Pediatric Weight Management

PWM: Scope of Guideline (2015)

Guideline Scope Characteristics

Below you will find a list of characteristics that describe the Scope of this Guideline.

Disease/Condition(s)

The purpose of this guideline is to provide a summary of evidence-based practice in the nutrition management of pediatric overweight and obesity.

Recommendations have been formulated for pediatric weight management within the context of the Nutrition Care Process. The major focus of this guideline is on nutrition assessment and nutrition intervention, including multicomponent treatment for pediatric weight management.
 
While the Pediatric Weight Management work group views this guideline as part of a broader emphasis on pediatric health promotion, the explicit focus of the guideline is on the treatment of pediatric overweight and obesity. Issues such as the prevention of obesity, while critical, are beyond the scope of this guideline. Additional information on prevention, screening, assessment, and treatment of overweight and obesity in the pediatric population may be found in other evidence-based guidelines and publications/sources such as the Nutrition Evidence Library (NEL) Dietary Guidelines Advisory Committee (DGAC) 2015 and the US Preventive Services Task Force.

This guideline is intended for use by registered dietitian nutritionists (RDNs) primarily involved in pediatric weight management. It may also be a valuable resource for RDNs involved in the care of overweight or obese children and adolescents with concomitant conditions or disease states, such as coronary heart disease, metabolic syndrome, type 2 diabetes, hypertension, sleep apnea, osteoarthritis, gallstones and stress incontinence. It is hoped that the information in this guideline will be used to provide individualized nutrition care with practical nutrition recommendations that are based on the current state of the science for pediatric weight management.

The primary purpose of this practice guideline is to provide resources specifically for the RDN. However,  other stakeholders (e.g., teachers, school nurses, and community outreach workers) may find the information in this guideline helpful.

This guideline is not intended:

  • For treating overweight or obesity among children under six years of age, unless specified in the recommendation
  • For prevention of child and adolescent overweight or obesity
  • As a replacement for interventions typically within the scope of practice of an athletic trainer or behavioral or psychological professional, for which adequate training in physical activity interventions or behavioral therapy is necessary.
Note: Interventions for adult weight management may be related to treatment of childhood overweight (especially when treating overweight or obesity in parents), however, the research and treatment approaches are sufficiently different for these two populations that separate interventions are appropriate. See Adult Weight Management Evidence-Based Nutrition Practice Guideline

Guideline Category

Counseling, Management, Treatment

Clinical Specialty

Family Practice, Nutrition, Pediatrics

Intended Users

Registered Dietitians, Physicians, Psychologists/Non-physician Behavioral Health Clinicians, Students

Guideline Objective(s)

Overall Objective
 

To provide evidence-based recommendations for pediatric weight management that reduce adiposity, prevent further weight gain, and maintain improvements in adiposity over a prolonged period.

To provide evidence-based recommendations on medical nutrition therapy (MNT) for pediatric weight management.

Specific Objectives
  • To define evidence-based recommendations for RDNs that are carried out in collaboration with other health care providers.
  • To guide practice decisions that integrate medical, nutritional, and behavioral elements and strategies
  • To reduce variations in practice among RDNs
  • To promote self-management strategies that empower the patient and family to take responsibility for day-to-day management, and to provide the RDN with data to make recommendations to adjust MNT or recommend other therapies to achieve target clinical outcomes
  • To provide the RDN with evidence-based practice recommendations to adjust MNT or recommend other therapies to achieve positive outcomes
  • To enhance the quality of life for the patients and their families by utilizing customized strategies based on the individual’s preferences, lifestyle, and goals
  • To develop guidelines for interventions that have measurable clinical outcomes

Target Population

Child (6 to 12 years), Adolescent (13 to 18 years), Male, Female

Target Population Description

This guideline applies to overweight or obese children and adolescents and their families.  
 

Interventions and Practices Considered

The Pediatric Weight Management Evidence-Based Nutrition Practice Guideline is based on the Academy of Nutrition and Dietetics' Nutrition Care Process and Model, which involves the following steps. 

  • Nutrition Assessment
  • Nutrition Diagnosis
  • Nutrition Intervention
  • Nutrition Monitoring and Evaluation.
This guideline addresses topics that correspond to the following areas of the Nutrition Care Process.
 
I. Referral to a Registered Dietitian Nutritionist

II. Medical Nutrition Therapy.
 
Terms relevant to the treatment of children and adolescents come from the International Dietetics & Nutrition Terminology (IDNT) Reference Manual: Standardized Language for the Nutrition Care Process. Fourth Edition.
 
Nomenclature

The terms "adolescent" and "teen" are used interchangeably throughout this guideline to describe the pediatric population aged 13-18.

Definitions

Adiposity:
 The degree of fatness (including obesity, but also including body composition)   

Cognitive Behavioral Theory (CBT):  Based on the assumption that all behavior is learned and is directly related to internal factors (i.e., thoughts and thinking patterns) and external factors (i.e., environmental stimulus and reinforcement) that are related to the problem behaviors.  Application involves use of both cognitive and behavioral change strategies to affect behavior change.

Complex Interventions: Treatment approaches characterized by multicomponent intervention that interact in non-linear ways and which are highly contextually dependent (i.e., slight changes in some context characteristics may have large effects on individual outcomes).

Component Fungibility: When different components of an intervention are functionally interchangeable or have the same net effect if substituted for each other in treatment management.

Context Characteristics:  Factors or elements outside the direct content of the intervention that may influence study outcomes (i.e., mode of delivery, setting, qualifications of professionals, etc.).

Context Dependence: When the effect of an intervention component depends on some feature or combination of features of the context of the intervention.

Group Sessions: Involve a group discussion between a health professional (RDN or behavioral health counselor, or exercise physiologist, etc. or all facilitators) and multiple (two or more) pediatric clients who share similar weight management issues. Group pediatric clients may include only multiple children/teens, multiple parents (or guardians), or multiple families, or any combination of these at one time, in a single visit. 

Individual Sessions: Involve a one-on-one discussion between a health professional (e.g., RDN or behavioral health counselor, or exercise physiologist, etc.) and one pediatric client. A pediatric client may include only the child/adolescent, only the parents (or guardians), or both youth and parents, or youth and entire family.

Interpretation of Differences between Intervention Mix Types
  • Multicomponent intervention group (MCI): Study arms characterized by interventions that tend to include all of the following major components: diet/nutrition, physical activity, and behavior, and involve an RD/Nutritionist or psychologist/mental health provider
  • Minimal/No intervention group (MI): Minimal intervention type (MI): Study arms characterized by interventions that are likely to be missing at least one of the above major intervention components.
Intervention: A strategy for therapy within a particular program component or mode of treatment.

Intervention Component: Discrete components (e.g., energy intake goals, behavioral counseling method, strength training, etc.) within a multicomponent treatment plan

Intervention Mix: A particular configuration of intervention components.

Medical nutrition therapy (MNT): An evidence based application of the Nutrition Care Process. The provision of MNT (to a patient/client) may include one or more of the following: nutrition assessment/ re-assessment, nutrition diagnosis, nutrition intervention and nutrition monitoring and evaluation that typically results in the prevention, delay or management of diseases and/or conditions. Under Medicare Part B, MNT services are defined as “nutritional diagnostic, therapy, and counseling services for the purpose of disease management which are furnished by a Registered Dietitian or nutrition professional ... pursuant to a referral by a physician”. Reference: Medicare MNT Benefit US Code- 42USC§1395x(vv). Source: A.N.D. Scope of Dietetics Practice, Definition of Terms. Updated 4/2014

Mode of Delivery:  context characteristic that describes the location, setting, intervention delivery (frequency, duration, intensity) or method (who and how) in which the intervention is delivered (i.e., out-patient clinic, school, community-based settings, internet, phone, face-to-face, physician, registered dietitian/nutritionist). 

Multicomponent: A combination of different modes of treatment which may include medical nutrition therapy, physical activity, and behavior therapy. Depending on the expertise and training of the health care team members, different treatment components may be delivered by one or more persons.

Nutrition Counseling: A supportive process, characterized by a collaborative counselor–patient/client relationship to establish food, nutrition and physical activity priorities, goals, and individualized action plans that acknowledge and foster responsibility for self-care to treat an existing condition and promote health. Source: International Dietetics and Nutrition Terminology (IDNT) Reference Manual: Standardized Language for the Nutrition Care Process, Fourth Edition, 2013

Nutrition Education: Formal process to instruct or train patients/clients in a skill or to impart knowledge to help patients/clients voluntarily manage or modify food, nutrition and physical activity choices and behavior to maintain or improve health. Source: International Dietetics and Nutrition Terminology (IDNT) Reference Manual: Standardized Language for the Nutrition Care Process Fourth Edition, 2013

Suppressor Effect: The combination of two intervention components that may counteract the individual effects of each individual component. The combination of components may have no effect or could have an adverse effect.

Synergistic Effect: A combination of two or more intervention components that produce a total effect greater than the sum of the individual components.  The combined effect may either a positive or negative impact on the outcome.

Youth: Combined children and adolescent populations.