REvIEwS

­­Treatment of adolescent obesity

Katharine S. Steinbeck1, Natalie B. Lister1,2, Megan L. Gow2 and Louise A. Baur1,3*
Abstract | The increased prevalence of adolescent obesity and associated short-​term and long-​
term complications emphasize the need for effective treatment. In this Review , we aim to
describe the evidence for, and elements of, behaviour management and adjunctive therapies and
highlight the opportunities and challenges presented by obesity management in adolescence.
The broad principles of treatment include management of obesity-​associated complications; a
developmentally appropriate approach; long-​term behaviour modification (dietary change,
increased physical activity , decreased sedentary behaviours and improved sleep patterns); long-​
term weight maintenance strategies; and consideration of the use of pharmacotherapy , more
intensive dietary therapies and bariatric surgery. Bariatric surgery should be considered in those
with severe obesity and be undertaken by skilled bariatric surgeons affiliated with teams
experienced in the medical and psychosocial management of adolescents. Adolescent obesity
management strategies are more reliant on active participation than those for childhood obesity
and should recognize the emerging autonomy of the patient. The challenges in adolescent
obesity relate primarily to the often competing demands of developing autonomy and not yet
having attained neurocognitive maturity.

1
Discipline of Child and
Adolescent Health, University
of Sydney, Sydney, New
South Wales, Australia.
2
Institute of Endocrinology
and Diabetes, The Children’s
Hospital at Westmead,
Westmead, New South Wales,
Australia.
3
Weight Management
Services, The Children’s
Hospital at Westmead,
Westmead, New South Wales,
Australia.
*e-​mail: louise.baur@
health.nsw.gov.au
https://doi.org/10.1038/
s41574-018-0002-8
Adolescence is one of the most rapid phases of human
development, associated with marked physical, neuro­
developmental, psychological and social changes. The
WHO defines an adolescent as a young person in
the second decade of life (10–19 years)1. Adolescent
obesity has become a globally prevalent health problem
affecting young people from low-​income and middle-​
income countries, as well as those from high-​income
countries2,3. Figure 1shows the trends in obesity for
children and adolescents aged 5–19 years from differ­
ent regions over 40 years from 1975 to 2016 (ref.3). A
widening social disparity is recognized in economi­
cally advanced countries, with an increased prevalence
of obesity in more socially disadvantaged adolescents
compared with adolescents from higher socioeconomic
groups4. Additionally, growing evidence indicates that
the prevalence of severe or morbid obesity is increas­
ing in this age group in several countries, including the
United States and Australia5–7.
Obesity in adolescence is often complicated by
psychosocial distress and can be associated with a range
of other health problems; the normal neurobiological
development that occurs in this age group also has a con­
siderable effect1. Furthermore, the rate of spontaneous
remission of obesity to a healthy weight is low; at least
90% of adolescents with obesity will have overweight or
obesity in young adulthood8,9.
For all these reasons, both the prevention and the
treatment of adolescent obesity are important. In this
Review, we focus on obesity treatment and detail the
evidence for, and elements of, behavioural management,
the use of adjunctive therapies (such as more intensive
dietary therapies, pharmacotherapy and bariatric sur­
gery) and the management of the metabolic complica­
tions of obesity such as insulin resistance and polycystic
ovaries. The opportunities and challenges presented by
the management of obesity specifically in adolescents
are highlighted.
Clinical assessment
A thorough clinical history and physical examination
of the adolescent is essential to assess current obesity-​
associated complications, the risk of future compli­
cations and whether the patient has any modifiable
lifestyle practices. It is beyond the scope of this Review
to provide further details on clinical assessment, and
readers are referred to recent reviews and clinical guide­
lines for additional information10–14. Key recommenda­
tions for history-​taking and physical examination are
outlined in Boxes 1,2.
Factors that affect management
Neurocognitive development
The pace of brain development in adolescence and into
young adulthood is second only to that of early child­
hood15. Pruning of previous synaptic proliferation to
optimize neural networks and increasing myelination
of nerve fibres for rapid neural messaging are impor­
tant for the development of mature and efficient neu­
ral networks. The maturation of the emotional brain

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Reviews
Key points
• The preferred treatment approach for adolescent patients with obesity includes
management of obesity-​associated complications, a developmentally appropriate
approach, support for long-​term behavioural change, long-​term weight maintenance
strategies and consideration of other therapies.
• Long-​term weight maintenance therapy, through face-​to-face or electronic support,
phone coaching or group programmes, is likely to be required.
• Bariatric surgery should be considered in adolescents with severe obesity (BMI >40 kg/m2,
or >35 kg/m2 in the presence of complications), and patients should be treated in
centres experienced in bariatric surgery.
• Pharmacotherapy should be used as adjunctive therapy, particularly in the
maintenance of weight loss, and for the treatment of obesity-​associated
complications.
• Clinicians should understand where the adolescent is in puberty development — age
does not equal stage — and not support beliefs that young people will grow out of
obesity with the onset of puberty.
• Clinicians must work within the contexts of both the normal rapid changes in
adolescent brain development and the psychosocial tasks of adolescence that are
necessary for mature adulthood.
with its associated reward-​seeking, hyperexcitability
and proneness to impulse occurs in mid-​adolescence
(14–16 years). The development of the prefrontal
cortex, which is responsible for planning, organiza­
tion, risk versus benefit assessment and the ability to
delay immediate gratification for future gain, occurs
later with final maturation in the mid-20s 16 and
has important implications for the management of
adolescent obesity.
Choices based on emotion or impulse, difficulty in
consistently following through with action plans, ina­
bility to comprehend future health risks, the need to be
like their peers (which makes lifestyle change challeng­
ing) and the need to be independent (which reduces
responsiveness to adult directives and advice as a result
of prefrontal cortex immaturity16) are all likely to derail
attempts at lifestyle change. The concept that lifestyle
change programmes for adolescents need to be formu­
lated differently from those of adults now has a strong
neurocognitive rationale and an emerging clinical trial
evidence base17,18.
Puberty
Puberty is an early adolescent event that results in dra­
matic changes in body composition and has long-​term
implications for health and well-​being19. Puberty might
have both positive and negative effects on weight man­
agement. Positives include increasing lean body mass
in males and, for both sexes, if obesity management is
undertaken before the height growth spurt, then the
caloric deficit induced with weight maintenance in a
situation where weight would naturally increase with
height increase results in reduced adiposity. Negatives
include increasing adiposity in females as a result of
gonadal hormones and, in both sexes, the possibility that
the insulin resistance that occurs during puberty (related
in part to increased secretion of growth hormone)
might persist after puberty is complete if there are other
drivers such as obesity present20,21. These factors need
to be taken into account when managing individuals
with obesity.
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Stigmatization
Weight stigmatization is widespread and leads to
psycho­logical, social and physical health consequences.
Discussion of the causes and effects of weight bias and
stigmatization are beyond the scope of this Review,
and readers are referred to recent reviews for further
details22–25. Health-​care professionals have an important
role in reducing the negative effects of obesity stigma­
tization. The American Academy of Pediatrics recom­
mends that clinical care can be improved through role
modelling, using appropriate language, good clinical
documentation and ensuring a safe and welcoming
environment22. Elements of behavioural health screening
and behaviour change counselling, as outlined in more
detail in subsequent sections, can identify and address
weight-​based victimization to improve outcomes.
Overview of treatment principles
Effective obesity treatment in adolescents can be defined
in various ways, including a reduction in BMI or weight
outcomes, improvement in obesity-​associated compli­
cations, a reduction in markers of risk of future com­
plications or a changed weight gain trajectory. In adult
studies, effectiveness is often categorized into ‘success’ or
‘failure’; however, no standard definition of effectiveness
exists26,27, and different criteria have been used between
and within studies to classify weight maintenance or
regain. Calculations can also include initial weight,
initial weight loss, postintervention weight, postinter­
vention weight change or final weight. In adolescents,
dichotomizing success is even more difficult given the
need to normalize measures for age and sex in adoles­
cents aged <18 years (hence the frequent reporting of
BMI z-​scores) and the variability in the reporting of
treatment outcomes. A systematic review and meta-​
regression published in 2016 reports how weight loss
in children and adolescents translates to favourable car­
diometabolic outcomes28 (such as blood pressure and
HDL cholesterol levels), which might be more clinically
meaningful than weight loss perse.
Findings from systematic reviews
The 2017 Cochrane Review on diet, physical activity
and behavioural interventions for the treatment of obe­
sity in adolescents aged 12–17 years included 44 rand­
omized controlled trials (RCTs) with follow-​up periods
of 6–24 months17. A range of trials that mostly used
multibehavioural change interventions were included
in the review, with no specific programme being rec­
ommended over another. A meta-​analysis of studies
comparing intervention groups versus wait-​list or no-​
treatment control groups showed that, at the longest
follow-​up period, there was a mean reduction in BMI of
−1.18 kg/m2 (95% CI −1.67 to −0.69), in BMI z-​score
of −0.13 units (95% CI −0.21 to −0.05) and in body
weight of −3.67 kg (95% CI −5.21 to −2.13). The effect
on weight outcomes persisted in those trials with longer
follow-​up periods of 18–24 months, a finding that is
somewhat at variance with those from studies in adults,
which show more weight regain25.
The authors of the Cochrane Review noted that,
where measured, there were improvements in percentage
 Reviews

60 60

Number of boys with obesity (millions)

Number of girls with obesity (millions)

40 40

20 20

0 0
1980 1990 2000 2010 1980 1990 2000 2010
Year Year

West Africa Central Asia Melanesia Caribbean High-income English-speaking countries

Central Africa South Asia Polynesia and Andean Latin America Northwestern Europe
Southern Africa Southeast Asia Micronesia Central Latin America Southwestern Europe
East Africa East Asia Southern Latin America Central Europe
Middle East and High-income Asia Pacific Eastern Europe
North Africa

Fig. 1 | Trends in the number of girls (left panel) and boys (right panel) aged 5–19 years with obesity , by region,
from 1975 to 2016. There has been a dramatic increase in the number of children and adolescents affected by obesity
over more than four decades. Middle Eastern, East Asian, high-​income English-​speaking and central and southern Latin
American countries are especially affected. Adapted with permission from ref.3, CC-​BY-4.0.

body fat, waist circumference and total fat mass follow­ Adapting the findings from such studies to ‘real-​
ing behavioural change interventions17. Improvements world’ obesity clinics that might be more poorly
in quality of life, although not in self-​esteem, were also resourced is often difficult25. For example, in comparison
noted at the longest follow-​up. However, outcomes for with clinical trials, in usual clinical practice it might not
dietary intake and physical activity were inconsistent be possible to review patients as frequently and suffi­
across the included studies. The review reported no sub­ cient specialist nursing, allied health or medical exper­
group differences in interventions with or without paren­ tise might not be available. Further, the patients in usual
tal involvement or by intervention type, setting (such as clinical practice might have additional comorbidities or
school, clinic or community) or mode of delivery (group be more socially disadvantaged than those who partic­
versus individual). The overall quality of evidence for the ipate in clinical trials, raising challenges in optimizing
primary outcomes of interest was rated as low, except treatment adherence. Nevertheless, the principles of
for body weight, which was rated as moderate. Adverse management are well recognized10–14 (Box 3).
effects were only infrequently reported and hence could
not be reliably assessed. Elements of treatment of obesity
The findings of this most recent systematic review Behavioural management
add to the evidence base from previous reviews12,18,29,30. Behavioural strategies are routinely used to support
The 2017 Cochrane Review did not report outcomes for changes in dietary intake, physical activity levels and
cardiometabolic parameters from behavioural change sedentary behaviours and to facilitate long-​term main­
interventions, although they were previously reported in tenance of these changes31,32. Although most RCTs
a 2012 systematic review18. This review showed that life­ of adolescent obesity management include a behav­
style interventions led to statistically significant improve­ ioural component, these details are often inadequately
ments in levels of LDL cholesterol (−0.30 mmol/l, 95% described in publications17,33.
CI −0.45 to −0.15), triglycerides (−0.15 mmol/l, 95% CI A 2015 evidence update of behavioural strategies
−0.24 to −0.07), fasting insulin (−55 pmol/l, 95% CI −71 for obesity treatment in children and adolescents
to −39) and blood pressure (systolic −3.72 mmHg, 95% identified much stronger evidence (‘well-​established
CI −4.74 to −2.69; diastolic −1.69 mmHg, 95% CI −3.15 interventions’) in children than in adolescents for both
to −0.24) up to 12 months from baseline. parent-​only interventions and family-​based behavioural

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Box 1 | Key elements of history taking in adolescents with obesity

General history
• Consider prenatal and birth — including history of gestational diabetes and birthweight
• Current medications — including glucocorticoids, some antiepileptics (for example, sodium valproate) and
antipsychotics (for example, risperidone or olanzapine)
Weight history
• Onset of obesity and duration of parental and adolescent concerns about the patient's weight
• Previous weight management interventions
• Previous and current dieting behaviours
Complications history
• Psychological effects of obesity, including bullying, poor self-​esteem, anxiety and depression
• Sleep routine, presence of snoring and/or possible sleep apnoea (for example, lack of refreshment after sleep, daytime
somnolence and witnessed apnoeas)
• Exercise tolerance
• Specific symptoms, including
- Acne and hirsutism
- Morning headache and visual disturbance (potential benign intracranial hypertension)
- Gastrointestinal: vomiting, abdominal pain, constipation and gastrointestinal reflux
- Nocturnal enuresis and daytime dribbling
- Hip and knee joint pain
- Menstrual history (girls)
Family history
• Ethnicity (high-​risk groups for cardiometabolic complications include Native American, Hispanic, Maori, Pacific
Islander, Australian Aborigine, South Asian, East Asian, Mediterranean and Middle Eastern)
• Family members with a history of
- Obesity
- Type 2 diabetes mellitus and gestational diabetes
- Hypertension, dyslipidaemia and cardiovascular disease
- Obstructive sleep apnoea
- Polycystic ovary syndrome
- Bariatric surgery
- Eating disorders
• Home environment, including
- Household members
- Parental relationship
- Parental employment, hours and home supervision
Lifestyle factors
• Diet and diet-​related behaviours
- Breakfast consumption
- Eating patterns, including snacking, sneaking food, fast-​food intake and binge eating
- Beverage consumption (sodas, juice and other sugary drinks)
- Family routines around food and eating
• Physical activity
- Transport to and from school
- Sports participation
- After-​school and weekend recreation
- Family activities
• Sedentary behaviours
- Screen time per day (TV, video game, cell phone, tablet and computer use)
- Number of TVs, computers, tablets, laptops, cell phones and gaming consoles in the house and bedrooms
- Pattern of TV or other screen viewing (for example, during meals)

treatments in which parents are specifically targeted
to change their own behaviours and achieve weight
loss31. The update included 11 studies involving both
children and adolescents undergoing behavioural
weight-​loss treatment with family involvement during
which the parent facilitates the lifestyle changes. Nine
of these studies demonstrated improvements in weight
outcomes compared with the control condition. The
evidence for family-​based interventions in adolescent-​
only interventions was, however, far more limited
in that few studies looked specifically at adolescents.
Overall, the authors rated the evidence for behavioural
weight-​loss treatment with family involvement in ado­
lescents as “possibly efficacious” while commenting
that treatment is optimized if parents are included in
the treatment programme.
Several common behaviour change techniques
are used in obesity treatment31,32,34. Some commonly
used techniques include goal-​setting, stimulus control
(modifying or restricting environmental influences)

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 Reviews

Box 2 | Notable findings on physical examination10–14

Dietary interventions
Following dietary interventions is effective for mod­
Skin or subcutaneous tissues est weight loss in adolescents with obesity18. Caloric
• Acanthosis nigricans (neck, axillae, skin folds and over joints) restriction is usually incorporated into multicomponent
• Keratosis pilaris lifestyle-​based interventions for weight management.
• Acrochordons (skin tags) Importantly, lifestyle interventions that include a dietary
• Hirsutism component can improve cardiometabolic outcomes in
• Acne adolescents with obesity even in the absence of weight
loss or changes in body composition18,29,33.
• Striae
Various dietary manipulations can achieve caloric
• Pseudo-​gynaecomastia in males
restriction and resultant weight loss in adolescents,
• Intertrigo with or without secondary infection most commonly by using the ‘stop/traffic light approach’
• Xanthelasmas (hypercholesterolaemia) but also by altering macronutrient distributions and/or
Neurological improving carbohydrate quality. No dietary intervention
• Papilloedema and/or reduced venous pulsations on fundoscopy (pseudotumour has been shown to be optimal, and adherence to die­
cerebri) tary protocols is the most effective predictor of weight
Head and neck loss35. Dietary interventions with evidence of being
• Tonsillar size and obstructed breathing effective for weight management are discussed in the
Cardiovascular following sections.
• Hypertension
• Heart rate (cardiorespiratory fitness)
Stop/traffic light approach. This calorie-​controlled inter­
vention categorizes foods according to caloric density
Respiratory
and uses these groups to guide intake frequency (Fig. 2).
• Exercise intolerance
Low-​calorie foods are labelled ‘green’ and can be eaten
• Wheeze (asthma) freely, moderate-​calorie foods are labelled ‘yellow’ and
Gastrointestinal should be eaten judiciously and high-​calorie foods are
• Hepatomegaly and hepatic tenderness (nonalcoholic fatty liver disease) labelled ‘red’ and should be eaten rarely36. This approach
• Abdominal pain (secondary to gallstones or gastro-​oesophageal reflux) can produce effective weight loss (BMI decreases range
Musculoskeletal from 0.18 to 2.6 kg/m2)37,38 in adolescents in the short to
• Pes planus medium term (6 months to 2 years)18.
• Groin pain and painful or waddling gait (slipped capital femoral epiphysis)
• Lower limb arthralgia and restriction of joint movement
Macronutrient distribution. Altering the macro­nutrient
ratio of a calorie-​restricted diet is purported to improve
Endocrine
dietary adherence, weight-​loss outcomes and cardi­
• Goitre
ometabolic measures39. Common diet interventions
• Extensive striae, hypertension, dorsocervical fat pad or ‘buffalo hump’ (signs of have different macronutrient distributions (Fig.  3) .
Cushing syndrome)
Conventional interventions are typically referred to as
• Pubertal staging ‘low fat’ and aim for <35% daily energy from fat. A low-​
• Reduced growth velocity carbohydrate diet, aiming for <50 g carbohydrate per day,
Psychosocial has often been compared to a low-​fat approach; however,
• Flat affect and low mood (depression) a 2014 systematic review found no evidence that either
• Poor self-​esteem and social isolation approach was more effective for long-​term weight loss
Other — evidence of a possible underlying genetic syndrome in adolescents39. Even so, low-​carbohydrate diets might
• Short stature or disproportion provide some benefit for short-​term weight loss (BMI
decreases from baseline range from 1.2 to 5.2 kg/m2)39
• Dysmorphism
and insulin concentrations (the decrease in fasting insu­
• Developmental delay
lin levels from baseline range from 6.0 to 7.5 μU/l)40,41
compared with low-​fat interventions. In longer-​term
and self-​monitoring (Box 4). Note that goals need to be studies of >12 months, weight loss was not significantly
concrete, developmentally relevant and achievable and different, possibly owing to eventual migration to a more
might take considerable time to set and review in clin­ typical carbohydrate intake35,39.
ical sessions. Reward systems support the repetition of Increasing protein from a typical 15% of daily energy
a desired behaviour and can include rewards based on in conventional diets to 20–40% of daily energy has
improvements in lifestyle behaviours as well as in weight no demonstrated benefit for weight loss in adolescents
outcomes. Importantly, behaviour change strategies under isocaloric conditions39. Increasing protein intake
should be used by all treating clinicians. is hypothesized to improve satiety and reduce hunger,
Further research is needed to develop a stepped thereby resulting in a lower ad libitum energy intake
model of care for treatment (especially for adolescents), and greater weight loss42. However, studies in free-​living
to identify the optimal intensity and frequency of behav­ adolescents demonstrate that achieving higher dietary
ioural treatments for long-​term sustainability and to protein targets is difficult43, which might contribute to
enhance scalability and implementation into community the lack of effect of increased levels of dietary protein in
and clinical settings. adolescents. The unique challenges to dietary compliance

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Box 3 | Principles of obesity treatment
• Assess and manage obesity-​associated disorders
• Ensure a developmentally appropriate approach
• Support long-​term behaviour change
• Dietary change
• Increased physical activity
• Decreased sedentary behaviours, including screen
behaviours
• Improved sleep
• Strategies for long-​term weight maintenance
• Consider more intensive dietary interventions
• Consider pharmacotherapy
• Consider bariatric surgery
during adolescence are not well defined in the literature
but include peer influences, reliance on parental support
(including the provision of meals) and the neurocognitive
development issues outlined in a previous section.
Carbohydrate quality. Glycaemic index (GI) and gly­
caemic load are used to describe carbohydrate qual­
ity. Although low-​GI diets do not seem to confer any
weight-​loss benefit for adolescents, a 2015 systematic
review found that lower-​GI diets improved insulin
resistance (HOMA index mean difference of −0.70, 95%
CI −1.37 to −0.04, P = 0.04) and triglyceride concentra­
tions (mean difference −15.14 mg/dl, 95% CI −26.26 to
−4.00, P = 0.008)44. The major limitation with manipulat­
ing GI to improve carbohydrate quality is that lower-​GI
foods do not always translate to ‘healthy’ options; for
example, high-​fat discretionary foods such as ice cream
and potato chips have a low GI.
Intermittent fasting. Over the past decade, intermit­
tent energy-​restricted diets have gained popularity as
a weight-​loss approach in adults45,46. Limited evidence
is available for their use in adolescents; however, these
diets have been used in clinical practice. Dietary model­
ling and nutrient analysis show that, over a 7-day period
(3 days restricted to ~2.5–2.9 MJ or 600–700 kcal), inter­
mittent energy-​restricted meal plans can be designed to
meet adolescents’ unique micronutrient requirements47.
More intensive dietary therapies
A very-​low-energy diet (VLED) is an intensive die­
tary regimen, typically consisting of <800 kcal per day,
with <50 g of carbohydrate and adequate provision of
micronutrients often being achieved using meal replace­
ments such as shakes and bars. Owing to the difficulty
of achieving the strict calorie prescription, this diet is
typically recommended only for short periods of time
(8–12 weeks)48.
In adolescents with obesity, a VLED can safely induce
rapid weight loss in the short term (4–15 kg over 3–12
weeks) while preserving lean body mass49,50. VLEDs
also lead to short-​term improvements in common met­
abolic risk factors49,51. Published in 2016, a small pilot
study demonstrated that VLED reversed type 2 diabetes
mellitus (T2DM) in newly diagnosed adolescents with
obesity50. However, the long-​term (>12 months after
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completion of VLED) outcomes remain unclear. The
severe nature of the diet requires intensive monitoring
by health professionals; however, these diets could be
an alternative to pharmacological therapies or surgical
interventions to treat adolescents with severe obesity.
Eating behaviours
An emerging area of research is the role of eating behav­
iours in obesity, defined as “self-​perceived behaviour and
attitudes towards eating behaviour and food” (ref.52),
which could partly explain the different responses to
dietary interventions seen in patients. Longitudinal data
on eating behaviours and weight gain are limited, and
few intervention studies directly assess more than one
eating behaviour53. In adolescents, prescriptive dietary
advice consisting of hypocaloric nutrition coaching by a
trained dietician can normalize eating behaviours in the
short to medium term54. However, more data are needed
to prospectively examine the long-​term effects of dietary
interventions on the eating behaviours of adolescents.
Physical activity
Adolescent obesity is associated with suboptimal physi­
cal activity levels, poor fitness and excessive time in sed­
entary behaviours55. Despite the certain contributions to
energy deficit, the specific weight-​reducing effect of the
physical activity component of a lifestyle intervention
in adolescents with obesity is not clear. However, phys­
ical activity is still an integral part of obesity treatment
owing to the additional health benefits attained through
regular exercise, including improved body composi­
tion, psychological profile and functional capacities55–62
(Fig. 4). Physical activity is also associated with improve­
ments in the cardiometabolic profile of an adolescent
with obesity, including improved insulin sensitivity,
blood pressure and cholesterol levels55–62. Hence, regu­
lar physical activity has an important role in preventing
the development of the metabolic syndrome and T2DM
in adolescents with obesity, irrespective of a change in
weight. One systematic review comparing diet-​only
with diet-​plus-exercise or an exercise-​only interven­
tion found that, although weight loss was not different
between the groups, the addition of exercise training to
a dietary intervention led to a greater improvement in
levels of HDL cholesterol and fasting insulin concentra­
tions in the short term (over 6 months) than a diet-​only
programme29.
Several national guidelines recommend that all ado­
lescents partake in at least 60 minutes of daily moderate-​
to-vigorous physical activity and that no more than 2 h
per day is spent using electronic media for entertainment
(for example, computer games, TV and Internet)63–66.
However, few adolescents achieve these targets55. This
challenge is exemplified in adolescents with obesity,
who often report negative peer experiences around
exercise67 and have reduced exercise tolerance, which
presents a barrier to participation in physical activity
owing to the early onset of fatigue68. Reduced capacity
to perform basic physical functioning tasks, including
walking and climbing stairs, has led to obesity in adoles­
cents being described as a disability69. Exercise capacity
in adolescents with obesity can be enhanced through

Box 4 | Examples of common behavioural change techniques
Goal-​setting — performance goals
• “I will decrease my discretionary screen time from 6 h per day to 4 h over the next
month. I will do this by moving my cell phone out of my room at night (I will charge it
in the family room) and by agreeing to move my laptop to the family room. When I
have done this, I will work out some new screen time goals.”
• “I will go to bed an hour earlier on school nights (11 pm instead of midnight). I will do
this by charging my cell phone in the family room overnight.”
• “I will get an extra half hour of physical activity into my day. I will do this by catching
the train and bus to and from school instead of asking my parents to drive me. I will
also ask my friend to go to the school gym with me twice a week after school.”
Goal-​setting — outcomes goals
• Specific weight-​loss goals (amount of weight loss or reduction in waist circumference
over a specified time), developed in consultation with the therapist
Self-​monitoring
• Daily monitoring and recording of physical activity via pedometer or other activity
monitor
• Daily recording of screen time
• Daily recording of eating habits (for example, eating breakfast and eating lunch) or of
specific food intake (for example, vegetable intake and soda drink intake)
• Weekly recording of weight
Stimulus control
• Parent agrees to not offer to drive the young person to school
• Television, laptops, cell phones and other mobile devices are out of the bedroom at
night
• Parent and young person agree to not store unhealthy foods (for example, processed
snack foods and soda drinks) in the house
• Parent agrees to serve evening meal using smaller-​sized plates
• Parent agrees to have a family rule about eating the evening meal at the table without
the television being on
participation in a 12-week exercise intervention of twice
weekly 45–60 minute sessions, including resistance and
aerobic exercise, supervised by a personal trainer62.
By increasing adolescents’ participation in physical
activity, it is anticipated that a flow-​on effect will occur,
resulting in reduced recreational screen time. However,
both issues need to be addressed. A recreational screen
time allowance of 2 h per day is increasingly difficult to
implement given the prominence and accessibility of
digital technologies. Effective interventions for reducing
screen time in adolescents with obesity are still needed.
Utilization of technologies, such as smartphone apps, is
a popular avenue of research in this area70.
Sleep behaviours
Cross-​sectional studies show an association between
short sleep duration and an increased risk of over­
weight or obesity in children and adolescents, with a
pooled odds ratio of 1.89 (95% CI 1.43–1.68) for short
sleep duration (different definitions used in the vari­
ous studies, including <5 h, <6 h and <10 h) and obesity
being noted in a systematic review of 12 studies71. In a
systematic review of 22 longitudinal studies, an inverse
association was found between short sleep duration and
subsequent BMI in both children and adolescents72. On
the basis of adult studies73,74, interventions targeting
sleep in the management of adolescents with obesity
might result in improved weight and body composi­
tion outcomes. Trial data in adolescents are limited, and
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Reviews
no trials have been conducted in young people already
affected by obesity75,76. Strategies might include an earlier
adolescent bedtime, removal of electronic screen devices
from the bedroom and family rules about exposure to
screens before bedtime. Importantly, targeting sleep has
additional benefits in terms of general health, mood,
school performance and quality of life77.
Digital technologies
High-​quality studies using digital technologies to man­
age obesity are lacking78. A 2017 meta-​analysis of all
mobile health interventions in youth concluded that
these “appear to be a viable behaviour change interven­
tion modality for youth” (ref.70). Digital technologies
represent a promising area of future clinical research
in adolescent obesity, including apps and activity track­
ers as lifestyle monitors. Apps and activity trackers
can give instant feedback on levels of physical activity,
sleep and active versus sedentary time, with little input
required from the user. Popular apps are also used for
tracking diet or providing healthy food alternatives.
Technologies including image or photo upload of foods
and/or barcode scanning are designed to minimize the
time required for input from the user and enable instant
feedback on dietary intake or advice on more appro­
priate choices. However, the capacity of such devices to
assist weight loss is not yet clear, with a study published
in 2016 demonstrating that adults randomly assigned
to the ‘wearable device’ (activity tracker) arm achieved
less weight loss at 24 months than those in the con­
trol arm79. Furthermore, these technologies will never
replace a clinician, but they might be a useful tool to
enhance motivation and assist in weight-​loss mainte­
nance, particularly in adolescents, who generally enjoy
digital devices. Discoveries from research in mental
health provide support for the use of the Internet to
deliver interventions80. In order to be engaging and
to be considered for long-​term use, such interventions
(including apps) should be co-​designed with adolescents
and undergo regular updates. Their commercial viability
is questionable.
Long-​term weight outcomes
Few high-​quality trials report long-​term outcomes of
obesity treatment in adolescents, as opposed to chil­
dren17,18,81. However, in a large central European health-​
care database from 157 paediatric specialist centres
managing obesity (patients aged 5–25 years), 2-year
outcomes were reviewed for 3,135 patients82. Compared
with children aged 5–11 years, adolescents aged
12–15 years had a 41% lower odds of successful weight
reduction and maintenance, defined as a decrease in
BMI z-​score of at least 0.2 from baseline. These findings
emphasize the importance of early treatment of estab­
lished obesity. In a 12 month and 24 month follow-​up of
adolescents participating in a trial of two different types
of dietary intervention, weight loss in the first 3 months
predicted long-​term weight outcomes83, a finding con­
sistent with those from other studies. Such studies sug­
gest that interventions with a focus on early weight loss
might have better outcomes than interventions started
after the patient has had obesity for some time.
volume 14 | JUNe 2018 | 337
Reviews
Red foods Eaten rarely Examples
Greater than 20 kcal of the • Sweets
average serving for foods • Desserts
within that food group • Fast food
• High-fat meat or
meat substitutes
Yellow foods Eaten judiciously Examples
Within 20 kcal of the average • Full-fat milk
serving for foods within that • Whole-grain breads
food group (i.e. fruit = 40 kcal and cereals
and milk and dairy = 80 kcal)
Green foods Eaten freely Examples
Less than 20 kcal of the • Fruits
average serving within that • Vegetables
food group • Legumes
• Low-fat milk
• Lean meat or meat
substitutes
Fig. 2 | Traffic light diet categories18,36,37,113. Foods are categorized according to high (top
panel), moderate (middle panel) or low (bottom panel) caloric density. These categories
are used to guide frequency of intake, with the aim to reduce overall calorie intake.
In adults, a comprehensive weight maintenance pro­
gramme is recommended for those who have had initial
weight loss32. This programme might entail continued
support from a therapist, via phone or face to face, pos­
sibly on at least a monthly basis for ≥12 months. The
sustainability of such an approach in usual health-​care
settings and the applicability to the adolescent popula­
tion remain unclear. However, given the importance of
digital technologies to young people, this might prove to
be of relevance in weight maintenance strategies.
Pharmacotherapy
In the long term, safe anti-​obesity drugs must be a
therapeutic goal given that the condition is chronic
and lifestyle therapies have had limited results. Current
anti-​obesity agents are universally limited in both num­
ber and availability, with few subsidized by govern­
ment agencies (Table 1). Trials are mostly performed in
adults, and use in adolescents is often off-​label. A 2016
Cochrane Review provided data for trials of current
(and some previously available) anti-​obesity agents in
children and adolescents84. The authors also identified
ongoing trials for topiramate and glucagon-​like peptide
1 receptor (GLP1R) agonists. Metformin and orlistat
both result in a reduction in weight in favour of the
active intervention, albeit around 2 kg. The review also
describes a greater overall attrition rate for adolescents
than reported in adult trials. Metformin and orlistat
are available for adolescent use in most jurisdictions,
although use of metformin generally remains off label
in those without diabetes mellitus.
Some antidepressants have weight loss as a bene­
fit but are not first-​line obesity pharmacotherapies. In
some countries, bupropion is used as an antidepressant
and in others it is licensed only for addiction therapies.
When bupropion is combined with naltrexone as a slow-​
release preparation, there is benefit compared with pla­
cebo for weight loss85. The data for topiramate's effect
on body weight in adults are positive but compromised
by adverse effects such as dizziness and drowsiness86.
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Topiramate is currently marketed for epileptic seizures
and migraine and could be considered in adolescents
with obesity who fulfil prescribing criteria. Topiramate
has been trialled for weight loss in adults in combination
with phentermine, with a significant dose-​dependent
percentage change in body weight of 7–9% compared
with placebo85. However, a pilot RCT in 30 adolescents
consisting of 24 weeks of topiramate following 4 weeks
of meal replacement therapy did not result in significant
BMI reduction87.
Glucagon-​like peptide 1 (GLP1) is a naturally occur­
ring incretin produced by the gut88. GLP1R agonists
were originally marketed for the treatment of T2DM.
An additional effect is appetite suppression and weight
loss89, and obesity management has become an addi­
tional indication for the use of this drug class. In adults,
the effects of liraglutide, which is approved for weight
loss in many countries as a once-​a-day injection, are
impressive compared with the effects of standard oral
anti-​obesity therapy. Published in 2017, the results of
an RCT showed that the oral GLP1R agonist semaglu­
tide had a statistically significant effect on weight loss
of 2–7 kg as well as control of diabetes mellitus in par­
ticipants with T2DM and a mean age of 57 years. This
finding suggests that oral therapy is a future, adolescent-​
attractive weight-​loss option90. In a pilot RCT, 3 months
of exenatide therapy in 26 adolescent patients with
severe obesity led to a greater percentage reduction in
BMI, as well as absolute weight and BMI, than placebo91.
Bariatric surgery
In adults, bariatric surgery is a well-​recognized form of
therapy for severe obesity as an adjunct to behavioural
therapy and pharmacotherapy92. The role of bariatric
surgery in adolescents is being established.
Evidence for bariatric surgery
To date, there has been only one published RCT of bar­
iatric surgery in adolescents: an Australian study of
50 patients aged 14–18 years (25 patients in both the
intervention and the comparator groups)93. The study
compared laparoscopic adjustable gastric banding
(LAGB) with a multicomponent lifestyle programme.
At 2 years, weight in the surgery group was reduced by
a mean of 34.6 kg (95% CI 30.2–39.0) compared with
3.0 kg (95% CI 2.1–8.1) in the lifestyle group. Although
both groups had improvements in the quality-​of-life
subscore of gene­ral health, the surgical group had bet­
ter performance in four additional subscores (physical
functioning score, self-​esteem, family activities and
change in health score), with no difference between the
groups for three other subscores. Revisional procedures
were required in 28% of the surgical group. The authors
commented that although this incidence is within the
range of other studies, there might be a need, in adoles­
cents, for additional education and supervision of eat­
ing to ensure they eat small meals slowly. This approach
might help reduce the need for revision. This study was
the only one included in the 2015 Cochrane Review of
bariatric surgery in adolescents94.
A systematic review with broader inclusion cri­
teria than the 2015 Cochrane Review investigated

Carbohydrate Protein Fat Energy intake required
for weight loss
Increased-protein diet
Low-carbohydrate diet
Conventional diet
0 20 40 60 80
Energy contribution from macronutrient (%)
Fig. 3 | Macronutrient distribution of common diet interventions39,42,43.
The percentage of energy contributions from carbohydrate, protein and fat can be
manipulated to achieve an energy intake level for weight loss. The purple and green areas
indicate overlap between the percentage energy contributions.
prospective clinical trials and observational studies of
bariatric surgery in patients ≤18 years old published up
to early 2014 (ref.95). The review included 37 studies,
with 15 being prospective and 1 being the RCT noted in
the previous paragraph. The mean BMI loss after LAGB
was 11.6 kg/m 2 (95% CI 9.8–13.4), compared with
16.6 kg/m2 (95% CI 13.4–19.8) after Roux-​en-Y gas­
tric bypass (RYGB) and 14.1 kg/m2 (95% CI 10.8–17.5)
after laparoscopic sleeve gastrectomy (LSG). The review
authors noted that adverse effects and long-​term com­
plications, including nutritional deficiencies, were more
frequent and serious after RYGB than the other two
procedures, although there were fewer data for LSG, a
procedure that has gained prominence more recently
than RYGB or LAGB. All forms of surgery resulted in
improvements in a range of obesity-​associated com­
plications, such as dyslipidaemia and T2DM, and in
quality of life.
Subsequent to this systematic review, the 3-year
outcomes of the Teen-​L ongitudinal Assessment of
Bariatric Surgery (Teen-​LABS) study were published.
The Teen-​LABS study is a prospectively enrolled study
of adolescents undergoing bariatric surgery in five cen­
tres in the United States96. A total of 242 patients (75%
female patients and 72% white patients) were enrolled,
with 67% undergoing RYGB, 28% LSG and 6% LAGB.
At 3 years after surgery, there was an overall mean weight
loss of 27% (95% CI 25–29) and marked improvement
or remission in T2DM, prediabetes, kidney disease,
elevated blood pressure and dyslipidaemia as well as
improvement in quality-​of-life measures. However,
the majority of patients had low iron concentrations
and 13% had undergone one or more additional intra-​
abdominal procedures. Such findings indicate that
there are risks associated with bariatric surgery in this
age group and highlight the importance of ensuring
that appropriate nutrient supplementation is provided
to adolescents after bariatric surgery.
Further high-​quality long-​term studies of bariatric
surgery in adolescents are required to monitor potential
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Reviews
surgical and nutritional complications, to determine
whether weight and cardiometabolic risk improvements
are maintained well into adulthood and to identify
which patients benefit most from surgery97.
Clinical guidelines
Consensus guidelines on bariatric surgery in adolescents
have been established by various medical professional
bodies in several countries11,98–101. In terms of patient
characteristics, the recommendations generally cover: a
minimum age, usually in mid-​adolescence; the patient to
have reached sexual maturity; the presence of severe obe­
sity, usually BMI >35 kg/m2 with an obesity-​associated
complication, or BMI >40 kg/m2; the persistence of obe­
100
sity despite involvement in a formal multidisciplinary
programme of lifestyle modification and pharmaco­
therapy; the patient being able to give informed consent;
and the adolescent and family being willing to partici­
pate actively in the treatment programme and agreeing
to ongoing review following the surgery.
Recommendations generally specify that the sur­
gery should be performed by a skilled bariatric surgeon
affiliated with a team experienced in the medical and
behavioural management of adolescents with obesity.
The specific recommendations for the type of sur­
gery vary depending upon regional expertise but have
included LAGB, RYGB and LSG. Finally, in terms of
postoperative management and follow-​up, recom­
mendations tend to specify the following: that more
frequent postoperative follow-​up is generally required
with adolescents than with adult patients; that there is
a need for ongoing care by a multidisciplinary team;
that contraception be considered owing to improved
fertility following weight loss; that clinicians be aware
that adolescent patients, especially, might not adhere
to nutritional supplementation; that very long-​term
follow-​up is required; and that the patient should be
enrolled in a bariatric surgery registry.
One of the major challenges in many countries is
the need to ensure equitable access to such services for
affected adolescents, because, in most health systems,
bariatric surgery remains largely available only in the
private sector, and bariatric surgery services for adoles­
cents are sparse25. Thus, specific strategies for the pro­
vision of bariatric surgery for adolescents in the public
sector are likely to be needed in most jurisdictions.
Treatment of complications
Many obesity-​associated complications, such as dys­
lipidaemia, fatty liver disease and elevated blood pres­
sure, will improve following weight loss. Nevertheless,
depending on the type and severity of such complica­
tions, it might be appropriate to manage these when
identified and not to wait until weight loss has occurred,
as weight loss might be difficult to achieve12.
During adolescence, the prevalence of individual
obesity-​associated complications increases, as does the
clustering of such complications. In addition, adoles­
cence sees the emergence of components of the met­
abolic syndrome and the development of sex-​specific
differences in risk factors for cardiovascular disease102.
No long-​term data are available in contemporary cohorts
volume 14 | JUNe 2018 | 339
Reviews
Musculoskeletal Psychosocial
• Improved body composition • Improved cognition
• Increased caloric expenditure • Reduced depressive symptoms
and metabolic rate • Improved academic performance
• Improved bone health • Better confidence and self-esteem
• Increased skeletal muscle mass
Fig. 4 | Benefits of exercise in adolescents with obesity55–62. A range of elements contributes to the musculoskeletal,
cardiometabolic, functional and psychosocial health improvements resulting from increased exercise.
that enable quantification of future combined or specific
risk of obesity-​associated complications or the cost of
that risk.
Multiple definitions of the metabolic syndrome in ado­
lescence exist, all of which have agreed core elements —
obesity, dyslipidaemia, abnormal glucose metabo­
lism and hypertension — but these vary in the spe­
cifics of cut points and reference standards103–106. The
International Diabetes Federation definition, which uses
age-​specific cut points for the core metabolic elements
listed above for 10–16 years of age (adult cut points for
those >16 years) and which specifies abdominal obe­
sity as defined by waist measure, is probably the most
common in use106,107. Concerns about which definition
to use, or whether the metabolic syndrome is present
or not103–106, should never impede management of the
individual components. The prevalence of the met­
abolic syndrome rises over the decade of adolescence
and might be present in up to 50% of adolescents with
obesity, depending on both the definition used and the
population being studied103–106.
Medication doses used in the treatment of obesity-​
associated complications will be closer to adult rec­
ommendations given their body weight. An important
adolescent proviso is that some of these medications are
not considered safe in pregnancy, and countries vary in
their labelling of safety recommendations. Many drugs
recommended for the treatment of metabolic morbid­
ity in obesity have not been trialled in the reproductive
age group; studies of safety in pregnancy will never be
undertaken and translating animal exposure results to
humans is not always reliable. Given that these newer
medications remain the optimal choice for treatment
of metabolic complications of obesity, a more nuanced
approach than previously used is being advocated
by the FDA, which introduced a new labelling system,
the PLLR (Pregnancy and Lactation Labelling)108, pub­
lished in 2016. The European Medicines Agency is due
to release its updated pregnancy guidelines for consul­
tation in 2018 (ref.109). Table 1 shows data from the cate­
gorization system of the Australian Therapeutic Goods
Administration (TGA), which provides currently acces­
sible and regularly updated110 ratings for some common
medications used in the management of obesity and
its complications.
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Functional Cardiometabolic
• Improved physical fitness • Improved insulin sensitivity
• Enhanced exercise tolerance • Improved blood pressure and
• Increased strength and endothelial function
proprioception • Reduced inflammation
• Improved lipid profile
The most common obesity-​associated complications
in adolescence are primarily related to metabolic abnor­
malities and mental health concerns (Fig. 5). Here, we
provide a brief overview of the management of the met­
abolic complications associated with obesity. Readers
are referred to recent reviews or clinical guidelines for
details of the management in the context of adolescent
obesity, obstructive sleep apnoea111, nonalcoholic fatty
liver disease112, slipped capital femoral epiphysis113,
depression114 and anxiety115.
The International Society for Paediatric and
Adolescent Diabetes (ISPAD) Clinical Guideline
acknowledges the limited evidence for diagnosis, man­
agement and monitoring of prediabetes and T2DM in
adolescents116,117. The prevalence of T2DM varies with
ethnicity, with T2DM occurring in 6% of adolescents
with diabetes mellitus in the United States and 40% of
adolescents with diabetes mellitus in Asia and the Pacific
Islands117. The prevalence of insulin resistance is less well
characterized, but increasing age and weight, abdom­
inal distribution of obesity, the presence of acanthosis
nigricans and a family history of T2DM should raise the
level of clinical suspicion118. Prediabetes might be tran­
sient, coinciding with the insulin resistance often seen in
puberty19, with continuing weight gain predicting pro­
gression to T2DM. Other than metformin, drugs used
in T2DM usually require off-​label use in those under
18 years of age. The rising community prevalence of
obesity and the tighter target range for diabetes mellitus
control mean that more than one-​third of adolescents
with confirmed type 1 diabetes mellitus might also have
overweight or obesity119, and metformin could be added
to their therapy to address insulin resistance.
In a study published in 2015 that examined trends
in dyslipidaemia and hypertension in youth, 20.2% had
adverse levels of total and HDL cholesterol and 11.0%
had elevated or borderline blood pressure recordings120.
The US National Lipid Association 121 provides an
annual update of lipid-​lowering therapies, hyperlinks to
resources and separate recommendations for children,
adolescents and adults <21 years of age. The common
dyslipidaemias of adolescent obesity are low levels of
HDL cholesterol, in which the effective treatments are
weight loss and physical activity, and elevated levels of
triglycerides. The risk of pancreatitis is increased with
 Reviews

Table 1 | Medications for the management of obesity and its complications

Name Indication Comments Safety in
pregnancy1
Orlistat Obesity Inhibits gut lipase with resulting steatorrhoea with high-​fat B1
meals — easy to manipulate
Phentermine Obesity Sympathomimetic amine that has addictive potential. B3
Rejected by some agencies in its combination with
topiramate owing to mental health and cardiovascular
system concerns
Topiramate Obesity If epilepsy or severe migraine are present, this fulfils D
prescribing indications. If prescribed off-​label, cost might be
prohibitive
GLP1R agonists Obesity Mostly by daily injection. Nausea and vomiting are B3
significant adverse effects
Metformin Type 2 diabetes mellitus, prediabetes Gastrointestinal upset if not up-​titrated slowly. Induces Approved for use (C)
and insulin resistance, polycystic ovary ovulation; consider contraception needs. Monitor vitamin
syndrome, acanthosis nigricans and B12 levels128
adjunctive treatment for weight loss
Statins Hypercholesterolaemia (LDL cholesterol) No data on long-​term adverse effects, including myopathy Teratogenic in
and increased risk of type 2 diabetes mellitus animals, but risk
appears lower in
humans (D)
ACE inhibitors and Hypertension and diabetic nephropathy Single daily dose and low adverse effect profile improve Might increase
ARBs compliance malformation risk
and pregnancy loss
in second and third
trimesters (D)
SSRIs Depression and anxiety in which talking Package warnings that these antidepressants may increase C
therapy is not successful risk of suicidal ideation and behaviours
COCP Polycystic ovary syndrome: lower COCP-​induced weight gain is disputed129. Contraindicated B3
oestrogen doses and newer gestagens in paralytic migraine or thromboembolism
have fewer adverse effects
Australian categories for prescribing medicines in pregnancy: the Australian Therapeutic Goods Administration (TGA) system is currently accessible and regularly
updated110, providing ratings from A (the safest drugs to take during pregnancy ; no known adverse reactions) to D (adverse reactions have been found in humans)110.
The TGA system provides guidance that aims to assist both clinicians and the women who use the medications and is reliable evidence-​based information for
patients who use the Internet for health advice. Health professionals should refer to the TGA website for further information (Australian Government Department of
Health). Practitioners should also be aware of local approvals and prescribing rules for medications in pregnancy. ACE, angiotensin-​converting enzyme; ARBs,
angiotensin receptor blockers; COCP, combined oral contraceptive pill; GLP1R , glucagon-​like peptide 1 receptor ; SSRIs, selective serotonin reuptake inhibitors.

concentrations of triglycerides >5 mmol/l, and if life­
style change is ineffective and aggravating factors are
excluded, omega-3 fatty acids, niacin or fibrates should
be trialled122.
Elevated blood pressure is defined as blood pres­
sure (adjusted for age, sex and height) >90th percen­
tile to <95th percentile or 120/80 mmHg (whichever
is lower), stage 1 hypertension is blood pressure >95th
percentile to <95th percentile + 12 mmHg, or 130/80 to
139/89 mmHg (whichever is lower) and stage 2 hyper­
tension is blood pressure >95th percentile + 12 mmHg,
or >140/90 mmHg (whichever is lower)123. Pharmaco­
therapy should not be withheld if weight loss does
not occur. The updated 2017 American Academy of
Pediatrics guidelines123 provide a management guide
and discussion around drug choices.
The Endocrine Society's Clinical Guideline for pol­
ycystic ovary syndrome124 considers adolescents sepa­
rately. The diagnosis should be based on clinical and/or
biochemical hyperandrogenism in the presence of per­
sistent oligomenorrhoea and should not rely on multi­
cystic ovarian change, which might be developmentally
normal. Although obesity and insulin resistance are
present in most patients with polycystic ovary syndrome,
insulin resistance at the receptor level is not present in
the ovary, and high insulin concentrations drive ovar­
ian androgen production and subsequent hirsutism and
menstrual cycle disturbances. Metformin prescribed
together with the combined oral contraceptive pill might
ameliorate any weight gain associated with the use of
combined oral contraceptives125.
Access to health care
One of the six major recommendations of the 2016
Report of the WHO Ending Childhood Obesity
Commission was the provision of weight management
services for both children and young people as part of
Universal Health Coverage126. Given that health sys­
tems vary considerably between countries and that
there is little published on obesity models of care in
young people, there will be a range of challenges
in the delivery of treatment services for this group.
Importantly, the report highlighted the potential for
weight bias by health professionals and hence the need
for strategies to avoid stigmatization of young people
with obesity.
Adolescent obesity can be managed in paediatric or
adult care teams. Neither of these approaches is likely to

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© 2018 Macmillan Publishers Limited, part of Springer Nature. All rights reserved.
Reviews
Benign intracranial hypertension
Patients without visual defects are
treated with acetazolamide, a carbonic
anhydrase inhibitor.
Skin
Skin tags might require physical removal. For
intertrigo, keep dry and use topical antifungals.
Metformin seems to be effective for acanthosis
nigricans, but much of the evidence is case-based.
Clinically, this effect might be positive for
adolescents and metformin might assist in
reduction in BMI in combined obesity treatment
regimens.
Lipids and other cardiovascular
risk factors
Statins are suggested for nonfamilial
hypercholesterolaemia if LDL
cholesterol is >4.1 mmol/l and if
additional risk factors are present, such
as obesity, hypertension and diabetes
mellitus. Concerns regarding long-term
safety exist, and data in younger
patients with secondary lipid disorders
are lacking.
Fatty liver
Weight loss is the only proven therapy.
Insulin sensitizers and vitamin E have
been used.
Polycystic ovary syndrome
Metformin will produce a more regular
menstrual cycle and induce ovulation,
of which the adolescent should be
warned. Weight loss, physical hair
removal, and the combined oral
contraceptive pill to suppress ovarian
androgen production are all standard
therapies. Weight gain induced by the
combined oral contraceptive pill might
occur in susceptible individuals.
Strength and balance training
might be useful.
Fig. 5 | Management of comorbidities122,129–134. Obesity-​associated complications are multisystemic, and the summarized
treatment recommendations should be considered when the complication is identified in conjunction with weight-​loss
advice. ACE, angiotensin-​converting enzyme; CPAP, continuous positive airway pressure.
be optimal for adolescents, in whom health care is best
served by clinicians with expertise in treating adoles­
cents and young adults127. Supported transitional care
from paediatric to adult care has not been reported in
the literature128, which is of concern given the preva­
lence of obesity and the need for ongoing management
to avoid further weight gain in young adulthood.
Conclusions
The importance of effective management of adolescent
obesity is underscored by its high prevalence in many
countries and the short-​term and long-​term impacts
of the condition. Although the evidence base for the
management of adolescent obesity is growing, more
pragmatic clinical trials in young people are needed.
These trials are needed because of the acknowledged
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Affective disorders, depression and anxiety
Depression and anxiety increase in prevalence in
adolescence, with a female preponderance.
Treatment in adolescents with obesity is along
standard lines. Fluoxetine is less likely to be
associated with weight gain than the newer
antipsychotics, which are associated with weight
gain and insulin resistance, and should be avoided.
Obstructive sleep apnoea
The American Academy of Pediatrics
Clinical Guidelines give the evidence for
weight management in obstructive sleep
apnoea as grade C. CPAP therapy should be
initiated if symptoms and/or signs of
objective evidence of obstructive sleep
if adenotonsillectomy is not performed
(grade B). Intranasal glucocorticoids might
also assist as adjuvant therapy.
Hypertension
Preferred agents are thiazide diuretics
and/or ACE inhibitors or angiotensin
receptor blockers. Once-a-day dosing
and a low adverse effect profile make
these drugs particularly useful in
adolescents.
Insulin resistance, prediabetes and
diabetes mellitus
Lifestyle intervention is essential in all
three conditions. Metformin also has a
role in all three conditions. Metformin is
a first-line therapy for type 2 diabetes
mellitus in adolescents, but medical
instability at presentation might require
insulin. Continuation of insulin use
should be reviewed at regular intervals
as weight gain, accompanied by
worsening insulin resistance, is an
undesirable effect of long-term therapy.
Slipped capital femoral epiphysis
High index of suspicion if pain and/or limp
are present. Orthopaedic intervention.
Pes planus
Supportive shoes and orthotics.
challenges in conducting traditional RCTs at this devel­
opmental stage and in this condition and because prag­
matic trials offer information that informs the real-​world
implementation of therapies. Additionally, improved
data are needed on how best to manage young people
with obesity who are from disadvantaged environments
and those from low-​income and middle-​income coun­
tries. Finally, it is vital that obesity in young people is
not dismissed as being too difficult to be addressed
by clinicians. Instead, there should be a recognition of
the WHO concept of adolescence as “a key decade in the
life-​course” where there is “a second chance in the sec­
ond decade” to improve health outcomes and provide
high-​quality clinical services1.
Published online 13 Apr 2018

1. World Health Organization. Health for the world’s
adolescents: a second chance in the second decade.
WHO http://www.who.int/maternal_child_adolescent/
documents/second-​decade/en/ (2014).
2. Ng, M. et al. Global, regional, and national prevalence
of overweight and obesity in children and adults
during 1980–2013: a systematic analysis for the
global burden of disease study 2013. Lancet 384,
766–781 (2014).
3. NCD Risk Factor Collaboration (NCD-​RisC). Worldwide
trends in body-​mass index, underweight, overweight,
and obesity from 1975 to 2016: a pooled analysis of
2416 population-​based measurement studies in
128.9 million children, adolescents, and adults.
Lancet 390, 2627–2642 (2017).
4. Chung, A. et al. Trends in child and adolescent obesity
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Author contributions
All authors contributed to researching data for the article,
discussion of content, writing the article and reviewing and/
or editing the manuscript before submission.
Competing interests
The authors declare no competing interests.
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Review criteria
This narrative review is based upon data from systematic
reviews, review papers and individual studies known to the
authors. Other studies were identified by a MEDLINE search
of English language papers published up to 2017 using the
search terms “obesity” and “adolescent” and then further
refined using such terms as “bariatric surgery”, “behaviour
therapy”, “drug therapy”, “diet”, “exercise”, “physical activity”,
“weight maintenance” or “sleep”. Where appropriate, reviews
or studies of obesity treatment involving children or adults
were included in the Review. Reference lists of key papers
were also checked to identify additional papers of interest.
We also searched for clinical guidelines on the management
of adolescent obesity. For the latter to be considered, the
guidelines had to be developed or endorsed by a national or
international health professional body or government agency
and available in English.
Related links
Australian Government Department of Health: https://www.
tga.gov.au/australian-​categorisation-system-​
prescribing-medicines-​pregnancy
CC-​BY-4.0: https://creativecommons.org/licenses/by/4.0/