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Effectively treating adolescents for obesity poses unique challenges

Adolescent obesity is a serious and growing public health problem that threatens both current and future health outcomes, according to an editorial by Drs Leonard H Epstein (SUNY Distinguished Professor and Division Chief of Behavioral Medicine in the Department of Pediatrics in the Jacobs School of Medicine and Biomedical Sciences at University at Buffalo (UB)) and Teresa Quattrin (a UB Distinguished Professor and senior associate dean for research integration in the Jacobs School).

The editorial, 'Ideas for Next-Generation Treatments of Adolescent Obesity', published in JAMA Pediatrics, states that attempts should be made to disseminate evidence-based behavioural, pharmacologic, surgical and device-based treatments and develop new interventions that incorporate multidisciplinary approaches to the treatment of adolescent obesity.

Citing research published in the issue, Epstein and Quattrin note that effectively treating adolescents for obesity poses unique challenges. The teen years range from 11 to 21, a span that involves many physical and psychological changes.

On the physical side, these changes include sexual dimorphism, sex-specific hormone changes that often occur prematurely in young people with obesity, and natural insulin resistance that is enhanced in individuals who are overweight.

From a psychological standpoint, teens' drive for autonomy, the shift from parental/adult influence to peer influence, and the development from immature to mature impulse control systems balanced by a mature reward system can complicate treatment, primarily because most treatments do not focus on the psychological factors.

The UB authors note that other researchers have provided ideas that are relevant both to treatment of adolescents as well as the broader paediatric population with obesity. For example, they cite the observation that obesity in teens should be considered a chronic disease and treated as such over a long-term basis.

"Approaching adolescent obesity as a chronic disease allows for treatments with the goal of reducing weight during adolescence to reduce health risks associated with obesity and changing the trajectory of weight from adolescence to adulthood," they write.

"Interventions are needed that adapt the treatments to the changing psychological needs of adolescents with obesity as they traverse the rocky road of adolescence."

Using a long-term care approach would likely to lead to reduced health care costs, they add.

Epstein and Quattrin also point out that since everyone learns at a different rate, mastery-based behavioural treatments that match the presentation of the treatment with the rate of learning may be more effective than treatments that provide the same protocol for everyone.

"The idea that there are individual differences in learning to implement lifestyle changes can be a platform to develop a personalized approach to treatment that targets the unique pathophysiology that led to obesity that may make weight loss or weight maintenance challenging," they write.

Epstein and Quattrin urge clinicians to examine new treatment designs to maximize outcomes. They cite the multiphase optimization strategy (MOST) and the Sequential Multiple Assignment Randomized Trial (SMART) model.

"The use of the SMART design may improve clinical translation because it mimics what health care professionals do in real life when they try new approaches when specific treatments do not work," they write.

The fact that teens live in a family group means that the best treatment approach would include the family, a concept that has not been explored, to their knowledge. Even though adolescents desire autonomy, they live in a family, and the approach to include the family in treatment has not been addressed for adolescents with obesity.

"This could ultimately lead to an innovative family-personalized approach, which can capitalize on the likelihood of genetic and psychosocial similarities among several family members," they write.

While there is little synergy of treatment methods in adolescent obesity treatment, there are many opportunities for integrating interventions to improve adolescent obesity treatment, according to Epstein and Quattrin.

They also note that while there are currently few approved drugs to treat for adolescent obesity, certain medications that reduce the reinforcing value of food to teens would be valuable to help them change their eating habits and lose weight.

"The next generation of treatments should attempt to integrate behavioural, pharmacologic, surgical, and device interventions simultaneously to capture their synergy.”

Because obesity affects a disproportionate number of teens with social disparities and heath inequities, who might not have access to an obesity specialist, there need to be interventions that can be carried out in paediatric primary care settings, they write. However, the general lack of specialized knowledge about diet, exercise, behaviour change, and obesity among clinicians poses a particular challenge.

"Adolescent obesity is a serious and growing public health problem that threatens both current and future health outcomes," they stated. "Attempts should be made to disseminate evidence-based behavioural, pharmacologic, surgical, and device-based treatments and develop new interventions that incorporate multidisciplinary approaches to the treatment of adolescent obesity."


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