Management of overweight and obesity 

Primary care 

Primary care is typically the first point of contact for children and families seeking assessment, advice and support for obesity. It plays an important role in identifying children and young people who may benefit from further assessment and support to improve long term health and wellbeing.  
 
Childhood obesity is a complex, chronic health condition influenced by biological, psychosocial and environmental factors. Management is most effective when delivered using a multidisciplinary and family centred approach. Depending on the young person and family’s circumstances, a care team may involve a dietitian, social worker, counsellor/psychologist, physiotherapist and/or exercise physiologist. 

Talking to young people and families about weight and growth 

Conversations about growth and health are an important part of routine care. Many clinicians find discussions about overweight and obesity challenging. Approaching these conversations with empathy, respect and a focus on a young person’s overall health can help create a supportive environment for families.  

Principles for supportive conversations:

• Use growth charts to guide discussions. This helps families understand that your assessment is based on standardised measures and the young person’s growth pattern over time.
• Use person-first language, rather than labels. For example, ‘child living with obesity’ or 'person living in a larger body' rather than ‘obese child’. Focus on the child as a person, rather than defining them by their weight or size.
• Use respectful, age-appropriate language. Avoid terms that may be perceived as blaming or judgemental (e.g. ‘lazy’, ‘fat’, ‘unmotivated’ or ‘weight problem’). Tailor discussions to the child’s developmental stage and involve them in the conversation where appropriate. Be mindful of your own biases and how you refer to your own weight/body shape.
• Focus on health, not weight. Emphasise healthy behaviours, growth, physical health, emotional wellbeing and reducing future health risks rather than focusing on weight loss.
• Explore the family’s goals and readiness to change. Ask about the family's priorities, strengths, challenges and what changes feel achievable, realistic and sustainable.
• Take a whole family approach. Encourage healthy habits that can be adopted by the entire family, rather than focusing on one child. Family wide changes are more supportive and sustainable.
• Promote a balanced approach to food and activity. Encourage healthy eating patterns and regular physical activity, without labelling foods as ‘good’ or ‘bad’. Instead, discuss everyday foods, occasional foods and focus on opportunities to make healthier choices.  
• Avoid restrictive diets. Support sustainable, lifelong healthy habits rather than short term dieting. Restrictive diets can contribute to unhealthy relationships with food and may increase the risk of disordered eating behaviours. 

Medical assessment of a young person living with obesity 

Assessment of growth, considering:

• Pubertal stage (e.g. using Tanner Staging) 
• Body composition  
• Genetic predisposition (i.e. parent height and weight)  
• Weight and height trajectory 
• Clinical and psychosocial history (i.e. medical conditions, neurodevelopmental disability and/or psychosocial circumstances that may influence growth)

Medical assessment of metabolic health, including screening for: 

• Impaired glucose tolerance or type 2 diabetes (HbA1c, presence of acanthosis nigricans, nocturia, increased thirst and/or weight loss)  
• Obstructive sleep apnoea (i.e. snoring, daytime somnolence and/or pauses in breathing +/- oximetry or PSG if clinically indicated) 
• High blood pressure (measured with appropriate cuff size +/- ABPM if clinically indicated) 
• Dyslipidaemia (total cholesterol and LDL)  
• Metabolic dysfunction associated steatotic liver disease (ALT +/- ultrasound if clinically indicated)  
• Thyroid function (TSH +/- free T4)
• Slipped upper femoral epiphysis (i.e. pain in groin, hip, thigh or knee +/- Xray if clinically indicated)  
• Polyendocrine metabolic ovarian syndrome (i.e. hirsutism, hyperandrogenism and/or irregular or absent periods)
• Idiopathic intracranial hypertension (i.e. headaches and/or visual disturbance) 
  

Routine screening investigations

Baseline: 

• Blood lipids including total cholesterol and LDL (fasted if possible) 
• Liver function tests 
• HbA1c (for youth >/= 10 years of age or younger if family history of T2DM or presence of acanthosis nigricans). Please note, there is no clinical value in testing serum insulin levels when insulin resistance is suspected. If unable to obtain venous bloods, consider fingerprick bloods (i.e. fasting BGL or HbA1c) and/or urine ACR 
• Thyroid function (TSH +/- free T4) 
• Blood pressure (using an appropriate sized cuff) +/- 24 hour ABPM if clinically indicated 
• Vitamin D
  
• Screening for obstructive sleep apnoea (+/- investigations if clinically indicated i.e. oximetry or PSG) 

Consider the following when clinically indicated:

• Vitamin and nutrient levels (such as ferritin, folate, B12 and zinc)   

Lifestyle history 

• Daily food and fluid intake (consider referral to dietitian for an assessment and further support) 
• Activity levels (considering the young person’s ability and enjoyment of participation in physical activity) 
• Time spent on devices 
• Sleep routine

The determinants of health 

Obesity is a health condition influenced by a complex interaction of biological, social, environmental and developmental factors, and should be understood within the broader context of a child’s health and family circumstances. Supporting young people and families with weight related concerns requires a holistic approach that considers the wider determinants of health that influence growth, development and wellbeing including: 

• Family and social circumstances including relationships, social connection, support networks and family stressors 
• Food access and security including availability, affordability and accessibility of nutritious foods 
• Socioeconomic factors including financial circumstances, housing stability, education and access to resources  
• Physical and built environments including opportunities for movement, recreation, safe spaces and community supports  
• Cultural factors including cultural identity, beliefs, practices and connection to community  
• Safety and experiences of adversity including trauma and advertise childhood experiences  
• Healthcare access including availability of appropriate, accessible and culturally safe health services 
• Disability and neurodivergence including the impact of physical, intellectual or neurodevelopmental disability on participation, daily functioning (including eating and moving), access to services and support needs of carers  
• Mental health and emotional wellbeing including recognising the impact of stress, anxiety, depression and related challenges.  

These factors all play a vital role in shaping long term health and wellbeing.  

Community supports 

Consider referral to allied health and other community supports as required, such as: 

• Dietitian 
• Psychologist or counselling services  
• Social worker 
• Exercise physiologist or physiotherapist 
• Occupational therapist 
• Family services  

Pharmaceutical management 

There are medications that may be indicated for use in children and adolescents with obesity related co-morbidities, including: 

• Pre-diabetes or impaired glucose tolerance (HbA1c >/= 5.8): consideration of the use of metformin, particularly if there is a strong family history of T2DM or clinical evidence of insulin resistance (acanthosis nigricans). If hyperglycaemia or elevated HbA1c, consider performing diabetes antibodies to rule out T1DM. It is recommended to monitor HbA1c every 3-6 months and B12 (annually or as indicated) during use of metformin. 
  
• Hypercholesterolaemia: statin therapy may be indicated. Please refer to the RCH clinical guideline here. 
• Hypertension: antihypertensive agents may be indicated. Please refer to the RCH clinical guideline here. 

Glucagon-like peptide-1 receptor agonists (GLP-1 RAs) 

In 2024, the Therapeutic Goods Administration (TGA) approved the use of certain glucagon-like peptide-1 receptor agonists (GLP-1 RAs) for adolescents aged 12 years and older living with clinical obesity, as an adjunct to comprehensive lifestyle and health support. 

GLP-1 RAs are a newer class of medications that have been shown to support meaningful weight reduction and improvements in some health outcomes for adolescents with clinical obesity, when combined with evidence-based lifestyle interventions. These medications work by mimicking naturally occurring gut hormones involved in appetite regulation and blood glucose control. They can help increase feelings of fullness, reduce appetite and support changes in eating patterns. 

Clinical obesity is a chronic disease and therefore the management usually requires long-term, individualised care. For some young people, pharmacotherapy may form part of a broader treatment plan alongside nutrition support, physical activity, mental health support, and management of medical and psychological factors. 

Individualised assessment and multidisciplinary care 

GLP-1 RAs are not suitable for every young person. Decisions about whether medication may be appropriate are made following a comprehensive assessment by a multidisciplinary team. This assessment should consider: 

• Growth patterns, pubertal stage and overall health 
• Medical complications associated with clinical obesity 
• Baseline blood tests (including lipase, calcitonin, metabolic bloods and micronutrient bloods)  
• Baseline bioelectrical impedance analysis (BIA) to measure body composition (estimated lean muscle mass and fat mass) 
• Nutritional intake and dietary adequacy 
• Screening of mental health, emotional wellbeing, psychiatric history and risk of disordered eating 
• Physical function, muscle mass and activity levels 
• Family history (including obesity, medical conditions and pharmaceutical usage/response) 
• Individual goals, family preferences and capacity to engage with multidisciplinary treatment 
• Ability to access medication. Cost and access remain a significant barrier as these medications are not currently subsidised through the Pharmaceutical Benefits Scheme (PBS) for adolescents with clinical obesity, resulting in substantial out-of-pocket costs for families 
• Contraindications (including an active or unstable eating disorder, personal or family history of medullary thyroid carcinoma and pregnancy)

Limitations and considerations 

• Long-term evidence in adolescents remains emerging, particularly for young people with complex medical conditions or neurodevelopmental disability
• Ongoing treatment may be required, as clinical obesity is a chronic condition and weight regain can occur following discontinuation of medication
• Side effects may occur including: 
  • GI symptoms (nausea, vomiting, bloating and/or abdominal pain)  
  • Pancreatitis and ileus  
  • Mental health difficulties (monitoring for suicide risk and self-harm, body image concerns, emergence of disordered eating or development of an eating disorder which may also present as fear of weight re-gain)
  • Reduced efficacy of oral contraceptive medications for females due to delayed gastric emptying  
  • Increased risk of aspiration during sedation or general anaesthetic (please refer to ANZCA clinical practice guidelines) 
    
  • Risk of malnutrition, micronutrient deficiencies and loss of lean muscle mass. Individualised dietitian assessment and monitoring is important to optimise nutrition and preserve lean muscle mass 

Supports recommended  

• Monthly GP reviews are recommended to monitor medication efficacy and side effects (including monitoring for changes in mental health) 
• Regular resistance training (ideally 3 times per week) is recommended under the guidance of an exercise physiologist or physiotherapist, to preserve lean muscle mass  
• Paediatric dietitian to support adequate nutrient intake, reduce loss of lean muscle mass and monitor for disordered eating  
• Mental health support to monitor mental health (including mood, emotional wellbeing and body image)