Adolescence can be a difficult time for assessing weight status because of pubertal changes and dif- ferences in individual patterns of growth. A dietary and health assessment should be conducted on ado- lescents with BMIs greater than or equal to the 85th percentile for age, but less than the 95th percentile for age to determine psychosocial morbidity and risk for future cardiovascular disease if:
• Their BMI has increased by two or more units during the previous 12 months
• They have a family history of premature heart dis- ease, obesity, hypertension, or diabetes mellitus • They express concern about their weight • They have elevated blood pressure or serum
cholesterol levels (43)
Adolescents with a BMI greater than or equal to the 95th percentile for age should have an in-depth dietary and health assessment to determine psy- chosocial morbidity and risk for future cardiovascu- lar disease. Obstetrician–gynecologists are strongly encouraged to provide this assessment (43). Early referral to a nutritional specialist skilled in adoles- cent care may be warranted. The patient usually is acutely aware of her weight issue and has likely attempted many of her own weight loss strategies. These adolescents need clear and direct support, guidance, and encouragement. Also they need a bet- ter understanding of the widespread nature of the disease to feel less alone and isolated. Family involvement in the treatment plan is critical. Any proposed diet should be consistent with the Dietary Guidelines for Americans and allow for individual- ized caloric intake recommendations that support gradual, not rapid, weight loss.
It is important to note that weight loss is recom- mended only for adolescents in certain circumstances (46). For example, older overweight adolescents who have completed linear growth or those with com- orbidities, may require weight loss (18, 49). More often, the goal is to slow the rate of weight gain while achieving normal growth and development. Discussion of portion sizes, snacking, and eating at restaurants and outside the home is helpful (46). (See box for examples of healthy snacks.) Wake Forest University has developed a web site (http://www1.wfubmc.edu/Nutrition/Count+Your+ Calories/dtd.htm) that provides the nutritional and caloric information of several of the largest fast food chains in the United States. This web site may be useful to adolescent patients and their parents.
There are sufficient adult data indicating that physical activity contributes to weight loss, both
Healthy Snacks
Providing some examples of healthy snacks may be useful when discussing the dietary needs of an over- weight adolescent female. These examples may include: • A bean burrito
• A cheese quesadilla with salsa and lettuce • A yogurt and fruit smoothie with graham crackers • A bowl of whole-grain cereal topped with sliced fruit
and milk
• A small salad with sliced deli meat, tuna or beans • Fruit, cheese, and whole-grain crackers
alone and when it is combined with dietary therapy. Efforts to achieve weight loss with physical activity alone generally produce moderate weight loss. Even so, increased physical activity is a useful adjunct to low-calorie diets in promoting weight reduction. Also, physical activity reduces obesity-associated comorbidities (1).
The amount of time an adolescent spends per- forming aerobic versus sedentary activities should be assessed. As stated previously, it is recommended that adolescents participate in at least 60 minutes of physical activity on most, preferably all, days of the week (46). Increased activity and decreased television viewing has been shown to reduce an adolescent’s weight (50). In children, family-based programs that encompass diet, physical activity, reduction of sedentary behavior, and behavioral ther- apy have been shown to help children lose weight compared with no treatment. It is important to pro- vide recommendations on diet and physical activity that are achievable given the patient’s family environ- ment. It also is important to evaluate the adolescent’s psychologic well-being (18). Often, collaboration with a mental health professional is indicated.
There are limited data to document the efficacy of prescription medications or over-the-counter drugs for weight loss in adolescents. The role of sur- gical intervention for overweight adolescents has yet to be established, but some recent studies have sug- gested that surgical weight loss improves the early mortality experienced by these adolescents (51). Bariatric surgery currently is recommended for ado- lescents who have a BMI greater than 40 and have comorbid conditions. Those who may be candidates for bariatric surgery should be referred to a multidis- ciplinary weight management team with expertise in treating overweight adolescents (52). Long-term studies are needed to determine the risk and benefits of bariatric surgery in adolescents. Nationally, a new paradigm has been proposed with an emphasis on promoting a healthy lifestyle in overweight patients instead of focusing solely on weight loss. This idea of “health at any size” may encourage patients to focus on their overall health improvement, rather than only their weight status (53).
Conclusion
Adolescent females who are overweight have signifi- cant health sequelae. There are limited evidence-based data for the successful prevention and treatment of
overweight adolescents. Because additional research is needed, our best tool is to extrapolate an approach from data and studies pertaining to children and adults, while remaining cognizant of the special needs that surround adolescent growth and develop- ment. Sound nutritional recommendations and regu- lar physical activity are essential components for overall good health because they convey myriad ben- efits for growth, brain and cognitive development, self-esteem, immunity, and disease prevention (54).
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Resources
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Other Resources
We have provided information on the following organizations and web sites because they have information that may be of interest to our readers. The American College of Obstetricians and Gynecologists does not necessarily endorse the views expressed or the facts presented by these organizations or on these web sites. Further, ACOG does not endorse any commer- cial products that may be advertised or available from these organizations or on these web sites.
American Academy of Family Physicians 11400 Tomahawk Creek Parkway Leawood, KS 66211-2672
Telephone: 800-274-2237 or 913-906-6000 http://www.aafp.org
American Academy of Pediatrics 141 Northwest Point Boulevard Elk Grove Village, IL 60007-1098 Telephone: 847-434-4000 http://www.aap.org/obesity
American Alliance for Health, Physical Education, Recreation, and Dance
1900 Association Drive Reston, VA 20191-1598
Telephone: 800-213-7193 or 703-476-3400 http://www.aahperd.org
American College of Sports Medicine 401 West Michigan Street
Indianapolis, IN 46202-3233 Telephone: 317-637-9200 http://www.acsm.org
American Dietetic Association 120 South Riverside Plaza, Suite 2000 Chicago, IL 60606-6995
Telephone: 800-877-1600 http://www.eatright.org American Heart Association 7272 Greenville Avenue Dallas, TX 75231 Telephone: 800-242-8721 http://www.americanheart.org American Obesity Association 1250 24th Street NW, Suite 300 Washington, DC 20037 Telephone: 202-776-7711 http://www.obesity.org
AWARE Foundation
1015 Chestnut Street, Suite 1225 Philadelphia, PA 19107-4302 Telephone: 215-955-9847 http://www.awarefoundation.org
Centers for Disease Control and Prevention Division of Adolescent and School Health Healthy Youth
PO Box 8817
Silver Spring, MD 20907
Telephone: 800-CDC-INFO (800-232-4636) http://www.cdc.gov/nccdphp/dash
Centers for Disease Control and Prevention
National Center for Chronic Disease Prevention and Health Promotion 1600 Clifton Rd Atlanta, GA 30333 Telephone: 404-639-3311 or 800-311-3435 or 800-232-4636 http://www.cdc.gov/nccdphp/dnpa/obesity http://www.cdc.gov/nccdphp/dnpa/bmi/index.htm Institute of Medicine 500 Fifth Street NW Washington DC 20001 Telephone: 202-334-2352 http://www.iom.edu/
National Association for Health & Fitness The Network of State and Governor’s Councils c/o Be Active New York State
65 Niagara Square, Room 607 Buffalo NY 14202
Telephone: 716-583-0521 http://www.physicalfitness.org
National Heart, Lung, and Blood Institute PO Box 30105
Bethesda, MD 20824-0105 Telephone: 301-592-5873
http://www.nhlbi.nih.gov/index.htm Society for Adolescent Medicine 1916 NW Copper Oaks Circle Blue Springs, MO 64015 Telephone: 816-224-8010 http://www.adolescenthealth.org U.S. Surgeon General
Office of Surgeon General 5600 Fishers Lane—Room 18-66 Rockville MD 20857
301-443-4000
http://www.surgeongeneral.gov/topics/obesity/ calltoaction/fact_adolescents.htm
Committee on
Adolescent Health Care
Reaffirmed 2009
ACOG
Number 355, December 2006 (Replaces No. 274, July 2002)
Committee
Opinion
This document reflects emerging clinical and scientific advances as of the date issued and is subject to change. The information should not be construed as dictat- ing an exclusive course of treat- ment or procedure to be followed. The Committee would like to thank Marc R. Laufer, MD, for his assistance in the development of this document.
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Vaginal agenesis: diagnosis, manage- ment, and routine care. ACOG Committee Opinion No. 355. American College of Obstetricians and Gynecologists. Obstet Gynecol 2006;108:1605–9.