Childhood Obesity

The term "obesity" is a medical classification used by health care professionals to describe a body size based on body mass index (BMI) thresholds. While it is a clinical term, we recognize that it can be stigmatizing or distressing. Weight-related language can carry emotional and social implications, and many people prefer different or more neutral terms when discussing their bodies.

At Boston Children’s Hospital, we are committed to using person-centered and compassionate language. In our clinical care, we strive to honor the preferences of each patient and family when discussing body size, weight, and health. Our goal is to provide supportive and non-judgmental care, recognizing that health and well-being are influenced by many factors beyond individual behaviors and weight alone.

When a child’s weight is significantly higher than what’s typical for their height, it may signal a risk for future health concerns. Children with elevated weight can be more likely to develop chronic conditions such as type 2 diabetes, high blood pressure, high cholesterol, joint problems, and liver disease.

Researchers are working to improve treatment approaches for children with higher weight. Current clinical guidelines focus on lifestyle changes (such as nutrition and physical activity), medications, and — in some cases — surgery. However, these strategies don’t always account for the full picture. Factors such as genetics, environment, income level, food access, and opportunities for safe physical activity all play an important role in a child’s health and ability to reach and maintain a healthy weight.

According to the Centers for Disease Control and Prevention, an estimated 19.7 percent of American children and teens ages 2 to 19 are affected by obesity. This amounts to approximately 14.7 million children and adolescents nationwide.

There are several tools your child’s doctor might use to assess their risk for future health concerns related to weight, including:

• Tracking weight percentile and BMI percentile over time to watch for sudden increases
• Reviewing family history of conditions like type 2 diabetes, high cholesterol, high blood pressure, sleep apnea, and early heart disease — all of which may be linked to weight-related health risks
• Recognizing that scale weight alone doesn't show the full picture. The scale doesn’t differentiate between bone, muscle, and fat. In some cases, doctors may use body composition tools like DXA (dual-energy X-ray absorptiometry) to get a more detailed understanding of a child’s fat distribution, muscle mass, and metabolic health.

Children can be healthy at many different sizes. Weight alone doesn’t determine a child’s well-being — many factors, including physical activity, nutrition, mental health, and family history, all contribute to overall health.

That said, there are times when additional evaluation may be helpful. If you notice any of the following signs or symptoms, it’s a good idea to talk with your child’s doctor:

• Signs of insulin resistance: Dark, velvety patches of skin (acanthosis nigricans), particularly around the neck or underarms; breast tissue development in boys
• Emotional and mental health challenges: Low self-esteem, withdrawal, signs of disordered eating, or distress related to body image; teasing or bullying
• Breathing issues: Shortness of breath with mild activity; loud snoring or pauses in breathing during sleep
• Digestive problems: Frequent constipation or symptoms of acid reflux
• Reproductive health issues: Early or irregular menstrual cycles in girls; delayed puberty or concerns about pubertal development in boys
• Musculoskeletal concerns: Persistent joint pain, flat feet, knock knees, or hip instability

If you have concerns or are unsure whether a symptom is related to weight or another issue, your pediatrician can help assess your child’s growth and development in context and support you in creating a plan that centers your child’s overall health and well-being.

In recent years, a growing number of children have experienced excess weight gain, making it an increasingly common health concern. There are many contributing factors — no single cause applies to every child. Weight gain can result from a combination of medical, genetic, behavioral, and environmental influences.

• Social and psychological factors: Chronic stress from living in poverty, facing discrimination, or experiencing weight stigma and bullying can also contribute to metabolic changes, such as increased cortisol levels, which may contribute to weight gain, independent of diet and physical activity. Fear of judgment from healthcare providers may also cause individuals with higher weight to delay or avoid medical care, missing opportunities for early intervention.
• Genetic factors: Having at least one parent with obesity. However, it’s important to remember that genetics alone do not necessarily mean a child is destined to develop obesity. There are many steps a child can take to lower their risk.
• Medications: Taking steroids, some antidepressants, and certain other medications can make it difficult to maintain a healthy weight.
• Medical conditions: Genetic syndromes like Prader-Willi syndrome, and hormonal conditions like Cushing’s syndrome are among the medical disorders that can cause weight gain. If you are concerned that your child’s weight might be related to a medical condition, consult their pediatrician, who can perform tests to check for underlying causes.
• Behavior and environment: Every child’s appetite is different, and that’s completely normal. Some children may feel hunger more intensely or find it harder to recognize when they’re full. Others may eat in response to emotions like stress, boredom, or the need for comfort — a common and understandable way of coping. Appetite cues are influenced by a complex mix of biology, emotions, environment, and past experiences.

Daily routines and activity levels also shape how a child relates to food and their body. Encouraging fun activities through play, sports, dance, or simply spending time outside can help children build a positive relationship with their bodies. Supportive environments that make physical activity fun, inclusive, and low-pressure are key to helping kids feel confident and capable.

One theory that helps explain why maintaining a healthy weight can be challenging is the Body Weight Set Point theory. This theory suggests that a person’s weight is regulated by a complex balance of genetic, hormonal, and metabolic factors that can make it difficult for some individuals to sustain long-term weight changes.

If a child is diagnosed with obesity, their doctor might do a full physical exam and screen for the following:

• Diabetes
• High blood pressure
• Abnormal blood lipids (high cholesterol, high triglycerides, and low levels of good, HDL cholesterol)
• Fatty liver
• Menstrual problems
• Psychological problems

Children who are at risk for developing obesity may be screened for:

• Family history of cardiovascular disease, elevated total cholesterol, diabetes, parental obesity
• Large increases in BMI assessments from year to year
• Mental health concerns
• Blood pressure

No matter what factors contribute to a particular child’s weight gain, making sustainable changes can greatly improve their overall health and well-being. This includes adopting healthier eating habits, incorporating more physical activity into daily routines, and supporting mental and emotional wellness. These positive changes can lead to long-term health improvements rather than simply aiming for weight loss.

It's also important to remember that weight loss is not always the goal when treating a child with higher weight. In some cases, especially with young children, maintaining their current weight while growing taller can naturally result in a more balanced weight for their height.

Depending on your child's needs, a multispecialty team consisting of a medical provider (e.g., physician or nurse practitioner), a registered dietitian, and a mental health professional may be helpful to develop a specific treatment plan that may include:

• Nutrition counseling and modification of diet quality and caloric content
• Increased physical activity
• Behavior modification to address self-esteem and attitudes about food
• Individual or group therapy focused on changing behaviors and confronting feelings related to weight and normal developmental issues
• Family counseling to help support changes in the home

Supporting families with compassion

At Boston Children’s, we believe that promoting children’s health means supporting their families as well. We understand that parents and caregivers want the best for their children and may face barriers beyond their control.

Our programs prioritize creating a safe and welcoming environment for patients and their families. We focus on sustainable lifestyle changes that promote health and well-being rather than solely emphasizing weight loss. Our team is committed to partnering with families to create realistic, compassionate, and culturally sensitive care plans.

Diet

The low-glycemic diet

Low-fat, low-calorie diets can be hard to follow because they are inherently restrictive, limiting the variety and amounts of food people can enjoy. Even when a person following a low-fat, low-calorie diet does achieve weight loss in the short term, maintaining that weight loss over time can be challenging due to feelings of deprivation and difficulty sustaining restrictive eating patterns.

The EMPOWER program uses an approach known as a low-glycemic diet. This diet:

• Combines slowly digested carbohydrates, such as vegetables, fruits, beans, and minimally processed grains, with protein and healthy fats, such as nuts, avocado and olive oil, all of which help us stay full longer after eating
• Is based on whole foods that digest slowly, helping blood sugar and hormones stay at a steady level for many hours after eating

How do I follow a low-glycemic diet?

Following a low-glycemic diet is easier than it may sound. You don't have to memorize the glycemic index or count grams of carbohydrates in foods. Instead, you can:

• Eat fiber-rich, natural carbohydrates such as non-starchy vegetables, fruits, and beans along with protein and healthy fat (like nuts, avocado, or olive oil)
• Eat grain products in their least-processed state possible (for example, stone ground whole grain bread rather than white bread)
• Have a sugary treat, but do so only in moderation and after a balanced meal
• Limit fruit juice to one cup a day, avoid sugary soda, and drink mostly water

Research has shown that the low-glycemic diet has many benefits, including:

• Lowering risk for diabetes, heart disease, and fatty liver
• Lowering blood sugar and cholesterol levels in people with both type 1 diabetes and type 2 diabetes 
• Controlling appetite, which supports healthy weight in both kids and adults

However, to be as healthy as possible, children should eat a balanced diet and strive for daily physical activity.

Physical activity

Maintaining a healthy weight requires a combination of balanced eating and consistent physical activity.

What’s the best kind of exercise for kids to stay healthy and active?

Experts recommend that children get at least 60 minutes of moderate physical activity each day. However, if your child hasn’t been active before, it’s important to start slowly with activities that are accessible, enjoyable, and appropriate for their developmental level.

Encourage movement that feels fun and focus on building confidence and stamina over time. For example, just 20 minutes of daily walking can be a great way to get started and make progress toward a more active lifestyle.

Making physical activity enjoyable and suitable for your child's abilities not only supports long-term weight management but also boosts their self-confidence and motivation to stay active.

If left untreated, living with higher weight can lead to:

• Increased risk of developing overweight or obesity as an adult
• Increased risk for medical problems such as asthma, diabetes, heart disease, liver disease, reproductive problems, and some cancers
• Psychosocial disabilities, including social isolation and depression

Boston Children’s has hospital-based programs that can help children and their families manage their weight:

• EMPOWER: The EMPOWER program uses modern tools and evidence to approach weight management. Our team can help identify and incorporate the right combination of exercise, healthy nutrition, counseling, and medication into your child’s treatment plan. And we’ll work together with you to improve their health and quality of life.
  • The Optimal Wellness for Life (OWL) Program is a tier within EMPOWER which offers a six-month, intensive intervention with Nutrition and Behavioral Medicine.
• STEP: Based in the Division of Adolescent and Young Adult Medicine at Boston Children’s, this multidisciplinary program works with 13- to 25-year-olds in their primary care clinic to develop a teen- and young adult-friendly approach to weight and lifestyle management.
• Preventive Cardiology Clinic (Lipid Clinic): The Preventive Cardiology Clinic at Boston Children’s Hospital specializes in evaluating and treating high cholesterol and high blood pressure in children to reduce their risk of heart disease later in life. Using a team-based approach, the clinic provides personalized care plans that include heart-healthy lifestyle guidance, medical treatment when needed, and long-term monitoring.
• Adolescent Weight Loss (Bariatric) Surgery Program: This multidisciplinary program is for adolescents who are considering surgical interventions to reduce weight. Patients must have attempted at least six months of medically supervised weight loss before they would be considered for eventual surgery.

Researchers continue to search for effective ways to treat obesity, but prevention remains a key focus. This means encouraging balanced eating habits that include vegetables, fruits, legumes, whole grains instead of refined grains, protein, and healthy fats. Staying active is also important — aiming for around one hour of physical activity each day can support overall health.

However, systemic factors such as poverty, food insecurity, limited health care access, and weight stigma significantly influence children’s health and ability to engage in preventive behaviors. Addressing these broader issues is essential to creating equitable opportunities for health.

At the same time, it's crucial to provide supportive treatment for children living in larger bodies. This involves creating a safe and encouraging environment that fosters healthy habits without placing blame or judgment.

You can support your child's overall health and well-being by:

• Role modeling. Parents who eat a healthful diet and maintain an active lifestyle can set a positive example for their child.
• Serving water instead of sugar-sweetened drinks as much as possible.
• Offering age-appropriate portion sizes and keeping serving platters and bowls off the table to avoid overeating.
• Limiting screen time to two hours a day (TV, computer, and video games).
• Not using food as a reward for good behavior, academic achievement, or eating a healthful food.
• Focusing on overall health. Improvements in nutrition, physical activity, and emotional well-being can benefit children’s health, regardless of changes in weight.

If my child has been diagnosed with a weight-related condition such as type 2 diabetes, is it too late to make changes that will help them?

It's never too late to improve health. Many problems such as high cholesterol and high blood pressure, elevated insulin, fatty liver, and even type 2 diabetes, can be reversed. With careful monitoring of changes in height and weight, many weight-related problems can be identified early enough to prevent their progression to more serious and chronic health problems.

Boston Children's has initiated several community programs and partnerships to help further address overweight and obesity in local Boston communities:

• Healthy in the City (FIC) program: Healthy in the City, supported by Boston Children’s Hospital, partners with 11 community health centers to provide case management, nutrition education, and referrals to physical activity programs for over 1,100 children and families each year. Through collaborations with local organizations, the program helps participants set wellness goals, access resources, and engage in healthy lifestyle activities in their communities.
• Healthy Kids, Healthy Communities: A partnership between Boston Children's, the Boston Red Sox, and Northeastern University. This is an obesity prevention program targeting preschool-age children. The program partners with Action for Boston Community Development, Head Start, and the Boston Centers for Youth and Families to provide nutrition workshops and exercise programs for families in the community.

Boston Children's offers three programs that provide medical, nutritional, and behavioral supports:

• The EMPOWER Program treats children and adolescents between 2 and 17 years old who are living in larger bodies or are at risk of developing it.
• STEP treats patients between 13 and 25 and focuses more on teens and young adults, although encourages family involvement as well.
• The Adolescent Weight Loss (Bariatric) Surgery Program offers medical and lifestyle intervention for patients preparing for Roux-en-Y gastric bypass (RYGB) or vertical sleeve gastrectomy (VSG) bariatric surgeries.

All these programs are family based to some extent; that is, they encourage an approach that includes all family members and not just the child.

At Boston Children’s Hospital, our care is informed by our research, and we have many studies investigating causes of, and treatments for, obesity. Read more about some of our research breakthroughs:

• Helping the body hear "I’m full": Scientists at Boston Children’s Hospital found a way to help the body respond better to leptin — a hormone that tells us when we’re full. In people with obesity, the body often stops listening to leptin, so they keep feeling hungry. The researchers discovered that a protein called HDAC6 gets in the way of leptin’s signal. When they blocked HDAC6 in mice, the mice ate less and lost weight, without losing muscle. This could one day lead to a new medicine to help people with obesity feel full and stay healthy. This research was published in Cell Metabolism.
• Sugary calories in liquid form: A foundational study published in the New England Journal of Medicine (NEJM) provides definitive evidence that drinking sugar-sweetened beverages directly impacts weight gain and pediatric obesity. Boston Children’s researchers Cara Ebbeling, PhD, and David Ludwig, MD, PhD, find that compared to adolescents who consistently drink sugar-sweetened beverages, those who stopped drinking them for a year gained significantly less weight and avoided BMI increases.
• Boost your metabolic rate: Research from Cara Ebbeling, PhD; David Ludwig, MD, PhD; and colleagues in the New Balance Foundation Obesity Prevention Center suggest that all calories are not alike from a metabolic perspective. Reducing consumption of highly processed carbohydrates — like white bread, white rice, refined breakfast cereals, and sugary beverages — can provide a metabolic boost of several hundred calories a day, equal to an hour of physical activity. This metabolic boost may be a key to successful long-term weight loss maintenance.
• Reviving leptin's promise for obesity: The 1995 discovery of leptin, a hormone that suppresses appetite, raised hopes of an obesity cure. But researchers later discovered differences in the way the brains of people with obesity and those within a healthy weight range respond to leptin. Specifically, they found that the brains of people with obesity become leptin-resistant. Now, Umut Ozcan, MD, and colleagues in Boston Children’s Division of Endocrinology report two existing drugs can restore the brain's sensitivity to leptin in obese mice. How this translates into humans is far from certain, but researchers are beginning to try to answer this question through clinical trials.
• Cracking the code on obesity: When an international consortium led by Joel Hirschhorn, MD, PhD, of Boston Children’s Division of Genetics and Genomics and Division of Endocrinology, analyzed data from about 90,000 people, they discovered six new genetic variants linked with body mass index. Most of the variants highlight genes active in the brain, suggesting that differences in appetite regulation may play a role in obesity. The team is now performing larger-scale studies to identify additional genetic variants with the goal of one day developing an effective treatment for obesity.

• Compass PWS (Prader-Willi syndrome) Study: This is a multi-center, randomized, double-blind, placebo-controlled study where participants will receive either a carbetocin nasal spray or a placebo nasal spray three times a day to evaluate the efficacy of treatment in people with Prader-Willi syndrome (PWS). Learn about the Compass PWS Study.
• Setmelanotide in acquired hypothalamic obesity: The goal of this trial is to learn how well Setmelanotide works to improve weight reduction, hunger, and quality of life in patients 4 years of age and older with acquired hypothalamic obesity. Learn about the Setmelanotide trial.