How did we get to this point? Scientists have suggested that despite the importance of biologic factors in the development of obesity, the epidemic is due primarily to environmental factors [11]. The energy imbalance that defines obesity is fueled by the intersection of several societal factors, most notably the toxic food environment [12]. This concept refers to both the unhealthy quality and oversized portions of the food we eat and to the ubiquitous availability of eating opportunities in a society blanketed by fast food outlets. The use of high-fructose corn syrup has increased more than 1,000% in the past 40 years and is now a staple in almost every soft drink and snack food [13]. In addition, society has created an environment by means of an economic structure that makes processed foods more affordable than fresh foods, and the food industry and mass media market energy-dense foods to children [14,15]. It surprises no one that the rates of cardiovascular and metabolic illnesses have reached all-time highs.

Obesity has also been defined as a culture-bound phenomenon, with ethnic and class variations regarding desirable body image and standards of attractiveness [22,23]. In some cultures, overweight women are considered more appealing and obesity in children is not recognized as problematic unless the child is victimized by peers or unable to participate recreationally. This greater acceptance of excess weight within the culture can reduce the negative psychosocial consequences associated with weight bias, but unfortunately may also delay the treatment of emerging health problems. Practitioners should embrace these non-quantified definitions of obesity as equally valid and central to the clinical process. Finally, an adjunct to all definitions of obesity is the concept of energy imbalance reflecting the greater intake than expenditure of calories [24,25].

As noted, in 2017–2020, the prevalence of obesity was 12.7% among children 2 to 5 years of age, 20.7% among children 6 to 11 years of age, and 22.2% among youth 12 to 19 years of age. Childhood obesity also is more common among certain populations. Obesity prevalence was 26.2% among Hispanic children, 24.8% among non-Hispanic Black children, 16.6% among non-Hispanic White children, and 9.0% among non-Hispanic Asian children [26].

Three factors appear to be predictive of obesity becoming a lifelong condition: early onset, chronicity, and genetic loading [29]. An estimated 80% of children with two overweight parents will be obese; this number is decreased to 40% if only one parent is obese [30]. Among obese toddlers, 93% of boys and 73% of girls were still obese as adults, and obese teens are almost 18 times more likely to become obese adults than their normal-weight peers [31]. Research has suggested that the persistence of obesity in childhood follows several trajectories: chronic (since infancy), transient (spontaneous onset and remission), and adolescent-onset [32].

Childhood obesity has been termed an accelerator of adult diseases and is associated with several cardiovascular risk factors, metabolic syndrome (a prelude to type 2 diabetes), fatty liver disease, sleep apnea, asthma, and a range of other health problems [24,33]. However, the most immediate and common consequences of obesity among children are psychosocial, hence the vital role of mental health professionals in responding to the epidemic [34,35]. Childhood obesity, compounded by social and familial weight bias, has been associated with diminished quality of life, societal victimization and peer teasing, low self-esteem, and specific psychiatric diagnoses [32,36,37,38]. Factors associated with a greater risk of these comorbidities include: female sex, minority status, severity of obesity, the child's lack of compensatory or bias-protective mechanisms, and negative family responses [39].

Childhood obesity has been termed an accelerator of adult diseases and is associated with several cardiovascular risk factors, metabolic syndrome (a prelude to type 2 diabetes), fatty liver disease, sleep apnea, asthma, and a range of other health problems [24,33]. However, the most immediate and common consequences of obesity among children are psychosocial, hence the vital role of mental health professionals in responding to the epidemic [34,35]. Childhood obesity, compounded by social and familial weight bias, has been associated with diminished quality of life, societal victimization and peer teasing, low self-esteem, and specific psychiatric diagnoses [32,36,37,38]. Factors associated with a greater risk of these comorbidities include: female sex, minority status, severity of obesity, the child's lack of compensatory or bias-protective mechanisms, and negative family responses [39].

Obesity is a multidetermined disorder, and etiologic theories involve biologic, psychologic, familial, and societal factors [40]. Biologically, the storage of adipose tissue, the regulation of appetite and satiety, metabolic rates of burning calories, and capacity for physical activity are all genetically loaded [16]. Other physiologic mechanisms include early and excessive fat cell formulation and set point theory [29,41].

Biologic, psychosocial, and cultural aspects converge in the concept of the obesogenic family, which transmits to children both the genetic component for excess weight as well as faulty eating and exercise patterns [46]. Four family processes have been identified as increasing the risk of obesity in children. These are [47,48,49]:

Parental deficiencies in knowledge about nutrition and fitness

Faulty parental modeling regarding healthy eating and exercise

Authoritarian, neglectful, and unstable parenting styles

Parental psychopathology, especially a history of past or present eating disorders, depression, and/or attention deficit hyperactivity disorder (ADHD)

One major child health epidemiologic survey observed that nearly 15% of the survey population had never had a normal BMI [32]. Evident even in infancy, the excess adiposity is strongly related to parental genetics. These infants and toddlers may have intense appetite demands, and their parents, many with their own weight problems, may respond with faulty feeding and nutritional practices. As noted, the interplay between heredity and environment defines the obesogenic family, and early-onset childhood obesity is predictive of continuing excess weight through later childhood, adolescence, and adulthood. The chronicity is also associated with a more severe degree of obesity, which in turn is related to higher rates of medical, psychologic, and social consequences.

While adult obesity is associated with more than two dozen diseases, overweight and obese children suffer mainly from negative emotional and social difficulties [34,50,51,52,53]. In some instances, the psychosocial distress is a consequence of the child's obesity, usually mediated by some degree of peer or family weight bias. These dual-diagnosis children have been characterized in the research and clinical literature as having consequent low self-esteem, diminished quality of life, or actual psychiatric disorders [32,36,38]. For other children, the comorbid problem can include any psychiatric or developmental condition or family stressor or dysfunction that interacts with the weight issue and requires clinical attention [54]. Practitioners should explore dynamic mechanisms that might link the two conditions, thereby providing targets for intervention with potential serendipitous value. An example of this would be the clinical focus on poor self-regulation in an obese child with ADHD. Executive functions deficits like impulsivity compromise academic and social behavior as well as the ability to limit caloric intake or to maintain a weight-reduction effort [43,55].

Another subgroup of obese children whose prevalence is undetermined is those who appear unaffected by weight bias or the limitations associated with excess weight. The family or cultural environment may buffer these children from societal weight prejudices or the child may possess admired talents or desirable personality traits that promote popularity and a positive self-image [56,57]. Researching these protective and adaptive factors can provide important therapeutic strategies for helping children and families cope with the stigma of excess weight.

Who to engage initially is a decision dependent on the clinician's orientation and the age of the patient. Using a family behavior modification model, the provider would conduct the intake interview with the parent(s) or caretaker(s) without the pre-pubertal child for several reasons. First, most pre-teens are dependent on their adult caregivers for menu planning. Second, there is evidence that child obesity treatment can be successful with parent counseling alone [65,66]. Third, a behavioral assessment is relatively structured and detailed, and collecting a significant amount of data is more easily accomplished in an adult-only interview. Fourth, the conjoint interview more comfortably allows for discussion of parental emotional distress regarding the child's obesity and the need to seek professional help. In this regard, early family theorists recognized that building alliances and "joining" are fostered by trying to relieve the parents' anxiety, guilt, and shame, efforts that convey the practitioner's nonjudgmental acceptance and support [67,68]. Finally, when family stressors such as individual psychopathology or marital conflict are issues, these are obviously more appropriately reviewed with the parents alone. (When the patient is an adolescent, the initial session can include him/her, saving a few minutes at the end to connect with the teen alone.)

Engaging the parents may also involve encountering various forms of resistance, which itself can provide additional diagnostic information about the family. Last minute cancellations, an absent parent, blaming self or each other, or denying the problem and its significance reflect a variety of motivational obstacles and, from a systems perspective, may indicate the family's protective stance and reluctance to change [75]. Practitioners should demonstrate both competence and genuine concern and should certainly be mindful of not using pejorative terms regarding excess weight. Respect for and sensitivity toward the family's cultural and ethnic values is also critical. However, if parents continue to deny the current or future seriousness of the child's obesity and relevant information has been provided in discussion and print, the family's boundaries should be respected without further challenge or disapproval, thereby allowing for future consultations.

The materials forwarded should address four basic types of information [28,76,77,78,79,80]:

A child and family background form, common to many intake procedures, that includes identifying data; obstetrical, developmental, and temperament histories; current biopsychosocial functioning; and family stressors

A screening device for a broad-based quantification of behavioral difficulties

A questionnaire to survey the child's eating behavior

A three-day food record

Effective practice with children requires that the choices of interview activities (e.g., talking vs. playing) and structured measures be consistent with the child's age and presenting problems [88]. The interview(s) with the child can include a variety of age-appropriate structured measures to assess general functioning, self-esteem, body image, and specific disorders such as depression and anxiety [89,90,91,92,93,94,95]. When there is a clear or suspected comorbid psychosocial disorder, the clinician will need to allocate additional diagnostic time and materials to achieve an understanding of both conditions. Enabling the obese child to feel comfortable, a universal task of all professional helping, begins with clarifying his or her understanding of the nature of the practitioner and the process of the evaluation. Notably, because the child may associate the visit with a medical examination, it is important to draw the distinction and to assure the child of no injections, undressing, or touching.

Many preadolescent obese children will not be able to provide specific reasons for wanting to lose weight, though older girls may express distress regarding body contour and fashion problems and athletic youth may complain about impaired performance. The motivation to lose weight for the majority of obese boys and girls is more likely the need to escape the teasing and rejection associated with weight bias [96].

The informing interview with the parents is the pivotal session, linking the diagnostic and treatment processes. It is essential that all sources of information—interviews, structured measures, collateral reports, and consultations with other professionals—be coordinated and reviewed prior to meeting with the parents. The data should be analyzed to provide a clear and comprehensive formulation regarding the causative and maintaining factors in the child's obesity and any comorbid psychosocial disorders. Apparent or presumed connections between the two conditions, as well as the role of family dynamics in either issue, should also be presented to the parents. Familiarity with theories of obesity and weight-loss methods is essential for practitioners, as parents will often have questions about their child's weight disorder, popular diets, supplements, and exercise activities during this interview. As such, this can be an important opportunity for the mental health provider to demonstrate competence and thereby increase the family's trust in the consultation.

The next task of the session is to preview recommended treatment strategies prior to setting short-and long-term goals. This enables parents to gauge the effort needed to help their child and to more confidently commit to the treatment program. There are several formulas for assessing motivation and readiness for change, generally derived from clinical work with addictive disorders [98,99,100]. Determining the parent's level of motivation can yield more realistic expectations as well as highlight potential resistances.

Often neglected in clinical practice, establishing goals of intervention in collaboration with the family is crucial to both measuring success and fostering important treatment processes [102]. While the actual treatment goals will vary with each typologic profile, there are general principles that guide the overall process [101]. It should be noted that in instances in which the data collection has been insufficient, the preliminary goal will involve extending the diagnostic process to achieve a more complete case formulation. This may not be prudent when there is a crisis or urgent situation or when delaying any intervention risks the family's discontinuing contact.

The research literature indicates that many weight-reduction approaches with children are beneficial on a short-term basis, with positive outcomes observed one year post-treatment [109]. Whether the weight loss could be maintained over a longer period and what level of intervention would be needed to achieve this are undetermined, though one seminal paper documented sustained improvement 10 years after treatment, and a follow-up found that these results were replicated over a 25-year period [110,111]. In general, these findings can be interpreted to parents as validating a variety of methods and techniques and should also challenge clinicians to extend these results. Unfortunately, there are still no consensus findings regarding the best strategies for achieving long-term weight control or for preventing relapse [112]. The other significant deficiency in childhood obesity treatment is the lack of guidelines regarding cultural variations [113].

For obese children with no medical or psychosocial comorbidities, the outcome goal is weight reduction followed by maintenance [14]. Most intervention efforts recognize that acquiring knowledge about healthy nutrition and physical fitness (as described for type 1) are corollary goals of losing weight [101]. However, decades of research and clinical practice confirm that, for the majority of children and families, didactic material and discussions are insufficient to achieve sustained weight loss outcomes.

As discussed, there is general consensus that the components of most effective weight-loss programs consist of a parent-mediated diet and exercise plan, enhanced by cognitive-behavioral techniques [101,125]. The parents are the primary agents of intervention, with responsibility for purchasing and preparing nutritious food; regulating eating opportunities, portion size, and snacking; limiting electronic entertainment; and promoting physical activity.

A clinically useful concept is that exercise functions synergistically with a reduced-calorie diet, enhancing both the child's metabolic rate and his or her motivation and persistence to maintain food restrictions. The self-perception of feeling fit can serve as a stimulus to continue healthy eating and to more readily engage in physical recreation. Parents can serve as positive role models in this area [101]. Moreover, the same positive self-image can be a source of cognitive dissonance in avoiding snacking and fast food meals. Efforts to improve the child's physical fitness may also require a simultaneous reduction in access to electronic entertainment. In fact, there is some data indicating that decreasing this kind of sedentary activity may have a greater impact on weight loss than structured aerobics [109].

In addition to monitoring, behavioral methods such as stimulus control, contingency contracting, and response cost may be needed to reward (or penalize) compliance with dietary and sedentary activity restrictions [112,135]. It is, in fact, not uncommon for monitoring itself to require positive reinforcement. A guiding principle here is that smaller changes introduced gradually are more likely to be incorporated on a permanent basis [14].

The parameters of childhood obesity treatment contain a wide assortment of formats with much variation in the frequency of sessions, the content of interventions, and the length of contact. As such, there are no consensus guidelines for treatment of this subtype. However, given the chronicity of excess weight for many afflicted children, much of the research supports the notion that longer contact (not necessarily continuous), measured in years, is associated with more favorable outcomes. Based on this observation, it is reasonable to proceed with the position that obese children will require more clinical contact to achieve a normal-range BMI. Weekly individual and parental sessions (the general model for therapeutic processes) can be a starting point for ongoing opportunities to modify ineffective methods and provide support and encouragement. When there has been limited or no weight loss over a three- to four-month period, there are several appropriate responses by the counselor:

Review accuracy of monitoring: There is a documented tendency to underestimate portion sizes or to not recall the extent of grazing and snacking; make adjustments as needed.

Search for faulty cognitive patterns in child and parent, especially negative or dichotomous thinking. Overgeneralizing a temporary setback, for example, can undermine motivation and result in inflexible coping.

Recognize the child's and family's disappointment. Suggest genetic/metabolic explanations regarding the body's resistance to losing weight.

Refocus on maintaining current body weight. Re-initiate weight loss efforts in three to six months.

Due to the wide-reaching boundaries of mental health care, mental health practitioners maintain liaisons with a variety of other disciplines and often develop an expertise in collaboration [144,145,146]. These relationships are not only clinically necessary but can generate creative research and novel interventions, important ingredients in addressing any epidemic. The key to effective teamwork begins with genuine appreciation and respect for one's colleagues. Cooperation is enhanced by learning about the philosophies and methods of other practitioners, which can also minimize potential territorial conflicts. Communicating diagnostic and intervention data is best achieved by formally structuring the frequency and method of contact. This kind of team effort is exemplified in tertiary-level childhood obesity clinics and facilities involving continuous interaction among physicians, nutritionists, mental health professionals, and exercise trainers.