BEHAVIOR MODIFICATION

Behavior Modification

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Worldwide prevalence of pediatric obesity has increased at an alarming rate over the past three decades, which has prompted tremendous concern in the medical, as well as in the lay communities. A 15-year-old boy who had been overweight since the age of 6 months was referred to an adolescent obesity clinic for further assessment of his comorbidities and management of his obesity. The patient was assigned to an extensive lifestyle-modification and behavior-modification program, with clinic-based follow-up every 4 weeks.

Behavior Modification

Participant Demographics

A 15-year-old African American boy presented to a tertiary, adolescent obesity clinic because of continued concerns from the primary-care physician and the patient's family about his rapid, uncontrolled weight gain—approximately 17 kg over the previous 12-month period. The patient had not had any surgery, was not taking any medication and had no allergies.

On physical examination, the patient was morbidly obese, with a central distribution of adiposity; he breathed comfortably at rest. His blood pressure, obtained with an appropriately sized upper-extremity cuff, was 130/85 mmHg. The patient had prominent acanthosis nigricans in the skin folds of the neck and the axillae (Figure 1), no dysmorphic features and no palpable enlargement or nodules of the thyroid gland on examination. His tonsils were not enlarged significantly. He had moderate gynecomastia and numerous, deep striae in the lateral aspects of the abdomen. Examination of the patient's abdomen revealed no enlarged organs, or abnormal tenderness or masses. He was Tanner stage 4 for physical development, which was normal for his age. He had normal digits on both upper and lower extremities(Jolliffe Janssen 2007).

The patient was born after a 36-week, uncomplicated pregnancy and was delivered vaginally with a birthweight of 3.8 kg (36th percentile). He was breastfed for the first month of life. The patient had normal physical and language development. He began walking at age 11 months and his height had always tracked along the 50th to 75th percentiles.

The patient had been home-schooled since the age of 11 years, owing to his anxiety and difficulties that arose from being bullied by peers. In the state where the patient's family lived, the law required only written notice on the part of the parent of their intent to home-school a child and maintenance of current immunization records. No requirement for routine physical examination or health screening existed for home-schooled children, although this patient did have regular check-ups with his primary-care physician. The patient lived at home with his parents, who were both medically disabled—the father from complications of a meningioma and the mother from debilitating arthritis. In addition, both parents had a history of obesity(Ogden et al. 2006), hypertension and type 2 diabetes mellitus. His mother had undergone gastric-bypass surgery 2 years before the patient's presentation at the adolescent obesity clinic.

The patient had in the past participated in numerous diet and exercise programs under the guidance and direction of his primary-care physician, including meal-replacement products, over-the-counter dietary supplements, nutritional counseling and a prescribed exercise program with a personal ...