Note from the National Guideline Clearinghouse (NGC) and the American Dietetic Association (ADA): Recommendations for the determination of energy expenditure and energy requirements for children and adolescents draw from 2005 US Institutes of Medicine Dietary Reference Intakes for Energy, Carbohydrate, Fiber, Fat, Fatty Acids, Cholesterol, Protein, and Amino Acids (Macronutrients) (available online at http://www.nap.edu/catalog/10490.html -- especially Chapter 5 and Appendix I).
Ratings for the strength of the recommendations (Strong, Fair, Weak, Consensus, Insufficient Evidence), conclusion grades (I-V), and statement labels (Conditional versus Imperative) are defined at the end of "Major Recommendations."
Pediatric Weight Management (PWM) Comprehensive, Multicomponent Weight Management Program for Treating Childhood Overweight
PWM: Multicomponent Program
Interventions to reduce pediatric overweight should be multicomponent and include diet, physical activity, nutrition counseling, and parent/caregiver participation. A large body of strong research indicates that clinically supervised, multicomponent weight management programs are more successful than single component programs for short-term and longer-term (>1 year) improvement in child and adolescent overweight.
Strong, Imperative
Recommendation Strength Rationale
- Conclusion statements are Grades I and II
Pediatric Weight Management (PWM) Treating Overweight in Children Ages 2-5
PWM: Children Ages 2-5 Years Old
Weight maintenance is generally recommended in overweight children 2-5 years old within a multicomponent weight management intervention with active participation of parent/caregiver. Weight loss may be recommended when the child has serious medical complications. Research was not identified on the efficacy and safety of weight loss interventions among children ages 2-5.
Consensus, Imperative
Recommendation Strength Rationale
Pediatric Weight Management (PWM) Assessing Foods and Pediatric Overweight
PWM: Foods Associated with an Increased Risk of Overweight
Dietary factors that may be associated with an increase in the risk of overweight and should be included in Nutrition Assessment are: increased total dietary fat intake and increased calorically sweetened beverages. American Dietetic Association (ADA) Evidence Analysis has shown that these factors are positively associated with childhood overweight.
Strong, Imperative
PWM: Foods Associated with a Decreased Risk of Overweight
Dietary factors that may be associated with a decrease in the risk of overweight and should be included in Nutrition Assessment are: increased fruit and vegetable intake. ADA Evidence Analysis has shown that these factors may be negatively associated with childhood overweight.
Strong, Imperative
PWM: Assessment - Total Energy Intake and 100% Fruit Juice
Dietitians should be aware of the research on the following dietary factors when carrying out their Nutrition Assessment: reported total energy intake and 100% fruit juice intake. ADA Evidence Analysis has found that these factors may or may not be related to pediatric overweight, but the research is still unclear on the relationship.
Fair, Imperative
PWM: Assessment - Dairy and Calcium
Dietitians should be aware of the observational research that indicates an inadequate intake of dairy and calcium may be related to an increase in the risk of pediatric overweight. Consideration should be given to including dairy and calcium intake as part of the nutrition assessment.
Fair, Imperative
Recommendation Strength Rationale
- Conclusion statements are Grades II and III
Pediatric Weight Management (PWM) Assessing Child and Family Diet Behaviors in Pediatric Overweight
PWM: Family Diet Behaviors - Increased Risk of Overweight
Child and family diet behavior factors that may be associated with an increase in the risk of overweight and should be included in Nutrition Assessment are: parental restriction of highly palatable foods, consumption of food away from home, increased portion size of meals, breakfast skipping. ADA Evidence Analysis has shown that these factors are positively associated with childhood overweight.
Fair, Imperative
PWM: Family Diet Behaviors - Relationship Unclear
Dietitians should be aware of the research on the following child and family diet behavior factors when carrying out their Nutrition Assessment: parental encouragement/pressure to eat, parental control over child's dietary intake, meal frequency, snacking frequency or snack food intake, and using food as a reward. ADA Evidence Analysis has found that these factors may not be related to pediatric overweight, or that the research is still unclear on the relationship.
Fair, Imperative
Recommendation Strength Rationale
- Conclusion statements are Grades II and III
Pediatric Weight Management (PWM) Assessing Physical Activity and Sedentary Behaviors
PWM: Behavior - Increase the Risk of Pediatric Overweight
Physical activity and sedentary behavior factors that may be associated with an increase in the risk of overweight and should be included in Nutrition Assessment are: excessive television viewing and excessive use of video games. ADA Evidence Analysis has shown that these factors are positively associated with childhood overweight.
Fair, Imperative
PWM: Behavior - Decrease the Risk of Pediatric Overweight
Physical activity and sedentary behavior factors that may be associated with a decrease in the risk of overweight and should be included in Nutrition Assessment are: regular physical activity and sports participation. ADA Evidence Analysis has shown that these factors may be negatively associated with childhood overweight.
Fair, Imperative
Recommendation Strength Rationale
- Conclusion statements are Grades II and III
Pediatric Weight Management (PWM) Determination of Total Energy Expenditure
PWM: Option for Determining Energy Expenditure
If possible, resting metabolic rate (RMR) should be measured (e.g., indirect calorimetry). If RMR cannot be measured, then the equations for estimating total energy expenditure in overweight youth provided in the 2005 US Institutes of Medicine "Dietary Reference Intakes for Energy, Carbohydrate, Fiber, Fat, Fatty Acids, Cholesterol, Protein, and Amino Acids (Macronutrients)," may be used. Estimated energy needs should be based on Total Energy Expenditure (TEE).
Refer to the original guideline document for types of TEE indices and calculations.
Consensus, Conditional
Recommendation Strength Rationale
Pediatric Weight Management (PWM) Assessing Family Climate Factors
PWM: Family Climate - Increased Risk of Overweight
Family climate factors that may be associated with an increase in the risk of overweight and should be included in Nutrition Assessment are: parental dietary disinhibition and restraint, negative aspects of family functioning (such as lack of parental support or over-possessiveness), and parental concern about child's weight status. ADA Evidence Analysis has shown that these factors are positively associated with childhood overweight.
Fair, Imperative
PWM: Family Climate - Decreased Risk of Overweight
Family climate factors that may be associated with a decrease in the risk of overweight and should be included in Nutrition Assessment are: positive aspects of family functioning (such as family cohesion, expressiveness, democratic style, parental support and cognitive stimulation at home). ADA Evidence Analysis has shown that these factors may be negatively associated with childhood overweight.
Fair, Imperative
PWM: Family Climate - Relationship Unclear
Dietitians should be aware of the research on the following family climate factors when carrying out their Nutrition Assessment: household food insecurity. ADA Evidence Analysis has found that these factors may not be related to pediatric overweight, or that the research is still unclear on the relationship.
Fair, Imperative
Recommendation Strength Rationale
- Conclusion statements are Grades II and III
Pediatric Weight Management (PWM) Nutrition Prescription in the Treatment of Pediatric Overweight
PWM: Nutrition Prescription
A nutrition prescription should be formulated as part of the dietary intervention in a multicomponent pediatric weight management program. The exact specification of nutrients and energy is often translated into a specific eating plan. Nutrition interventions are selected based on the nutrition prescription. Research shows that when individualized nutrition prescription is included, improvements in weight status in children and adolescents are consistent. When an individualized nutrition prescription is not included, results are less consistent.
Strong, Imperative
Recommendation Strength Rationale
- Conclusion statements are Grades I, II and III
Pediatric Weight Management (PWM) Energy Restricted Diets
PWM: Energy-Restricted Diets - Children 6 to 12 years Old
If energy restriction is appropriate based on the registered dietitian's professional judgment, then a balanced macronutrient diet that contains no fewer than 900 kilocalories (kcal) per day is recommended to improve weight status within a multicomponent pediatric weight management program in children ages 6 -12 who are medically monitored. Research indicates that balanced macronutrient diets at 900 to 1200 kcal per day are associated with both short term and longer term (>1 year) improved weight status and body composition among 6 to 12-year-old children.
Strong, Conditional
PWM: Energy-Restricted Diets - Adolescents
If energy restriction is appropriate based on the registered dietitian's professional judgment, then a balanced macronutrient diet that contains no fewer than 1200 kcal per day is recommended to improve weight status within a multicomponent pediatric weight management program in adolescents ages 13-18 who are medically monitored. Research indicates that energy restricted balanced macronutrient diets no lower than 1200 kcal per day are associated with both short term and longer term (>1 year) improved weight status and body composition among 13 to 18-year-old adolescents.
Strong, Conditional
Recommendation Strength Rationale
- Conclusion statements are Grade I
Pediatric Weight Management (PWM) Reduced Glycemic Load Diet
PWM: Reduced Glycemic Load Diet - Children 6 to 12 Years
If an ad libitum reduced glycemic load diet is selected for use in children (age 6-12), then this diet could be used to produce modest, short term improvement in weight status. Limited research shows that an ad libitum reduced glycemic load diet results in short term improvement in weight status in this age group.
Weak, Conditional
PWM: Reduced Glycemic Load Diet - Adolescents
If an ad libitum reduced glycemic load diet is selected for use in adolescents (age 13-18), then this diet could be used to produce modest, short term and longer term improvement in weight status and body composition. Limited research shows that an ad libitum reduced glycemic load diet results in short term improvement in weight status and body composition in this age group. One study shows weight status improvement at 1 year.
Fair, Conditional
Recommendation Strength Rationale
- Conclusion statements are Grade III
Pediatric Weight Management (PWM) Very Low Carbohydrate Diet
PWM: Very Low Carbohydrate Diet - Adolescents
If a low carbohydrate diet is selected for use in adolescents, then it is recommended for short term (up to 12 weeks) use. The use of an ad libitum very low carbohydrate diet which is defined as a diet containing 20 to 60 grams of carbohydrates to treat overweight adolescents has shown short-term improvement in weight status. However, due to the lack of evidence, it is not recommended for long-term treatment of pediatric overweight.
Weak, Conditional
Recommendation Strength Rationale
Pediatric Weight Management (PWM) Using Protein Sparing Modified Fast Diets for Pediatric Weight Loss
PWM: Protein Sparing Modified Fast Diets: Short-term Treatment
If overweight (>120% ideal body weight [IBW]) children and adolescents with serious medical complications would benefit from rapid weight loss, then a Protein Sparing Modified Fast Diet (PSMF) could be utilized in a short-term intervention (typically 10 weeks) under the supervision of a multidisciplinary team of healthcare providers who specialize in pediatric overweight. Research shows that short term use of a PSMF brings about short term and longer term improvement in weight status and body composition when part of a medically supervised, multicomponent program.
Weak, Conditional
PWM: Protein Sparing Modified Fast Diets: Long-term Treatment
The Protein Sparing Modified Fast Diet is not recommended for long-term weight management for overweight children or adolescents. There are few well designed studies to support the use of this intervention for longer than 10 weeks.
Weak, Imperative
Recommendation Strength Rationale
- Conclusion statements are Grades III and V
Pediatric Weight Management (PWM) Very Low Fat Diet (Less than 20% Daily Energy Intake from Fat)
PWM: Very Low Fat Diet
Use of a very low fat diet (<20% of total daily energy) is not recommended for use in pediatric weight management. The efficacy of a very low fat diet defined as <20% of total daily energy intake from fat in the treatment of pediatric overweight has not been studied.
Insufficient Evidence, Imperative
Recommendation Strength Rationale
- Conclusion statement is Grade V
Pediatric Weight Management (PWM) Nutrition Education in the Treatment of Pediatric Overweight
PWM: Tailor Nutrition Education to Nutrition Prescription
In a multicomponent program, if there is a nutrition diagnosis for food and nutrition-related knowledge deficit, then Nutrition education should be tailored to the nutrition prescription. Research shows that if nutrition education is not tailored to nutrition prescription, improvement in weight status is not consistent.
Fair, Conditional
Recommendation Strength Rationale
- Conclusion statements are Grades I, II, and III
Pediatric Weight Management (PWM) Nutrition Counseling and Behavior Therapy Strategies in the Treatment of Overweight in Children and Adolescents
PWM: Nutrition Counseling
Nutrition counseling delivered by a registered dietitian (RD) (which is inclusive of goal setting, self monitoring, stimulus control, problem solving, contingency management, cognitive restructuring, use of incentives and rewards, and social supports) should be a part of the behavior therapy component of a multicomponent pediatric weight management program.
Consensus, Imperative
PWM: Behavioral Therapy
Behavior therapy strategies should be included as part of a multicomponent pediatric weight management program. Research shows that when behavior therapy strategies are included within the context of a multidisciplinary team, weight status and body composition improve.
Strong, Imperative
PWM: Family-Based Counseling
Family-based counseling that includes parent training or modeling should be included as part of a multicomponent weight management program that targets children ages 6 to 12 years. During the development of a multicomponent treatment program for children ages 12 years and younger, the registered dietitian should advise the health care team on the advantages of incorporating parent training or modeling as part of the treatment program. Research studies including parent training or modeling as part of a multicomponent weight management program for children 12 years and younger showed positive changes in a child's weight status and adiposity.
Strong, Imperative
Recommendation Strength Rationale
- Conclusion statements are Grade I
Pediatric Weight Management (PWM) Family Participation in Treating Pediatric Overweight in Children and Adolescents
PWM: Family Participation - Children 6 to 12 Years Old
Parent/caregiver should be included in multicomponent pediatric weight management programs as an agent of change when treating children ages 6-12. A strong body of research indicates that including parents/caregivers as agents of change in the treatment of their child's overweight is associated with both short-term and longer term (>1 year) improvements in weight status. A more limited body of research indicates that treating 6 to 12-year-old children without parental participation is not effective.
Strong, Imperative
PWM: Family Participation - Adolescents
Parent/caregiver may be included in multicomponent pediatric weight management programs when treating adolescents. A limited body of research indicates that programs with or without parent/caregiver participation may be effective for improvements in weight status and adiposity in adolescents.
Fair, Conditional
PWM: Family Participation - Treatment Format
If parent/caregiver participation is included in child and adolescent weight management programs, health professionals should tailor the format (e.g., group versus individual format, parent/caregiver with child versus parent/caregiver and child separate, etc.) to meet individual, family, and program needs. Research does not show a clear superiority of one format versus another for parent/caregiver participation.
Consensus, Conditional
Recommendation Strength Rationale
- Conclusion statements are Grades I, II, and III
Pediatric Weight Management (PWM) Nutrition Counseling: Setting Weight Goals with Patient and Family
PWM: Weight Goals
Weight goals should be individualized for the child. Because of growth occurring within children and adolescents, the goal of pediatric weight management programs may be weight stabilization rather than weight loss. Research indicates that weight stabilization in children and adolescents may be associated with improvements in body mass index (BMI) and other measures of adiposity.
Consensus, Imperative
Recommendation Strength Rationale
Pediatric Weight Management (PWM) Coordination of Care in Pediatric Weight Management
PWM: Coordination of Care
Dietitian should collaborate with members of the healthcare team (as available) in planning and implementing behavior, physical activity, and adjunct therapy strategies. Effective multicomponent pediatric weight management interventions benefit from the diverse expertise of different healthcare professionals.
Consensus, Imperative
Recommendation Strength Rationale
- Conclusion statements are Grades I, II, and III
Pediatric Weight Management (PWM) Decreasing Sedentary Behaviors in Children and Adolescents
PWM: Decreasing Sedentary Behaviors - Children
Children should be counseled to reduce or limit sedentary activities (e.g., TV, video games, "screen time"). Intervention research indicates that reducing sedentary activities may have both short term and longer term benefits in terms of pediatric overweight. Observational research also indicates that TV time may also be associated with increased consumption of energy dense foods.
Fair, Imperative
PWM: Decreasing Sedentary Behaviors - Adolescents
Adolescents should be counseled to reduce or limit sedentary activities (e.g., TV, video games, "screen time"). Limited intervention research indicates that reducing sedentary activities may have both short term benefits in terms of overweight.
Weak, Imperative
Recommendation Strength Rationale
- Conclusion statements are Grades II and III
Pediatric Weight Management (PWM) Physical Activity in the Treatment of Childhood and Adolescent Overweight
PWM: Physical Activity
Physical activity should be included as part of a multicomponent pediatric weight management program. Research indicates that increasing physical activity as part of a multicomponent program results in significant improvements in weight status and/or body composition in children and adolescents.
Strong, Imperative
Recommendation Strength Rationale
- Conclusion statement is Grade III
Pediatric Weight Management (PWM) Adjunct Therapies: Use of Weight Loss Medications in Treating Overweight in Adolescents
PWM: Collaboration with Health Care Team
The dietitian should collaborate with the health care team regarding the use of weight loss medications as an adjunct therapy within a multicomponent pediatric weight management program for adolescents. Clinical outcomes are likely to be enhanced with the participation of a dietitian.
Consensus, Imperative
PWM: Weight Loss Medication
If a weight loss medication is selected as an adjunct therapy, then an over the counter or prescription gastrointestinal lipase inhibitor (e.g., orlistat) approved by the U.S. Food and Drug Administration (FDA) for use in adolescents may be recommended to treat overweight adolescents participating in a multicomponent pediatric weight management program. Research indicates that a gastrointestinal lipase inhibitor further improves weight status and body composition in some individuals within a multicomponent adolescent weight management program. However, the FDA has not studied or approved the use of this class of medication for children under the age of 12.
Fair, Conditional
Recommendation Strength Rationale
- Conclusion statement is Grade II
Pediatric Weight Management (PWM) Adjunct Therapies: Weight Loss Surgery and Adolescent Overweight
PWM: Weight Loss Surgery
Dietitians should collaborate with other members of the health care team regarding the appropriateness of weight loss surgery for severely overweight adolescents who have not achieved weight loss goals with less invasive weight loss methods and who meet specified criteria (see Conditions of Application in the original guideline document). Research indicates that for a subset of adolescents who meet the recommended criteria, weight loss surgery may be effective in bringing about significant short term and long term weight loss. Overweight children (< 13 years of age) are generally not considered to be appropriate candidates for weight loss surgery.
Consensus, Imperative
Recommendation Strength Rationale
Pediatric Weight Management (PWM) Treatment Format Options: Group versus Individual Intervention
PWM: Group Versus Individual Interventions
Either group or individual nutrition intervention may be used as part of a multicomponent pediatric weight management program. Limited research that compares individual versus group format does not indicate differences in overall pediatric weight status. However, two studies suggest that some dietary outcome measures may be improved with an individual counseling format.
Weak, Imperative
Recommendation Strength Rationale
- Conclusion statement is Grade III
Pediatric Weight Management (PWM) Optimal Length of Weight Management Therapy in Children and Adolescents
PWM: Optimal Length of Treatment
During the intensive treatment phase, Medical Nutrition Therapy for pediatric overweight should last at least three months or until initial weight management goals are achieved. Because overweight is a chronic, often life-long, condition, it is critical that a weight management plan be implemented after the intensive phase of treatment. A greater frequency of contacts between the patient and practitioner may lead to more successful weight loss and maintenance.
Consensus, Imperative
No evidence grade given
Definitions:
Conditional versus Imperative Recommendations
Recommendations can be worded as conditional or imperative statements. Conditional statements clearly define a specific situation, while imperative statements are broadly applicable to the target population without restraints on their pertinence. More specifically, a conditional recommendation can be stated in if/then terminology (e.g., If an individual does not eat food sources of omega-3 fatty acids, then 1g of EPA and DHA omega-3 fatty acid supplements may be recommended for secondary prevention).
In contrast, imperative recommendations "require," or "must," or "should achieve certain goals," but do not contain conditional text that would limit their applicability to specified circumstances. (e.g., Portion control should be included as part of a comprehensive weight management program. Portion control at meals and snacks results in reduced energy intake and weight loss).
Levels of Evidence
| Strength of Evidence Elements |
Grade I
Good/Strong
|
Grade II
Fair
|
Grade III
Limited/Weak
|
Grade IV
Expert Opinion Only
|
Grade V
Grade Not Assignable
|
Quality
- Scientific rigor/validity
- Considers design and execution
|
Studies of strong design for question
Free from design flaws, bias and execution problems
|
Studies of strong design for question with minor methodological concerns
OR
Only studies of weaker study design for question
|
Studies of weak design for answering the question
OR
Inconclusive findings due to design flaws, bias or execution problems
|
No studies available
Conclusion based on usual practice, expert consensus, clinical experience, opinion, or extrapolation from basic research
|
No evidence that pertains to question being addressed |
Consistency
Of findings across studies
|
Findings generally consistent in direction and size of effect or degree of association, and statistical significance with minor exceptions at most |
Inconsistency among results of studies with strong design
OR
Consistency with minor exceptions across studies of weaker designs
|
Unexplained inconsistency among results from different studies
OR
Single study unconfirmed by other studies
|
Conclusion supported solely by statements of informed nutrition or medical commentators |
NA |
Quantity
- Number of studies
- Number of subjects in studies
|
One to several good quality studies
Large number of subjects studies
Studies with negative results having sufficiently large sample size for adequate statistical power
|
Several studies by independent investigators
Doubts about adequacy of sample size to avoid Type I and Type II error
|
Limited number of studies
Low number of subjects studies and/or inadequate sample size within studies
|
Unsubstantiated by published studies |
Relevant studies have not been done |
Clinical Impact
- Importance of studies outcomes
- Magnitude of effect
|
Studied outcome relates directly to the question
Size of effect is clinically meaningful
Significant (statistical) difference is large
|
Some doubt about the statistical or clinical significance of effect |
Studies outcome is an intermediate outcome or surrogate for the true outcome of interest
OR
Size of effect is small or lacks statistical and/or clinical significance
|
Objective data unavailable |
Indicates area for future research |
Generalizability
To population of interest
|
Studied population, intervention and outcomes are free from serious doubts about generalizability |
Minor doubts about generalizability |
Serious doubts about generalizability due to narrow or different study population, intervention or outcomes studied |
Generalizability limited to scope of experience |
NA |
This grading system was based on the grading system from: Greer N, Mosser G, Logan G, Wagstrom Halaas G. A practical approach to evidence grading. Jt Comm. J Qual Improv. 2000; 26:700-712. In September 2004, The ADA Research Committee modified the grading system to this current version.
Criteria for Recommendation Rating
| Statement Rating |
Definition |
Implication for Practice |
| Strong |
A Strong recommendation means that the workgroup believes that the benefits of the recommended approach clearly exceed the harms (or that the harms clearly exceed the benefits in the case of a strong negative recommendation), and that the quality of the supporting evidence is excellent/good (grade I or II)*. In some clearly identified circumstances, strong recommendations may be made based on lesser evidence when high-quality evidence is impossible to obtain and the anticipated benefits strongly outweigh the harms. |
Practitioners should follow a Strong recommendation unless a clear and compelling rationale for an alternative approach is present. |
| Fair |
A Fair recommendation means that the workgroup believes that the benefits exceed the harms (or that the harms clearly exceed the benefits in the case of a negative recommendation), but the quality of evidence is not as strong (grade II or III)*. In some clearly identified circumstances, recommendations may be made based on lesser evidence when high-quality evidence is impossible to obtain and the anticipated benefits outweigh the harms. |
Practitioners should generally follow a Fair recommendation but remain alert to new information and be sensitive to patient preferences. |
| Weak |
A Weak recommendation means that the quality of evidence that exists is suspect or that well-done studies (grade I, II, or III)* show little clear advantage to one approach versus another. |
Practitioners should be cautious in deciding whether to follow a recommendation classified as Weak, and should exercise judgment and be alert to emerging publications that report evidence. Patient preference should have a substantial influencing role. |
| Consensus |
A Consensus recommendation means that Expert opinion (grade IV)* supports the guideline recommendation even though the available scientific evidence did not present consistent results, or controlled trials were lacking. |
Practitioners should be flexible in deciding whether to follow a recommendation classified Consensus, although they may set boundaries on alternatives. Patient preference should have a substantial influencing role. |
| Insufficient Evidence |
An Insufficient Evidence recommendation means that there is both a lack of pertinent evidence (grade V)* and/or an unclear balance between benefits and harms. |
Practitioners should feel little constraint in deciding whether to follow a recommendation labeled as Insufficient Evidence and should exercise judgment and be alert to emerging publications that report evidence that clarifies the balance of benefit versus harm. Patient preference should have a substantial influencing role. |
*Conclusion statements are assigned a grade based on the strength of the evidence. Grade I is good; grade II, fair; grade III, limited; grade IV signifies expert opinion only and grade V indicates that a grade is not assignable because there is no evidence to support or refute the conclusion. The evidence and these grades are considered when assigning a rating (Strong, Fair, Weak, Consensus, Insufficient Evidence - see chart above) to a recommendation.
Adapted by the American Dietetic Association from the American Academy of Pediatrics, Classifying Recommendations for Clinical Practice Guideline, Pediatrics. 2004;114;874-877.
