Obesity Management in Female Adolescents

Summary:

Global childhood obesity continues to rise, particularly in adolescent females. In this review, we discuss the multiple options available for assisting an adolescent female in accomplishing their weight loss goals, to improve their overall health and longevity. Lifestyle changes, including decreases in overall calorie consumption and simple carbohydrates as well as increases in activity/exercise have been the mainstay of obesity therapy due to their effects on decreasing insulin resistance and associated metabolic disease, as well as weight loss. However, the combination of provider encouraged weight loss and societal obesity stigma leads to an increased risk for disordered eating. The high prevalence of mental health and sleep disorders in female youth with obesity are recent findings, as is the importance in treating these conditions for improved quality of life as well as success with lifestyle changes. The American Academy of Pediatrics’ 2023 obesity guidelines are the first across the globe to recommend early adjunctive use of weight loss medications for obesity. These recommendations correspond with the development and increasing availability of new combinations of existing mediations as well as the glucagon like peptide-1 receptor agonist class of medications. Youth with a body mass index in excess of 35–40 kg/m², can now undergo bariatric surgery in many countries, with very encouraging short- and medium-term success. In summary, there are now many approaches to consider when treating an adolescent female for obesity or associated metabolic disease, and customized approaches may be needed for optimal success at the individual patient level.

Introduction:

Across the globe, childhood obesity is becoming more common – since 1990, there has been a four-fold increase in obesity in children ages 5–19 years with now 160 million children and adolescents with obesity globally. [1, 2] Worldwide, females had a higher BMI as compared to age-matched males in many sub-Saharan African and south Asian countries, and females gained more weight than males in Europe and Latin America between the years 1975–2016. [3] While rates of overweight and obesity increased the setting of the COVID-19 pandemic, continued surveillance is important as some evidence suggests a return to pre-pandemic trends. [4] The etiology of obesity is complex with a broad range of risk factors including genetic, socioeconomic, and environmental influences but disproportionately affect children and adolescents who experience racism, live in poverty, or have limited access to resources including food. [2]

Overweight is classified based on percentile of body mass index (BMI) ranging from 85–95% while obesity is divided into classes including class 1 obesity defined as a BMI between 95–119%, class 2 obesity as BMI between the 120–139%, and class 3 obesity as BMI >140%. [5] The impact of obesity, particularly severe obesity defined as class 2 or 3 obesity, during the critical years of adolescence includes increased rates of metabolic comorbidities such as prediabetes, type 2 diabetes, hypertension, metabolic dysfunction-associated liver disease (MASLD), dyslipidemia, polycystic ovary syndrome (PCOS), and obstructive sleep apnea (OSA). [6–8] As a result, high BMI represents the greatest contributor to increasing disease burden worldwide over the last decade. [5] With these known risks of increasing BMI, identifying the underlying causes of obesity and finding lasting solutions to address associated metabolic and psychosocial issues with lasting results remains essential.

Impact of Obesity:

With the rising prevalence of overweight and obesity among youth, a similar increase in a variety of metabolic comorbidities has been observed. For example, the prevalence of type 2 diabetes among youth ages 10 to 19 in the United States has increased by 8.5% from 2001 to 2017 with the greatest increase in type 2 diabetes seen among Hispanic youths with a 10.5% increase. [9] Importantly, the prevalence of metabolic conditions including pre-diabetes, diabetes, dyslipidemia, hypertension and MASLD also rises in relation to increasing BMI categories and screening for these conditions remains critical (Table 1). [1, 8] Longitudinal study of these youth remains an area of ongoing research. However, initial studies have demonstrated increased risk of heart failure and cardiomyopathy as well as increased overall mortality in adulthood for youth with severe obesity. [8] Fortunately, with lifestyle changes focused on nutrition, activity, and mental health as well as weight loss adjuncts including medications and bariatric surgery, overweight and obesity as well as associated metabolic conditions can be managed if not prevented altogether. [1]

Table 1:

Recommended screening for comorbidities in individuals with overweight or obesity

	Preferred screening strategy	Frequency of screening
Glucose intolerance	Fasting plasma glucose, 2-hour glucose tolerance test, Hemoglobin A1c	At diagnosis, then every 2 years if prior testing is normal
Dyslipidemia	Fasting lipid panel	At diagnosis, then every 2 years if prior testing is normal
Metabolic associated steatotic liver disease	Alanine aminotransferase	At diagnosis, then every 2 years if prior testing is normal
Hypertension	Blood pressure	At every visit
Obstructive sleep apnea	Berlin questionnaire	At least once a year
Depression	Multiple options	At least once a year
Anxiety	Multiple options	At least once a year
Disordered eating	Multiple options	At least once a year

The American Academy of Pediatrics (AAP), United States Preventative Task Force (USPSTF), World Health Organization (WHO), Society for Adolescent Health and Medicine (SAHM), Obesity Medicine Association (OMA), and American Society for Metabolic Bariatric Surgery (ASMBS) provide recommendations to support weight loss in adolescents living with obesity. [1, 2, 5, 10, 11] Multi-disciplinary lifestyle, surgical, pharmacological, and combination therapy approaches have all been recommended to support weight loss in adolescents at a higher weight, however the intensity and specificity of lifestyle interventions varies by guideline. Prioritization of different weight loss strategies also varies by age, degree of adiposity, and presence and/or severity of comorbidities present. In a departure from the AAP and OMA, surgical approaches are not advised by the USPSTF for weight loss in adolescents. We note considerable efforts to understand the short- and long-term health benefits and risks to metabolic bariatric surgery in adolescents are the focus of the TeenLABS consortium, with 10-year outcomes beginning to be published. [12–14] Regardless of the weight loss method implemented, a team-based and culturally appropriate approach is universally advised for the success of any weight loss method implemented. [1, 2, 5, 10, 11] That said, structural and health inequities persist that limit access to the continuum of care, medical, nutritional, of geospatial resources needed to implement any of these weight loss methods, which disproportionately affect minority groups.

Role of Nutrition:

Nutritional intervention to promote healthy eating for the management of obesity in adolescents is recommended as a component of a multi-component lifestyle intervention by the WHO, AAP and USPSTF [2, 5] Whereas the AAP recommends dietary intervention for both adolescents with overweight and obesity (BMI ≥ 85th percentile), the USPSTF advises dietary intervention for adolescents with obesity (BMI ≥ 95th percentile). [2] None of the guidelines recommend a specific diet or dietary pattern per se. Rather, these guidelines focus on comprehensive interventions for a minimum of 26 contact hours of Intensive Health Behavior and Lifestyle Treatment (IHBLT) which includes nutritional education and counseling for healthy eating alongside physical activity and behavioral therapy delivered by a multidisciplinary team, which includes registered dietitian-nutritionists, diet assistants, or nutritionists. [5]

The Dietary Guidelines for Americans (DGA) and MyPlate put forward by the United States Department of Agriculture (USDA) provide nutritional recommendations for adolescents across the lifespan in the United States and therefore serve as a benchmark to establish nutrition-related goals and dietary behavior change towards. [15] A summary of the current guidelines for adolescents adapted from the DGA is provided in Table 2. The Healthy Eating Index (HEI) is a scoring method used to evaluate individual dietary pattern alignment with the DGA providing an estimation of diet quality. [16] Per the HEI, optimal diet quality reflects an average score >80, or meeting >80% of specific food serving goals each food group listed in Table 2. [17] Efforts to increase diet quality as defined by HEI are generally advisable, especially in adolescents, a group in which the majority meet criteria for a poor diet quality. [18] Micronutrient deficiencies are common in obesity, secondary to the pathophysiology of obesity or medication-induced malabsorption. [19] Common micronutrient deficiencies to consider in evaluation and management of adolescents attributed specifically to adiposity are iron deficiency and anemia attributed to increased hepcidin and decreased absorption, vitamin D deficiency, and folic acid (vitamin B12). [19]

Table 2. Healthy U.S.-Style Dietary Pattern for Adolescents Ages 14 Through 18, With Daily or Weekly Amounts from Food Groups, Subgroups, and Components.

Adapted from the Dietary Guidelines for Americans, 2020–2025.

CALORIE LEVEL OF PATTERN	1800	2000	2200	2400	2600	2800	3000	3200
FOOD GROUP OR SUBGROUP	Daily Amount of Food from Each Group (Vegetable and protein foods subgroup amounts are per week)
Vegetables (cup eq/day)	2 ½	2 ½	3	3	3 ½	3 ½	4	4
	Vegetable Subgroups in Weekly Amount
Dark-Green Vegetables (cup eq/wk)	1 ½	1 ½	2	2	2 ½	2 ½	2 ½	2 ½
Red and Orange Vegetables (cup eq/wk)	5 ½	5 ½	6	6	7	7	7 ½	7 ½
Beans, Peas, Lentils (cup eq/wk)	1 ½	1 ½	2	2	2 ½	2 ½	3	3
Starchy Vegetables (cup eq/wk)	5	5	6	6	7	7	8	8
Other Vegetables (cup eq/wk)	4	4	5	5	5 ½	5 ½	7	7
Fruits (cup eq/day)	1 ½	2	2	2	2	2 ½	2 ½	2 ½
Grains (ounce eq/day)	6	6	7	8	9	10	10	10
Whole grains (ounce eq/day)	3	3	3 ½	4	4 ½	5	5	5
Refined Grains (ounce eq/day)	3	3	3 ½	4	4 ½	5	5	5
Dairy (cup eq/day)	3	3	3	3	3	3	3	3
Protein Foods (ounce eq/day)	5	5 ½	6	6 ½	6 ½	7	7	7
	Protein Foods Subgroups in Weekly Amounts
Meats, Poultry, Eggs (ounce eq/wk)	23	26	28	31	31	33	33	33
Seafood (ounce eq/wk)	8	8	9	10	10	10	10	10
Nuts, Seeds, Soy Products (ounce eq/wk)	4	5	5	5	5	6	6	6
Oils (grams/day)	24	27	29	31	34	36	44	51
Limit on Calories for Other Uses (kcal/day)	140	240	250	320	350	370	440	580
Limit on Calories for Other Uses (%/day)	8%	12%	11%	13%	13%	13%	15%	18%

Motivational interviewing and goal-setting are recommended tools to promote nutritional behavior change during adolescence. Mobile health interventions and mobile health apps such as food trackers are also emerging tools to promote nutritional behavior change in adolescents. However, the use of these tools remains an area of active study and still requires validation. [20] Inclusion of the family, parent, or caregiver is also consistently recommended to ensure a supportive environment for lifelong dietary behavior change. Therefore, working closely with the adolescent to understand their unique needs and preferences is essential for successful intervention, appreciating that the role of the parent/guardian may evolve based on the adolescent’s age and developmental stage. [21] While the potential risk of eating disorders within this population is high, both the AAP and USPSTF report that structured weight management programs do not increase the likelihood of developing disordered eating behaviors. [22] The AAP highlights that structured multi-component behavioral interventions can decrease current and future eating disorders symptoms by promoting healthy eating, physical activity, and improved self-esteem. [5]

Because overweight and obesity increase the risk of several comorbidities during adolescence, the American Diabetes Association (ADA) recommends culturally appropriate lifestyle programs alongside diabetes management, targeting 7–10% weight loss, nutrient-dense over calorically dense foods as part of an overall healthy dietary pattern, and reducing beverages with added sugars. [23] For adolescents with PCOS, the International Guidelines for the Diagnosis and Management of PCOS advise individuals follow their country-specific guidelines for healthy eating, acknowledging a lack of studies in this population limit more targeted dietary recommendations. [24] Generally, compliance remains a persist issue in nutritional interventions among adolescents and ability to implement dietary behavior change may be hampered by modifiable health disparities such as food insecurity, which highlights the need for further research into effective behavior change strategies tailored to this unique demographic. [25]

Role of Physical Activity:

Decreased physical activity (PA) and increased sedentary behaviors both contribute to the development of obesity. [26] As above, the WHO, AAP and USPSTF recommend supervised PA as an important part of the IHBLT model. Though the USPSTF does not explicitly state the amount of time that should be dedicated to PA, the AAP aligns with the WHO and recommends 60 minutes daily of moderate to vigorous physical activity (MVPA). [1, 2, 5] Furthermore, the AAP also emphasizes that reduction in sedentary behavior (including screen time) has been shown to have a positive impact on BMI. [5] It is important to note that weight loss in response to PA is often modest, with exercise-only intervention leading to small effects on weight. However, interventions that combine diet and PA are more effective than diet alone. [27] Additionally, maintaining adequate PA is an important preventive strategy with decreased risk of overweight and obesity among children participating in 60 minutes of daily PA. [28] Among adolescents, exercise interventions are associated with a small but consistent improvement in BMI z-score and cardiometabolic risk factors, most consistently in relation to decreasing insulin resistance. [29] While high intensity interval exercise as well as resistance training may improve body composition and cardiometabolic risk factors, there is insufficient evidence to recommend one over the other. [30]

While most adolescents do not achieve the recommended PA, adolescent females are less active than adolescent males (85% vs 78% not achieving the WHO target of 60 minutes/day, respectively). [31] With low rates of PA at baseline as well as the observation that PA among girls begins to decline in puberty due to a variety of psychosocial and biological factors, increasing PA participation in females is both a clinical and research priority. [32] In a systematic review and meta-analysis, a small effect of interventions on PA behaviors in adolescent females was noted, indicating that behavior change is possible but potentially challenging. Multicomponent interventions including PA along with reducing sedentary behavior and improving dietary behaviors were most successful, as well as programs that leveraged existing social supports and were adaptable to the adolescent’s preferences. [33] Additionally, leveraging community- and school-based resources are a crucial component of promoting PA among this population. [34]

Role of Sleep:

Sleep problems are highly prevalent in females, with sex differences emerging beginning in adolescence. Insomnia prevalence is similar among males and females in childhood, but following puberty, adolescent females have a 1.4x greater risk for insomnia. [35] Conversely, sleep-disordered breathing (SDB) is more prevalent in males, hypothesized to be related to the protective effect of hormones such as estrogen and progesterone. [36, 37] Notably, however, adolescent females with PCOS have higher rates of SDB compared to healthy peers. [24] These sleep problems and other poor sleep health behaviors may contribute to insufficient sleep duration and late sleep timing for adolescent females, which are associated with increased risk of obesity in youth. [38]

The relationship between sleep and obesity is thought to be due to the impact of sleep health on dietary intake, physical activity, and cardiometabolic health. [38] Insufficient sleep duration results in increased energy expenditure while also increasing hunger, appetite, and food intake, resulting in a net positive energy balance. [39] Indeed, adolescents consumed 10% more calories during a week of experimentally induced insufficient sleep (6.5h time in bed) compared to a week of longer sleep (10h time in bed). [40] Poor sleep health may also relate to levels of appetite-regulating hormones such as leptin and ghrelin, though findings in adolescents have been mixed. [41] Adolescents tend to eat later in the day, and this may be particularly prevalent in adolescents with late bedtimes. [42] Food intake late at night, particularly during times of high circulating melatonin, may contribute to weight and metabolic dysregulation. [43] An association between insufficient sleep duration, low physical activity, and high sedentary behaviors has been observed in adolescents. [44, 45] Finally, short sleep duration and late bedtimes are associated with poorer insulin sensitivity and other markers of cardiometabolic health in adolescents. [46]

Taken together, the existing literature suggests that sleep health is an important consideration for weight management in adolescent females. Screening for SDB is recommended for adolescent females with overweight or obesity, particularly symptoms that are more common in females such as waking unrefreshed, morning headache, and fatigue. [37, 47] Polysomnography is the gold standard assessment method to diagnose OSA (Table 1). Additionally, screening for other sleep problems such as insomnia and assessment of habitual sleep duration and bed/wake times may be beneficial in the context of weight management for adolescent females.

Role of Mood:

Mental health issues, including depression and anxiety, are more prevalent among female adolescents with overweight and obesity, as compared to the general population of adolescents. A 2017 meta-analysis found that youth with obesity, compared to youth with normal weight, were 34% more likely to report depression. In a sub-group analysis comparing females and males, females with obesity reported more elevated depression symptoms compared to females with normal weight. [48] Even fewer studies have examined prospective relationships linking youth obesity and depression. Data from a multidisciplinary referral clinic in the United States found that 60% of females with PCOS and obesity had symptoms of depression. [49] A large observational study of youth ages 6–17 years in Sweden found that females with obesity had a 43% higher risk for a clinical diagnosis of either depression or anxiety, compared to females without obesity. [50] These mental health concerns not only cause distress and psychosocial impairment but may also negatively impact engagement in healthy lifestyle recommendations to manage weight and health.

Given the higher prevalence of depression and anxiety concerns for females with overweight and obesity, evidenced-based mental health treatments for depression and anxiety have been tested to ameliorate both psychosocial and physical health concerns. Cognitive-behavioral therapy (CBT) is the most tested behavioral approach to depression and similarly has been tested for depression and excess weight among youth with obesity. A randomized controlled trial comparing brief group-based CBT, compared to a time and attention matched health education comparator (HE) for adolescent females with overweight found greater reductions in depression symptoms at post-intervention in CBT, versus HE, for those who reported moderately elevated depression symptoms at baseline. The study did not find within-condition changes in BMI at post-intervention or 1-year follow-up. [51] Another pilot RCT compared CBT enhanced with a healthy lifestyle intervention (CBT-HL), compared to CBT, alone, and found that adolescents with overweight and obesity in both conditions reported decreases in depression symptoms from the clinical to non-clinical range. [52] Adolescents assigned to CBT-HL showed a trend towards reduction in BMI, whereas adolescents assigned to CBT alone showed a small increase in BMI.

A meta-analysis reviewing the effects of interpersonal psychotherapy (IPT) on primarily female adolescents with overweight or obesity found that IPT, when compared to CBT, HE, or behavioral weight loss intervention, showed a small effect for reducing depression symptoms. Furthermore, IPT showed commensurate effects as CBT or behavioral weight loss for reducing BMI and showed a small effect when compared to HE. [53] Finally, a pilot RCT comparing a brief, group-based mindfulness-based intervention (MBI) to time and attention matched group CBT found preliminary evidence that those decreases to MBI, compared to CBT, showed greater decreases in depression symptoms at post-intervention and 1-year follow-up. Furthermore, those randomized to MBI showed decreases in BMI at 1-year, compared to those in CBT who showed stable BMI at 1-year. [54] In summation, RCTs testing behavioral interventions for youth with mental health concerns and overweight or obesity have found positive results not only for improvements in mental health concerns but also encouraging results for reducing or stabilizing BMI. Future research is indicated for mental health interventions targeting anxiety in this population.

Concern for Disordered Eating:

Eating disorders are serious mental health conditions marked by significant and persistent changes in eating behaviors and food intake, which can lead to impairments in one’s physical health and psychosocial functioning. [55] In a 2011 cross-sectional survey of over 10,000 nationally representative US adolescents 13 to 18 years of age, an estimated prevalence of Anorexia Nervosa (AN), Bulimia Nervosa (BN), and Binge Eating Disorder (BED) were noted to be 0.3%, 0.9%, and 1.6%, respectively. Symptoms consistent with AN and BED but not meeting diagnostic criteria were shown in another 0.8% and 2.5%. [56] Data indicates higher rates of BN and BED in individuals with higher weight, however atypical anorexia nervosa is also seen and can be a missed diagnosis in individuals of higher weight or normal weight. [57] A 2021 review of screening questionnaires for eating disorders in individuals with higher weight found the Adolescent Binge Eating Disorder Measure and Children’s Brief Binge-Eating Questionnaire to have high sensitivity for BED. [58] The Eating Disorder Examination Questionnaire is another helpful and frequently used tool to screen for eating disorders, however the cut-points have not been tested specifically in adolescents. [59] Comprehensive clinical interviewing, use of growth charts, physical examination, bloodwork/labs, and vitals are additional important screening tools for disordered eating and eating disorders. [58] Querying for rigid food rules, eating disorder cognitions, body image distress, drive for weight loss/thinness, changes in eating patterns, loss of control with eating, or compensatory behaviors (i.e. laxative use/diet pill use/purging/over-exercise) can also help determine whether disordered eating or an eating disorder is present.

With medications such as Glucagon-like peptide receptor agonists (GLP-1A) becoming more frequently discussed and prevalent in their use, it is important to consider their potential risks, particularly for those with disordered eating or a history of an eating disorder. While a handful of studies show potential benefits of GLP-1A medications in adults with BED in decreasing binge eating episodes, these studies indicate early findings, and it must be noted that they were not completed in adolescents. [60] For adolescents who are prescribed these medications, taking steps to monitor the rate of weight loss, assess for skipped meals or overly restricted food intake, check for nutrient deficiencies, and assess for eating disorder cognitions or severe body image disturbance are all crucial in determining whether a person is safe to continue taking these medications or whether the medication needs to be stopped and intervention for disordered eating/eating disorder pursued. Due to limited data and research, there are currently no agreed upon guidelines for the use of these medications in eating disorder populations. [61] It is important to monitor for signs of disordered eating or eating disorders in all adolescents who take these medications.

Role of Weight Loss Medications:

The provision of medications for weight loss in youth has increased following regulatory approvals for the pediatric population. However, the availability of these weight loss medications varies widely across the globe. The AAP obesity guidelines are the first set of professional guidelines globally to explicitly recommend the use of weight loss medications in pediatrics. [5] There are several classes of medications with data to support their use in combination with caloric restriction in a pediatric population as seen in Table 3, however achieved weight loss in youths is typically less than what is observed in adults. [62]

Table 3:

Weight loss achieved with maximal dosing of weight loss medications

		Percentage of participants to achieve degree of relative BMI%ile decrease
	Absolute BMI% change Relative BMI% change [Mean weight (kg)]	< 5% loss	> 5% loss	>10% loss	>15% loss	>20% loss
Orlistat 120 mg orally three time a day 54 weeks Age 12–16 years	−0.55 A BMI% [+ 0.53 kg]	73.5	26.5	13.3
Phentermine/topiramate, 15mg/92mg orally daily 56 weeks Age 12–16 years	−4.15 ± 0.31 A BMI% −7.11 ± 1.01 R BMI% [−9.2 ± 0.9 kg]	52	46.9	42.5	28.3
Liraglutide 3.0 mg SQ injection daily 56 weeks Age 12–17 years	−0.23 ± 0.05 A BMI% −8.32 R BMI% [−2.3 ± 0.9 (kg)]	57	43	26
Liraglutide 3.0 mg SQ injection daily 56 weeks Age 6–11 years	−5.8 R BMI% [+ 0.55 kg]	54	46
Semaglutide 2.4 mg SQ injection daily 64 weeks Age 12–17 years	−15.3 kg	24*	76*	63*	57*	40*

Amount of weight loss achieved at the maximal dose of each medication. The drug, dose, duration of therapy and age of participants is listed on the left. The absolute change and change relative to starting BMI percentile are shown, in addition to change in absolute weight in kg, as the expected BMI rises across puberty. Not all data types were provided in source manuscripts. BMI% data was not published in the Semaglutide manuscript, and the degree of percentage weight loss in kg are shown instead and demarcated with *. A= absolute, R = relative, SQ=subcutaneous

Orlistat, an orally ingested lipase inhibitor, prevents the absorption of dietary fat and though it results in modest weight loss, compliance remains an issue due to intolerable GI side effects demonstrated by an approximate 35% drop-out rate in studies. [63] Phentermine is a stimulant that has been used in isolation for weight loss for decades, although there is little data on its use in adolescents. [64] There was a concern for increased blood pressure especially with doses in excess of 15 mg, although this has not been demonstrated in recent trials which utilize doses 15mg or less. [64] In the last decade, the combination of phentermine with topiramate has been found to be efficacious with maximal dosing of phentermine at 15 mg and even demonstrated decreases in blood pressure. This medication does not induce >5% loss in BMI% for half of patients, but for those who do respond, the weight loss can be profound, with 40% losing at least 10% of their body weight. [65] A promising and powerful new class of medication includes GLP-RAs which act by decreasing intestinal motility and induce early satiety. These medications have been approved for both glycemic control and weight loss, however higher doses are often recommended for weight loss. Liraglutide has been demonstrated to induce mild weight loss in youth aged 6 and older, however it remains less effective than phentermine/topiramate. Semaglutide is a particularly efficacious GLP-RA and showed a total relative decrease in BMI by 16% with 76% of participants losing at least 5% of their body weight, and 40% losing more than 20% of their body weight. [66]

Role of Bariatric Surgery:

Metabolic bariatric surgery (MBS) has increasingly become a treatment of obesity and its complications, especially impacting women who make up >80% of those undergoing the procedure. [67] MBS is a term used to refer to a variety of weight loss surgeries including Roux-en-Y gastric bypass (RYGB), biliopancreatic diversion with duodenal switch, adjustable gastric banding, and vertical sleeve gastrectomy (VSG), with the latter being the most used MBS procedure at this time due to a favorable balance of efficacy and lower complications. MBS can be utilized in any individuals with a BMI >35, or >30 with obesity associated comorbidities (including type 2 diabetes, hypertension, OSA and PCOS) as surgery can lead to dramatic improvement in obesity associated comorbidities. [68] In females with infertility associated with PCOS or obesity associated anovulation, MBS can also improve fertility. [69] For those with type 2 diabetes, improved glycemic control, including diabetes remission, MBS can provide substantial long-term improvements in health. While the positive impacts of MBS are large, special attention must be paid to potential long term side effects that most specifically impact females. For those with future plans of fertility, avoiding pregnancy for at least one year post surgery, maintaining adequate nutrition and vitamin intake, and informing the obstetric team of a history of MBS is critical. [70] Females with history of MBS will require high vitamin supplementation and monitoring of levels during pregnancy and may not tolerate the standard oral glucose tolerance test for screening of gestational diabetes. Later in life, bone health is of critical importance for postmenopausal females. Due to changes in calcium and vitamin D metabolism following surgery, there is an increased risk of osteoporosis, especially for those who have undergone the more invasive surgeries such as RYGB. [70] Overall MBS provides a great opportunity to improve the health of females, however education and counseling remain central in balancing improvements with possible complications.

Conclusions:

Strategies for weight loss are most successful when utilizing a multi-disciplinary patient centered approach. [2, 5] This is typically termed a “lifestyle” approach, and includes the components - diet, activity/exercise, mental health and sleep - to be addressed with both the adolescent and the parents. The use of multiple modalities is likely necessary as research where each of these modalities is studied in isolation has not demonstrated any meaningful changes in weight or BMI. However, when reviewing the placebo groups from the weight loss clinical trials listed in table 2, many of these participants did experience some degree of weight loss. [62–66] Importantly, these trials also included dietary counseling with recommendations with low-calorie goals of 1300–1700 kcal and increases in exercise but did not include therapies for mood or evaluation of sleep. More recently, the adjunctive use of medications to decrease hunger has been recommended and once these medications are broadly available, there may be a demonstrable change in rates of pediatric obesity. [2, 5]

Providing multi-faceted obesity care in a busy pediatric clinic can be challenging. Per the consensus guidelines it is estimated that at least 26 hours of obesity related patient facing care are needed across a 12-month period to induce modest changes in weight, or approximately a 3–5% decrease. [2, 5] Longitudinal care over more than 12 months is a positive prognostic factor for success in weight loss intervention, and this can be achieved within a primary care setting however a one-hour visit every other week is prohibitive outside of the setting of a clinical trial, due to time, missed school for youth and missed work for parents. Ultimately, treatment of obesity in adolescents needs to be patient and family centered utilizing the full spectrum of medical care with a multi-disciplinary approach. Beyond changes in dietary habits and activity, addressing mental health concerns and sleep remain critical components of this care.