Weight Management
Introduction
This page discusses the main aspects of weight management in children and adolescents and allows you to download an action plan to guide and track progress towards this purpose. More specifically, this page discusses:
- the importance of good sleep and how to achieve this
- the importance of exercising appropriately
- basic nutritional principles and dietary advice for success
- an action plan you can download that will remind you of the tips on this page
- an additional section for healthcare providers with general advice and an overview of weight loss medications
Sleep
Below you can see general sleep recommendations, why this is important when working to lose weight, tips for improving sleep, and what to do if your child is still always tired.
Recommendations
It is very important for children to get enough high-quality sleep for general health purposes, emotional well-being, and weight management. Lots of research has shown that short sleep duration associates with higher rates of obesity in children and a future risk of obesity in adolescents. The amount of sleep children should get depends on their age; general recommendations include:
- 4-12 months: 12-16 hours per day (including naps)
- 1-2 years: 11-14 hours per day (including naps)
- 3-5 years: 10-13 hours per day (including naps)
- 6-12 years: 9-12 hours per day
- 13-18 years: 8-10 hours per day
- 19 years and older: 7-9 hours per day
Based on when your child needs to wake up you can determine what their bedtime should be. For example, if your child wakes up at 6:00 am to get ready for school and they need 10 hours of sleep, they need to go to sleep at 8:00 pm to get 10 hours.
Why sleep matters
Too little or poor quality sleep contributes to excess weight gain by impacting:
Hunger cues
Poor sleep disrupts the brain's ability to regulate hunger and fullness.
This makes it easier to overeat when larger portion sizes, more snacks, and sugary drinks are available.
Emotional eating
Poor sleep leads to increased emotional eating.
Poor sleep also worsens mood; children may eat to feel better rather than for their energy needs.
Hedonic eating
Poor sleep leads to an increased desire for tastier, energy-dense foods.
These are typically poorly nutritious, processed foods that people crave and are easy to overeat.
Physical activity
Poor sleep leads to decreased physical activity.
This reduces energy expenditure, worsens overall health, and makes it harder to sleep appropriately.
Hormone levels
Poor sleep increases ghrelin and decreases leptin.
Ghrelin increases hunger & leptin senses energy. This increases hunger when we do not need more energy.
Stress
Poor sleep leads to increased cortisol, a hormone that increases stress.
This worsens overall health, makes good decision-making more difficult, and can lead to stress-eating.
How to improve sleep
For many children their sleep will improve if they make an effort to do so. That means putting away phones, video games, tablets, computers, TVs, etc, so that they are not distracted by anything. You may have to take away these screens and even lock them up to prevent your child from using them when they are supposed to sleep. Beyond that, here are several tips to improve overall sleep:
Set a bed time to allow enough total sleep based on when your child needs to wake up.
Go to sleep and wake up the same time every day (weekdays and weekends).
Keep the bedroom dark. Limit bright lights and screens 1 hour before bed.
Follow a consistent, calming bedtime routine at the same time each day.
Exercise regularly in the morning or afternoon.
Do not eat at night. Eat throughout the day to avoid nighttime hunger.
Beyond age 4-5 years minimize naps and keep them <30 minutes.
Eliminate loud noise and use something for background noise.
Avoid any caffeine intake in the afternoon and evening.
What to do if your child is always tired
Sometimes there are untreated medical conditions that make it very difficult or impossible to sleep well, such as sleep apnea, allergies, anxiety etc. Children with obesity in particular are more likely to have trouble breathing properly when sleeping, leading to loud snoring and even pauses in their breathing. If your child is not able to get refreshing sleep and feels tired frequently, or if there are breathing issues while sleeping, please discuss this with your child's healthcare team.
Exercise
Below you can see the general exercise recommendations, health benefits of exercise, specific health benefits of exercise for children with obesity, and tips for overcoming some challenges of exercising with obesity.
Recommendations
You can look at this page to see general exercise recommendations for all ages, several example videos from YouTube channels, other links that show how to exercise, and an overview of resistance training. As a quick overview:
- Age 3-5 years: Be physically active throughout the day. Encourage many different types of physical activity.
- Age 6-17 years: Perform ≥60 minutes of moderate-to-vigorous intensity physical activity daily. Perform vigorous-intensity, muscle-strengthening, and bone-strenghtening activity at least 3 days a week.
- Adults: Perform a combination of moderate-intensity (150-300 minutes) and vigorous-intensity (75-150 minutes) physical activity spread throughout the week. Perform muscle-strengthening activity ≥2 days per week.
- Additionally, decreasing sedentary time and increasing light-intensity physical activity is helpful as long as this does not come at the expense of higher-intensity physical activity.
Light-intensity physical activity
This is general movement that is not physically challenging, such as walking slowly.
Moderate-intensity physical activity
This is activity that is 5-6/10 on a difficulty scale, or where you can talk but not sing.
Vigorous-intensity physical activity
This is activity that is 7-8/10 on a difficulty scale, or where you become short of breath when speaking.
Health benefits
Children who follow the general exercise guidelines will experience many benfits as this will:
- build muscle, strength, and athleticism
- increase cardiorespiratory fitness
- raise metabolism
- strengthen bones
- benefit sleep
- decrease unhealthy body fat stores
- enhance intelligence and academics
- aid mental health and self-esteem
- improve cardiometabolic risk factors
- help regulate hunger levels
Health benefits of exercise for obesity
Besides all the general health benefits of exercise, there are specific benefits when exercising with obesity:
Getting stronger
Strength training helps build and maintain muscle while losing fat, which improves health and helps prevent weight regain in the future.
Getting fitter
Aerobic training increases your cardiorespiratory fitness, which helps prevent many of the negative effects of too much body weight.
Fitting in
Improving fitness levels and athleticism can help children fit in better with their peers while boosting their self-esteem and social confidence.
Sleeping better
Exercising regularly can improve sleep, which as discussed above aids health, eating habits, stress, and makes physical activity easier.
Exercise challenges
People with obesity may have a harder time exercising for several reasons. Here are some strategies to get around any limitations:
Exercise is fatiguing
When you weigh more you have to use more energy to move your body through space. This makes exercise more tiring.
You do not have to move as quickly as everyone else to be produtive. Push yourself to the point where your heart is beating quickly, you are breathing heavily, and you cannot talk easily and this will have great benefits even if you are moving more slowly than others.
Exercise is challenging
Higher body weight can impair mobility and make certan exercises more difficult to perform correctly.
Choose exercises and make needed modifications to perform them effectively. For example, if you cannot do a full squat, sit down on a low chair and stand back up. Start with easier versions of exercises and as your fitness improves progress to harder variations.
Self-consciousness
Many people trying to lose weight feel self-conscious in gyms or fear they cannot keep up in group settings.
Most people in gyms are there for self-improvement, and you can ask trainers or experienced people for guidance. However, if you prefer to workout at home, either permanently or until you feel comfortable going to a gym, look here for lots of example workouts you can do.
Physical pain
Heavier body weight can increase the impact on your joints, and pain will make any exercise more difficult.
If you are experiencing pain, consult a doctor for injury concerns and choose exercises you can perform without pain that minimize joint impacts. For example, instead of running or jumping, ride a bicycle or use an elliptical. Choose strength exercises that do not hurt.
Nutrition
General principles
In children we usually do not provide strict diet plans, rather it is helpful to learn general nutritional principles and apply these, as this can go a long way in helping someone achieve a healthy body weight without forcing them to eat in a specific manner. These principles include:
Hunger vs appetite
Eat mostly for your hunger and minimally for your appetite.
Hunger is a need for energy; you may be so hungry you would eat anything. Appetite is a want for something tasty; you may be full after dinner but still have room for dessert.
Eating speed
Eat slowly to give yourself time to feel satisifed.
It takes time for food signals to reach your brain to let you know you have eaten enough. Eating too quickly can make you eat more than needed to feel satisfied.
Portion sizes
Serve and encourage smaller portions to prevent overeating.
People naturally eat more when served larger portions; avoid this by serving smaller portions. Wait 20 minutes and then only have seconds if you are still hungry.
Ultraprocessed foods
Minimize their intake.
These are often snack, junk, and fast foods with extra sugar, fat, and salt. These may taste great but can worsen your health and are easy to overeat.
Food cravings
You can change how your brain processes taste.
Cut back on snack food, junk food, and sugary beverages. After 4 weeks the cravings will decrease and you will find less-processed foods more satisfying.
Less-processed foods
Mostly eat these.
Whole grains, fruits, vegetables, lean meats, nuts, eggs, yogurt, cheese, beans, and legumes are nutritious, filling foods that should be the majority of your daily nutrition.
Home food environment
Set yourself up for success.
People tend to consume tasty treats when they are available. Either hide or do not bring snack and junk food or sugary drinks into your home to avoid their temptation.
Healthy options
Allow your child to choose from healthy options.
Provide healthy meal and snack options in appropriate amounts. Let your child choose what they want to eat and how much they want to consume.
Nutrition in social settings
Children should enjoy going to social outings.
Focus on eating healthily in the home and let children enjoy themselves when they are with friends in social settings. Occasional treats are perfectly fine.
Sugary drinks
Avoid these, just drink water and milk.
Other than 1-2 cups of milk a day, stick to water. 100% fruit juice has some nutrients but no fiber and thus is not filling. Other sugary drinks lack nutritional value.
Feeling full
Eat to get rid of hunger, not to feel full.
On a scale of 0-10 (0 is most hungry, 10 is most full), aim to be in the 6-8 range when you are done eating. If you feel uncomfortably full you likely ate more than needed.
Eat breakfast
Do not skip breakfast or other meals and do not eat late at night.
Skipping breakfast and other meals can lead to increased hunger and overeating later in the day. Late-night eating may worsen health and is linked to weight gain.
Food group advice
Here is some general information about the major food groups, including fruits, vegetables, grains, protein, and dairy:
Fruits
- Fresh, frozen, and canned are all healthy options.
- Consume fruits of different colors.
- Fruit juice loses some of the nutrients and fiber that are in the fruits themselves so will not be as filling or nutritous as actual fruits.
- Fruits make a great dessert option.
- Fruits can be added to other foods (such as plain yogurt) to provide flavor.
Vegetables
- Fresh, frozen, and canned are all healthy options.
- Consume vegetables of different colors.
- Vegetables are typically low in calories and thus are great for a snack (e.g., baby carrots or celery) or second serving.
- Potatoes are higher in calories but when prepared healthily (e.g., baked without lots of toppings) these can be quite filling.
Grains
- At least half the grains you consume should be labeled as whole grains.
- Whole wheat bread, whole wheat pasta, whole grain cereals, oatmeal, quinoa, and brown rice are good options. These have more nutrients, protein, and fiber.
- When consuming grains that are not labeled as "whole" (such as white bread), preferably choose options labeled as "enriched".
Protein
- Fish: stick to low-mercury fatty options such as salmon, herring, and sardines.
- Poultry: ideally bake, grill, roast, or steam chicken or turkey. Do not fry.
- Beef: ideally choose ≥90% lean cuts and remove fat from fattier cuts.
- Beans, peas, and lentils are healthy.
- Eggs, nuts, and nut butter are healthy if you do not have food allergies.
Dairy
- Dairy foods are generally a good source of vitamin D and calcium. Healthy options include yogurt, cheese, and milk.
- Whole-fat and reduced-fat dairy options are both fine if you are having 2-3 servings a day.
- People with lactose intolerance may be able to tolerate yogurt and hard cheeses. Fortified soy milk is an alternative.
Example meals and snacks
Here are some healthy example meals and snacks that follow the various advice provided above.
Breakfast
- oatmeal with blueberries
- whole grain cereal with milk and an apple
- whole grain toast with avocado and an egg
- egg omelette with chicken and sliced broccoli
- whole wheat tortilla with beans, spinach and an egg
- banana and peanut butter rolled in a whole wheat tortilla
- yogurt with strawberries and an egg
- whole grain crackers, cottage cheese, and banana slices
- quinoa with apples and cinnamon
- whole grain waffles with yogurt
Lunch
- whole wheat wrap with turkey, hummus, lettuce, and carrots
- whole wheat crackers with avocado, salmon, and an apple
- whole wheat sandwich with chicken, cheese, lettuce, and tomato
- quinoa with grilled chicken, beans, broccoli, and strawberries
- quinoa with chickpeas, olives, tomato, and hummus
- whole grain pasta with spinach, chicken, and olive oil
- brown rice with mixed vegetables, lean beef, and a banana
- whole grain crackers with turkey, cheese, and a kiwi
- whole wheat tortilla with lean beef, cheese, beans, and an apple
- brown rice with beans, avocado, mixed vegetables, and grapes
Dinner
- grilled chicken breast with roasted sweet potatoes, green beans, and a kiwi
- baked salmon with quinoa, steamed broccoli, and strawberries
- whole wheat pasta with turkey meatballs, diced tomatoes, and a banana
- lean beef with brown rice, asparagus, and an apple
- tofu with brown rice, grilled vegetables, and apple slices
- turkey chili with beans, broccoli, and bell peppers
- beef and barley stew with carrots and spinach
- baked chicken tenders with sweet potato wedges and mixed vegetables
- whole wheat pasta with grilled chicken, mixed vegetables, and strawberries
- vegetable lentil soup with whole grain crackers and cheese
Snacks
- apple slices or celery with peanut butter
- whole wheat crackers with cheese or sardines
- fruits or vegetables in isolation
- cottage cheese or yogurt with strawberries
- hard-boiled egg
- nuts
- sliced vegetables with hummus
- tomatoes with mozzarella
- air-popped popcorn
- roasted chickpeas
What about calories?
In general you need to be in a calorie deficit to lose weight, and thus many people talk about counting calories and eating fewer calories to lose weight. However, counting calories accurately is challenging, and in children who are trying to lose weight there is a significant concern that without appropriate guidance this can contribute to disordered eating and even eating disorders. Thus, it is better to stick to the above principles, which will naturally help people consume fewer calories, rather than try to aim for a specific number of calories directly.
If for some reason you or your child still want to track calories, or if you are concerned your child is developing disordered eating or an eating disorder, please discuss this with your child's healthcare team.
Weight management action plan
Click on the link below to download the weight management action plan and use it as a reference for the advice given above. You can choose to track progress with each sleep, exercise, and nutrition component and discuss any areas of struggle at a future healthcare visit.
Action PlanMedications
General principles
The American Academy of Pediatrics suggests offering weight loss medications to children ≥12 years old with obesity according to medication indications, risks, and benefits as an adjunct to health behavior and lifestyle treatment. Some general things to keep in mind:
- Response to these medications is variable. Generally within 12 weeks of an effective dose it will be clear if a patient is responding well.
- These medications can help normalize hunger and fullness signaling and thus they can help improve disordered eating in many situations.
- Obesity is a chronic disease and similar to hypertension, hyperlipidemia, diabetes, etc, patients will need to stay on medications long-term to have continued benefits.
- Consider advising patients and families to work on lifestyle changes for 1-2 months prior to starting medication so that they are in a good position to start, since success is assessed after being on the medication for 12 weeks.
- In adults the medications are generally considered successful if they lead to a 5% decrease in BMI in 12 weeks. In pediatrics success is harder to define and may simply indicate an improvement in the weight or BMI curve, even if the package label states a medicine should be discontinued if certain weight or BMI loss thresholds are not reached.
- The medications may decrease hunger and thirst so counsel about adequate nutrition and hydration. Ensure monthly follow-up until patients are on a stable dose to assess the rate of weight loss and to screen for various side effects.
- As patients eat less and consume fewer nutrients consider recommending a multivitamin and supplements for any nutrients of concern.
- For medication shortages patients can wait to start until they have 2 months of medication on hand to provide more time to fill future prescriptions without running out.
- Make sure to document your discussion with the family well, including:
- a conversation about whether the medication is on- or off-label and why it is indicated
- that you reviewed potential major and minor side effects
- a discussion regarding any black box warnings
- that you have confirmed there are no contraindications
- that you have counseled about lifestyle advice
- what criteria you will use to determine if the medication is successful
With all that general background out of the way, you can read through any of the more commonly or historically used weight loss medications (that have not been removed from the market) below. Click on the name of a medication to read more about it. Of these:
- Semaglutide, liraglutide, phentermine/topiramate, and orlistat (not commonly used) are FDA-approved for weight loss ages ≥12 years.
- Phentermine is FDA-approved for weight loss ages ≥17 years.
- Tirzepatide and bupropion/naltrexone are FDA-approved for weight loss in adults.
- Topiramate is not FDA-approved for weight loss but is used in children, adolescents, and adults for this purpose.
- Metformin is not FDA-approved for weight loss but can assist mildly.
- Dulaglutide is not FDA-approved for weight loss but can assist when used for diabetes control.
Medication information
Semaglutide (Wegovy)
- Adolescents with obesity had a -16.1% change in their BMI over 68 weeks with a 2.4 mg weekly dose compared to +0.6% change with placebo.
- Adults with obesity lost 15.2% of their body weight with a 2.4 mg weekly dose in 2 years compared to -2.6% with placebo.
- weeks 1-4: 0.25 mg SQ weekly
- weeks 5-8: 0.5 mg SQ weekly
- weeks 9-12: 1.0 mg SQ weekly
- weeks 13-16: 1.7 mg SQ weekly
- weeks ≥17: 2.4 mg SQ weekly
- Maintenance at the 1.7 mg dose is allowed to decrease side effects if needed.
- This video shows where and how to perform an injection, just make sure to stay at least 2 inches away from the umbilicus with abdominal injections.
- Injections should be the same day each week but can be different times of day. If a dose is missed it can be given up to 5 days late (>48 hours before the next dose is given).
- This delays gastric emptying and may impact the absorption of oral medications, though studies have not found this to be an issue.
- This may potentiate glucose-lowering medications.
- Monitor for signs of thyroid cancer (neck nodule, dyspnea, dysphagia, voice hoarseness), suicidal ideation, tachycardia, palpitations, and vision changes.
- Monitor for hypoglycemia in patients on glucose-lowering medications (and consider lowering the dose of these meds).
- possible medullary thyroid cancer ( black box warning, seen in rat studies, it is not clear if GLP-1 agonists will cause this in humans)
- common (>5%): nausea, vomiting, constipation, diarrhea, abdominal pain, headache, fatigue, dizziness
- less common (2-5%): gastroesophageal reflux disease, hair loss, dysesthesia
- faster heart rate (on average 1-4 beats per minute)
- severe gastroinestinal adverse reactions (causing 4.3% (vs 0.7% with placebo) of adults and 2.3% (vs 1.5% with placebo) of adolescents to discontinue the treatment)
- pancreatitis (~1 case/500 patient years vs 1/1,000 with placebo)
- cholelithiasis (in adults 1.6% vs 0.7% with placebo, in adolescents 3.8% vs 0% with placebo, some but not all of the risk is likely due to weight loss itself)
- hypoglycemia (~6% in patients with type 2 diabetes vs 2% with placebo, rarely in patients without diabetes and not on glucose-lowering meds)
- volume depletion from GI adverse effects contibutes to but does not fully account for the following:
- acute kidney injury (~1 case/250 patient years vs 1/500 with placebo)
- hypotension (adults 1.3% vs 0.4% with placebo, adolescents 2.3% vs 0% with placebo)
- syncope (0.8% vs 0.2% with placebo)
- diabetic retinopathy complications (8.2% vs 5.2% with placebo)
- fractures (overall ~1% vs 0.2% with placebo, ≥75 years old 2.4% vs 0.6% with placebo)
- urolithiasis (~1.2% vs 0.8% with placebo)
- dysgeusia (~1.7% vs 0.5% with placebo)
- appendicitis (0.5% vs 0.2% with placebo in adults)
- injection site reactions (1.4% vs 1% with placebo)
- suicidal ideation and behavior (there are reports of this but research suggests this is not worse than other weight loss medications and preliminary evidence evaluted by the FDA has not found a causal association)
- pulmonary aspiration during sedation - see this clinical practice guideline for guidance
- hypersensitivity (3% in pediatrics get a rash vs 0% with placebo, anaphylaxis/angioedema has been reported with GLP-1 receptor agonists in <1/1,000 person-years in this cohort and this cohort)
- ileus has been reported but an increased risk if present seems very small
- personal or family history of medullary thyroid cancer or multiple endocrine neoplasia type 2 (black box warning)
- known hypersensitivity to semaglutide
- pregnancy or within 2 months of becoming pregnant
- Be cautious in patients with diabetic retinopathy, a history of cholelithiasis or pancreatitis, frequent gastrointestinal symptoms or severe gastrointestinal disease (e.g. gastroparesis), and people ≥75 years old (increased risk of serious adverse reactions).
- Warn about the black box warning about a possible increased risk of developing medullary thyroid cancer and discuss signs to watch for (neck nodule, dyspnea, dysphagia, voice hoarseness).
- Warn about potential side effects and symptoms. Advise to additionally let you know about significant GI problems, vision changes, palpitations/racing heart rate, or suicidal ideation/behavior.
- Advise to let providers know they are on this prior to any procedure requiring sedation.
- Advise to take a daily multivitamin.
- Side effects often improve with continued use at a stable dose. Consider prescribing medication for nausea if this is prominent with dose escalations.
- For side effects with dose escalation revert to a lower dose and prolong the titration, or maintain at a lower dose if needed, though <1.7 mg is off-label.
- To minimize GI side effects advise to consume regularly spaced, low-fat, easy to digest, small meals. Eat slowly and only when hungry with adequate hydration. If needed, liquids can be consumed 30-60 minutes after meals.
- Single dose pens should be refrigerated but can be kept at room temperature for 28 days prior to cap removal. Do not freeze pens or expose them to light.
- Rotate injection sites (thigh, abdomen, upper arm) to decrease pain, and avoid injecting into striae or skin lesions. Choose different injection sites within the same area to help prevent lumps from forming.
- Discuss with patients how to dispose of sharps. Prescribe needles and a sharps container when initially prescribing the medication.
- Ozempic is also made from semaglutide, but the dosing is slightly different (it maxes at 2 mg instead of 2.4 mg per injection), it comes in multi-use pens, and it is only approved for adults with type 2 diabetes.
Conclusion
I hope you found this page informative. Weight management is difficult and it can take a lot of trial and error to find a way to make lifestyle changes stick. Many, many people struggle with this so do not hesitate to reach out for additional support if needed. Good luck!