional to the likelihood that a child will experience a reduction in BMI.[3]​ For example, the US Preventive Services Task Force found that ≥52 hours per year was associated with a difference in change in BMI z-score from baseline of -0.31, while 26 to 51 hours was associated with a difference in change in BMI z-score from baseline of -0.17 (this was 0.01 for 6 to 25 hours and -0.09 for 1 to 5 hours, respectively).[82]​ It may be delivered through regularly scheduled visits in primary care, with assistance from dieticians and clinicians with experience in behavior change/motivational interviewing, or through weekly visits to a dedicated pediatric weight management team, or as an in-hospital/residential program. Escalation to more intensive weight management programs depends on the child's age, response to treatment, risk factors, and motivation.[3]​​ In-hospital lifestyle modification programs are effective for children with obesity susceptibility gene loci, indicating the importance of addressing environmental, social, and behavioral factors.[91]

It is imperative that the parents and family also adopt healthy lifestyle habits and shared decision making for the child to have success with weight maintenance or weight loss.[92]

Diet: children should be encouraged to eliminate sugar-sweetened beverages, decrease portion sizes, and limit both energy-dense and fast foods.[59][93]​​[95][96][97]​​​ Eliminating sugar-sweetened beverages from the diet has been shown to significantly reduce caloric intake and obesity.[3][95]​​​​ Diets rich in fruits and vegetables should be suggested, and healthy food choices should be offered in the school. Family meals should be encouraged. More frequent family meals are associated with a higher intake of fruits and vegetables, and a lower intake of fast food and takeout food, in US adolescents.[98] If possible, unhealthy foods should be removed from the home.

US nutritional guidelines encourage all children to consume nutrient-dense foods, including fruits, vegetables, wholegrains, beans, peas, lentils, eggs, seafood, unsalted nuts and seeds, fat-free and low-fat dairy products, and lean meats (prepared without added sugar, salt, and saturated fats).[97]

Advise regular meals to avoid grazing and snacking, and provide education on portion control.[84]

Physical activity: children should be encouraged to get at least 60 minutes of physical activity per day.[93]​[97]​​[99]​ The activity should be age appropriate and fun for the child, to encourage compliance. Play activities such as climbing or playing catch or tag are encouraged.[58]​ Family involvement in promoting physical activity is encouraged. Parents and caregivers have an essential role in modeling healthy behaviors and setting realistic goals.[58]​ Television viewing and other discretionary screen time (e.g., computer and video games, internet) should be limited. The American Heart Association recommends: removing screens from bedrooms and during meals; encouraging daily, device-free social interactions and outdoor play; and supporting parents to enforce limitations on screen time, and set an example of healthy screen-based behavior.[100]​ Children with obesity often experience personal barriers to movement and exercise, including mobility barriers. Therefore, tailoring and adapting pediatric exercise interventions will often be necessary, particularly for those that report musculoskeletal pain, high rates of fatigue, urinary incontinence, skin chafing, or have impaired motor skills or other conditions (e.g., muscular dystrophy, immobility, etc).[8]

Comorbidities should be treated concurrently.[85]​ Associated psychosocial problems (e.g., bullying, teasing, low self-esteem) or psychiatric conditions (e.g., anxiety, depression) should be sought and treated.[84]

Plus – motivational interviewing

Back
ONGOING
|
body mass index (BMI) ≥95th percentile (obesity) or BMI ≥120% of 95th percentile (severe obesity)
|
age 12-18 years
Plus – 

motivational interviewing

Treatment recommended for ALL patients in selected patient group

A patient-centered counseling style which focuses on shared decision making and the patients’ self identified motivations for change, in contrast with a more traditional healthcare professional led approach. The objective is not to set and achieve a particular goal. Rather, it aims to result in a particular behavior change, such as reducing intake of a particular food or having more meals together as a family.

Motivational interviewing consists of four processes: (1) engaging - establishing a relationship and collaborative role; understanding patient issues; (2) focussing - identifying appropriate strategies to change weight; (3) evoking - highlighting motivations for change; (4) empowering patients to make change; planning - completing effective plans for change; appropriately managing relapse.

Plus – intensive health behavior and lifestyle treatment

Back
ONGOING
|
body mass index (BMI) ≥95th percentile (obesity) or BMI ≥120% of 95th percentile (severe obesity)
|
age 12-18 years
Plus – 

intensive health behavior and lifestyle treatment

Treatment recommended for ALL patients in selected patient group

Intensive health behavior and lifestyle treatment is recommended in all children 12-18 years of age. It is most effective with at least 26 hours of face-to-face, family-based, multicomponent treatment over 3-12 months.[85]

Consider – pharmacotherapy

Back
ONGOING
|
body mass index (BMI) ≥95th percentile (obesity) or BMI ≥120% of 95th percentile (severe obesity)
|
age 12-18 years
Consider – 

pharmacotherapy

Treatment recommended for SOME patients in selected patient group

Following conservative measures, treatment may include medication, with ongoing intensive lifestyle modification support. The American Academy of Pediatrics (AAP) recommends that pharmacotherapy should be offered to adolescents 12 years of age and over with obesity, in line with indication and risks, alongside lifestyle and behavior treatment.[3]

Orlistat inhibits fat absorption through the inhibition of enteric lipase, and is approved for children ≥12 years of age.[103] In clinical trials of orlistat in adolescents, BMI change ranged from -0.55 kg/m² up to -4.09 kg/m².[104]​ Adverse effects include steatorrhea, fecal urgency, and flatulence, which limits its use in children.

Liraglutide, a glucagon-like peptide-1 (GLP-1) agonist, is approved in the US and Europe for chronic weight management in children 12 years of age and older with obesity (i.e., body weight above 60 kg and an initial BMI corresponding to 30 kg/m² for adults by international cutoffs), in addition to a reduced-calorie diet and increased physical activity. One randomized controlled trial found that liraglutide plus lifestyle therapy is more effective for weight loss than placebo plus lifestyle therapy.[105] In the study of 251 adolescents with obesity, conducted over 3 years, 43% of participants in the liraglutide plus lifestyle therapy group achieved a 5% reduction in BMI, and 21% achieved a 10% reduction in BMI. In the placebo plus lifestyle therapy group, 19% of participants achieved a 5% reduction in BMI and 8% achieved a 10% reduction in BMI.[105]

Semaglutide, another GLP-1 agonist, is approved in the US and Europe for chronic weight management in children 12 years of age and older with an initial BMI ≥95th percentile for age and sex as an adjunct to diet and exercise. One phase 3 clinical trial including 201 participants (all except one with BMI ≥95th percentile) demonstrated a 16% decrease in BMI in treated participants as compared to the placebo group after 68 weeks. At the end of the study, 73% of those treated with semaglutide lost at least 5% of their starting body weight.[106]​ Common adverse effects include nausea, vomiting, and diarrhea.

Metformin inhibits hepatic gluconeogenesis and is commonly used in the treatment of type 2 diabetes mellitus (DM) in children 10 years of age and older. The evidence for effectiveness of metformin for weight loss in children is conflicting, and is not approved for the treatment of obesity in children.[3]​ Some studies demonstrate the benefit of adding metformin in mitigating the weight gain seen in children and adolescents.[88]​​[107]​ Those studies that did demonstrate effect typically included higher doses, more intensive lifestyle adjunct treatment and use in children with more severe obesity and/or a secondary diagnosis.[3]

One systematic review investigated the efficacy of metformin in treating obesity in children without type 2 diabetes mellitus. At 6 months, children prescribed metformin experienced an average BMI reduction of -1.38 kg/m² (95% CI -1.93 kg/m² to -0.83 kg/m²). However, reduction in BMI was considered to be modest, and metformin was not clinically superior to other options for treating childhood obesity.[108] A subsequent randomized controlled trial reported a decrease in BMI with metformin, compared with placebo, in prepubertal children, but not in pubertal children.[109] Further, larger studies are required. The AAP suggests that metformin can be considered as an adjunct to intensive health behavior and lifestyle treatment when other indications for use of metformin are present.[3]

The combination of phentermine/topiramate is approved in the US for the treatment of obesity in adolescents (12-17 years old) with an initial BMI in the 95th percentile or greater standardized for age and sex. Phentermine is an anorectic that decreases appetite and topiramate is an anticonvulsant with weak carbonic anhydrase inhibitor activity that induces weight loss (although the precise mechanism of action in weight loss is currently unknown). One study of the pharmacokinetic and pharmacodynamic properties of a fixed-dose combination of phentermine/topiramate conducted in adolescents with obesity demonstrated statistically significant weight loss.[112][113]​ However, adverse effects include depression and difficulties with concentration and memory, which may limit its usefulness in adolescents. Topiramate can cause fetal harm in pregnant women, and has been demonstrated to show an increase in oral clefts with first trimester exposure to topiramate.[114]

Primary options

orlistat: 120 mg orally three times daily with each main meal that contains fat

OR

liraglutide: 0.6 mg subcutaneously once daily for 1 week, increase dose by 0.6 mg/day at weekly intervals, maximum 3 mg/day

OR

semaglutide: 0.25 mg subcutaneously once weekly for 4 weeks initially, increase dose gradually according to response and tolerance every 4 weeks, maximum 2.4 mg once weekly

More

Secondary options

phentermine hydrochloride/topiramate: 3.75 mg (phentermine)/23 mg (topiramate) orally once daily in the morning for 14 days, followed by 7.5 mg (phentermine)/46 mg (topiramate) once daily in the morning, then adjust dose according to response, maximum 15 mg (phentermine)/92 mg (topiramate)

More

Tertiary options

metformin: 500-2000 mg orally/day given in 2 divided doses

Consider – specialist referral for consideration of surgery

Back
ONGOING
|
body mass index (BMI) ≥95th percentile (obesity) or BMI ≥120% of 95th percentile (severe obesity)
|
age 12-18 years
Consider – 

specialist referral for consideration of surgery

Treatment recommended for SOME patients in selected patient group

A referral does not necessarily mean the child will have surgery but provides opportunity for additional evaluation of risks and benefits, and provision of further information to families to make an informed decision. A referral to comprehensive pediatric metabolic and bariatric surgery programs should be made, to local or regional centers.

Guidelines suggest that surgery is considered in children with BMI ≥40 with mild comorbidities, or BMI >35 with clinically significant comorbidities.​[3][115]​​ Clinically significant comorbidities include: obstructive sleep apnea, type 2 diabetes mellitus, idiopathic intracranial hypertension, nonalcoholic steatohepatitis, Blount disease, slipped capital femoral epiphysis, GERD, and hypertension.[115]

Surgery does not negatively impact pubertal development, and therefore a specific Tanner stage and bone age should not be considered a requirement for surgery.[116]

The surgical approaches used most often are the Roux-en-Y gastric bypass and vertical sleeve gastrectomy.[115] One prospective cohort study found that long-term follow-up (7 to 10 years) after vertical sleeve gastrectomy in children and adolescents demonstrates durable weight loss, maintained comorbidity resolution, and unaltered growth.[120] Surgery should only be performed by an experienced surgeon who works with a team capable of following the patient for long-term nutritional or psychosocial issues.

Numerous risk factors associated with cardiovascular disease have been shown to improve among adolescents with severe obesity undergoing bariatric surgery. Increased weight loss, female sex, and younger age predict a higher probability of resolution of specific cardiovascular risk factors.[117] Outcomes of bariatric surgery in the adolescent population are being studied vigorously.[121]​​[122]​​

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Please note that formulations/routes and doses may differ between drug names and brands, drug formularies, or locations. Treatment recommendations are specific to patient groups. See disclaimer

Use of this content is subject to our disclaimer