The National Youth Risk Behavior Survey (YRBS) monitors health behaviors that contribute to the leading causes of death, disability, and social problems among youth and young adults in the United States. The national YRBS is conducted every 2 years during the spring semester and provides data representative of 9th through 12th grade students in public and private schools throughout the US.1
Under the obesity and nutrition portion of the survey, the results showed no change from the prior report regarding what students were obese, overweight, did not eat fruit at all, or ate fruits or vegetables 3 times or more per day, and those who did not eat vegetables, as well as those who drank soda or did not drink soda, and those who ate breakfast versus those who did not.1 There was an increase for those who did not drink milk, with a concomitant decrease in those who drank 3 or more glasses of milk per day.1
In terms of physical activity, there was no change from the last report for those who were not physically active for a total of at least 60 minutes on at least 1 day, or were physically active for a total of at least 60 minutes per day on 5 or more days, or were physically active for a total of at least 60 minutes per day on all 7 days, as well as those playing video or computer games or using a computer 3 or more hours per day.1 Regarding physical education (PE) classes, those who went to classes on 1 or more days, or on all 5 days, or played on at least one sports team, and finally those who did exercises to strengthen or tone muscles on 3 or more days showed no change from the previous report.1 There was a decrease in those watching television 3 or more hours per day.1
Obesity was demonstrated in 14.8% of students and 15.6% were overweight according to the survey.1 It was noted that 5.6% of students did not eat fruit or drink 100% fruit juices during the 7 days before the survey, 7.2% did not eat vegetables during the 7 days before the survey, 7.1% drank a can, bottle, or glass of soda or pop 3 times or more per day during the 7 days before the survey, 26.7% did not drink milk during the 7 days before the survey, and 14.1% did not eat breakfast during the 7 days before the survey.1
Regarding physical inactivity, 15.4% were not physically active for a total of at least 60 minutes on at least 1 day during the 7 days before the survey, 48.3% did not go to PE classes on 1 or more days in an average week when they were in school, 20.7% watched television 3 or more hours per day on an average school day, 43% played video or computer games or used a computer for 3 or more hours per day on an average school day, and 45.7% did not play on at least one sports team counting any teams run by their school or community groups during the 12 months before the survey.1
The School Health Policies and Practices Study of 2014 indicated that among US high schools, health education was required of 88% of students.2 This included receiving instruction on health topics as part of a specific course. It was noted that 86% of schools required students to receive instruction on nutrition and dietary behavior, and 80% required students to receive instruction on physical activity.2 PE was required for 96% of students and among these schools, 51% did not allow students to be exempted from taking a required PE course for various reasons.2 At least 4% required daily PE or its equivalent for students in all grades in the school for the entire year, and 48% offered opportunities for students to participate in intramural activities or physical activity clubs.2 In school cafeterias, 12% of students could purchase fruits or vegetables, and 58% of students could not purchase soda pop or fruit drinks that were not 100% juice.2 In 73% of schools, students could not purchase chocolate candy, and 77% did not allow students to purchase foods or beverages high in fat, sodium, or added sugars during school lunch periods.2 It was noted that 87% of nutrition programs offered a choice between 2 or more different fruits or types of 100% fruit juice each day for lunch, 72% did not sell any fried foods as part of school lunch, and 84% offered lettuce, vegetable, or bean salads a la carte to students during a typical week.2
Behaviors related to nutrition and exercise have not changed much as summarized by the survey over the last several years. Schools have implemented changes to nutrition services and physical activity classes to promote an increase in physical activity and healthier eating habits. However, there is still an obesity epidemic in this country that continues to worsen each year. Therefore, the current approach needs to be evaluated at all levels from the local schools to the state and national levels to develop an approach that is going to improve the lives of children and adolescents for the long term.
What Are the Myths Associated with Diet and Exercise?
Children and adolescents struggle with a healthy lifestyle due to the demands of school, home, and extracurricular activities, often not having time for breakfast, eating out for lunch, and rushing to eat dinner due to activities in the evenings. Having snacks throughout the day can make it more difficult to eat a healthy meal.
There is a lack of evidence on the changes that are usually suggested for weight reduction, physical activity, and eating habits that promote long-term behavioral shifts.
The idea that small sustained changes in energy intake or expenditure produce large, long-term weight changes are not accurate. In fact, changes in mass concomitantly alter the energy requirement of the body, causing less weight loss over time than predicted.3,4
Second, setting realistic weight-loss goals is thought to be important to avoid frustration in those trying to lose weight. However, having a specific goal has not been shown to effect weight loss or completing a particular weight loss program. As a matter of fact, studies have shown the opposite, with more weight loss noted when there are no specific goals set because most tend to be unrealistic, which lead participants to discontinue efforts.3,5
Losing weight quickly is thought to be associated with the inability to sustain the weight loss over the long term. It is thought that gradual weight loss is more beneficial for sustained weight loss. Studies have shown, however, that quick, large weight loss has been associated with great weight loss in the long term that can be sustained.3,6 The quick weight loss helps patients to feel a sense of accomplishment quickly, promoting the desire to continue losing weight. Therefore, recommending weight loss more slowly may interfere with successful weight loss efforts.
Normally the stage of change that a person is in, such as pre-contemplation, contemplation, preparation, maintenance or relapse, help determine his or her readiness for change. However, diet readiness does not predict the magnitude of weight loss or adherence to a plan.3,7 This is because those who are inquiring about weight loss are somewhat ready to engage in the efforts required to lose weight.7
A reduction in childhood obesity is thought to be a benefit of PE classes in schools. The frequency, duration, and intensity that needs to be achieved for reduction in body mass index is probably not sufficient in PE classes to maintain weight or prevent obesity.3 Physical activity, however, is very important for reductions in adiposity and it has established health benefits, so it should not be discouraged.3,8
Finally, it is believed that being breast-fed is protective against obesity. However, a randomized controlled trial involving more than 13,000 children who were observed for 6 years showed no evidence of this effect.9 It is still important to encourage breast-feeding due to other benefits associated with this practice.
Understanding that the common recommended practices are not based on scientific evidence should help providers think through other options for their patients in terms of weight loss, nutrition, and exercise.
Presumptions That Have Not Been Proven to Be Effective
As mentioned earlier, children and teens often do not eat breakfast. This has been thought to cause the metabolism to slow down, which can result in overeating at lunch due to the lack of calories in the morning.
The following presumptions have not been proved nor disproved so they may or may not be useful in a healthy lifestyle but could be considered. There is the thought that skipping breakfast will cause overeating later in the day. Two randomized controlled trials did not show a difference in people who ate breakfast versus those who skipped it.3 This could have been because people were assigned to a specific group based on their current breakfast eating habits. Having a particular breakfast pattern could be a confounding factor that causes one to overeat or not throughout the day.
Second, there is the notion that early childhood is when people learn exercise and healthy eating habits that influence behavior throughout life. There are no studies that prove this to be a fact. It is thought that genetics play a role in one's weight over their lifetime.3
The motto for decades has been that eating more fruits and vegetables will result in weight loss or reduction in weight gain even if one does not have any other behavioral changes. This is thought to be due to causing a reduction in calories overall. However, if there are no other changes in behavior, such as increased physical activity and reduced calorie intake, weight loss may not necessarily occur.3 It is still important to encourage fruits and vegetables due to the health benefits.
Next, fluctuations in weight are supposedly associated with increase in mortality due to observational studies showing lower mortality among those with stable weight throughout their lifetime.3 This is likely due to one's confounding health status at baseline but this is not supported by scientific studies at this time.
In addition, some think that snacking contributes to weight gain because they are not compensated for at subsequent meals, leading to obesity in the long term.3 No studies have supported the association between snacking and obesity.
Finally, there is the belief that the environment one lives in can be conducive to weight loss; for example, adding sidewalks and parks where people can be more physically active. There have only been observational studies on this topic so conclusive evidence is not available.3
Facts Associated with a Healthy Lifestyle
With all of this in mind and the growing number of obese children and adolescents in the US, there are some facts associated with a healthier lifestyle that include genetic factors, reduction in caloric intake, and physical activity. Obesity should be viewed as a chronic condition requiring continued management for successful maintenance of weight.
Genetic factors play a major role in obesity; however, modifying key environmental factors can lead to successful weight reduction. Reduction in calorie intake is necessary for overall sustained weight loss. Having someone eat breakfast or more fruits and vegetables will not affect obesity without overall reduction in calories.
Exercise is important in mitigating the effects of obesity even without weight loss, so this should be encouraged but not necessarily viewed as the way to lose weight in and of itself. It is true that exercise at the appropriate levels will help in long-term weight maintenance. Overweight children benefit from parents participating in an exercise program with them and at home.3
Having specific meals or meal-replacement products has been shown to help reduce weight rather than the “balance, variety, and moderation approach.”3 This is because people have an easier time not having to think through what they can and cannot eat. Meal replacements that lead to very little thinking lead to less chance for someone to go off the plan, which can lead to sustained weight loss.
Potential Pharmacological Options that Can Work in Conjunction with Lifestyle Changes
There are pharmaceutical agents that are shown to achieve meaningful weight loss and maintenance of weight loss, but these are best in conjunction with environmental changes and behavioral changes. These would be considered second-line therapy and not to be used alone.
For those who are severely obese, bariatric surgery results in long-term weight loss and reductions in health conditions such as diabetes and mortality.10 For some who are morbidly obese and have undergone extensive therapy and numerous failed attempts at lifestyle changes to lose weight, this may be an option but only in consultation with a team of physicians, mental health providers, and a nutritionist who specialize in weight management.
A search on Medline using dates from 1966 to 2014 was conducted to identify pharmacological options for managing pediatric obesity. In particular, randomized controlled trials with orlistat, metformin, glucagon-like peptide-1 agonists, topiramate, and zonisamide were reviewed.10 This review suggested that lifestyle modification is considered first-line therapy for pediatric patients with obesity; however, severe obesity may benefit from pharmacotherapy.10
Orlistat is the only medication approved by the US Food and Drug Administration for pediatric obesity; it has been shown to reduced body mass index (BMI) by up to 4 but gastrointestinal (GI) adverse effects were limiting.10 Metformin showed BMI reductions of up to 1.8 with mild GI adverse effects that were manageable by titration of the dose.10 Exenatide reduced BMI by up to 1.7 and was well-tolerated with mild GI adverse effects that were transient. Topiramate and zonisamide reduced weight when used in the treatment of seizures.10 Orlistat should be considered as second-line therapy for pediatric obesity, with the treatment of choice still being lifestyle interventions.10
The use of Motivational Interviewing to help children, adolescents, and their care givers understand and deal with ambivalence to change is helpful in promoting change. These techniques include patient-centered care focusing on working with families to come to a mutual understanding of the goals.11 Barriers and obstacles need to be evaluated and achievable goals discussed to avoid failure. The entire family should be a part of the process in leading to healthy lifestyle changes for children and adolescents.
- Centers for Disease Control and Prevention. Morbidity and Mortality Weekly Report. Youth risk behavior surveillance — United States, 2017. https://www.cdc.gov/mmwr/volumes/67/ss/ss6708a1.htm. Accessed October 22, 2018.
- Centers for Disease Control and Prevention. Adolescent and School Health. School Health Policies and Practices Study (SHPPS). https://www.cdc.gov/healthyyouth/data/shpps/index.htm. Accessed October 22, 2018.
- Casazza K, Pate R, Allison DB. Myths, presumptions, and facts about obesity. N Engl J Med. 2013;368(23):2236–2237. doi:. doi:10.1056/NEJMsa1208051 [CrossRef]
- Hall KD. Predicting metabolic adaptation, body weight change, and energy intake in humans. Am J Physiol Endocrinol Metab. 2010;298:E449–E466. doi:. doi:10.1152/ajpendo.00559.2009 [CrossRef]
- Linde JA, Jeffery RW, Levy RL, Pronk NP, Boyle RG. Weight loss goals and treatment outcomes among overweight men and women enrolled in a weight loss trial. Int J Obes (Lond). 2005;29:1002–1005. doi:. doi:10.1038/sj.ijo.0802990 [CrossRef]
- Nackers LM, Ross KM, Perri MG. The association between rate of initial weight loss and long-term success in obesity treatment: does slow and steady win the race?Int J Behav Med. 2010;17:161–167. doi:. doi:10.1007/s12529-010-9092-y [CrossRef]
- Fontaine KR, Wiersema L. Dieting readiness test fails to predict enrollment in a weight loss program. J Am Diet Assoc. 1999;99(6):664. doi:. doi:10.1016/S0002-8223(99)00159-5 [CrossRef]
- Dobbins M, De Corby K, Robeson P, Husson H, Tirilis D. School-based physical activity programs for promoting physical activity and fitness in children and adolescents aged 6–18. Cochrane Database Syst Rev. 2009;1:CD007651. doi:10.1002/14651858.CD007651 [CrossRef].
- Casazza K, Fernandez JR, Allison DB. Modest protective effects of breast-feeding on obesity: is the evidence truly supportive?Nutr Today. 2012;47(1):33–38. doi:. doi:10.1097/NT.0b013e3182435c98 [CrossRef]
- Boland CL, Boland CL, Harris JB, Harris KB. Pharmacological management of obesity in pediatric patients. Ann Pharmacother. 2015;49(2):220–232. doi:. doi:10.1177/1060028014557859 [CrossRef]
- Schwartz RP, Hamre R, Dietz WH, et al. Office-based motivational interviewing to prevent childhood obesity: a feasibility study. Arch Pediatr Adolesc Med. 2007;161(5):495–501. doi:. doi:10.1001/archpedi.161.5.495 [CrossRef]