**10. Nutritional and behavioral approach to genetic obesity**

The approach to the child with genetic obesity is very complex considering that obesity is associated with a number of complications that include the health of the child, and it must be focused on the entire family. Awareness about the problem by all family members and, in particular, changes in lifestyle and nutrition of the family are the most effective means both to ensure the compliance to the treatment, the success of the therapy and the maintenance of the long‐term results.

The family, especially the parents, should be actively involved in the therapeutic program and become protagonists. The targeted intervention with "individual" programs only for the child, on the contrary, is often unsuccessful and frustrating for the child himself [205].

According to NICE guidelines on weight management in children dating from 2014 [206], it is important to:


**•** create an environment that promotes lifestyle changes within the family and in social settings. Parents (or carers) are responsible of these changes, especially if children are younger than 12 years old [206].

The initial assessment is important to collect data necessary for diagnosis and subsequent treatment. In particular, these informations regarding patient history (personal, familiar, healthy and social history), food/nutrition‐related history (eating patterns, diet experience, physical activity, beliefs and attitudes about eating, etc.), anthropometric measures (current weight, weight history, etc.), biochemical data and medical tests (e.g., lipid profile, glucose profile, etc.); what the person has already tried and how successful this has been will be discussed, and what they learned from the experience; the person's readiness to adopt changes and their confidence in making changes will be assessed [206].

Multicomponent interventions are the treatment of choice. Weight management programs must include behavior change strategies to increase people's physical activity levels or decrease inactivity, improve eating behavior and the quality of the person's diet and reduce energy intake [206].

In particular, nutrition offered to obese children must also ensure the maintenance of adequate rhythms of growth and promote the maintenance of lean body mass (in particular of muscle mass), which represents the metabolically active compartment, and it is the large part of the total energy expenditure. Therefore, it must necessarily guarantee the macro‐ and micro‐ nutrients intake in relation to their age [205].

In overweight and obese children and young people, it is important a multidisciplinary intervention that includes dietary recommendations appropriate for age and complies with the principles for a healthy nutrition (in these patients, total energy intake should be below their energy expenditure) [206].

Dietary changes should be tailored to food preferences and allow for a flexible and individual approach to reducing calorie intake; it is important not to use unduly restrictive and nutri‐ tionally unbalanced diets because they are ineffective in the long term and can be harmful [206].

In these patients, it is also necessary that an intervention about physical activity is important not only for lose weight, but also for other health benefits, such as reduction risk of type 2 diabetes or heart diseases [206].

Therefore, obese and overweight children must be encouraged to become more active and to reduce inactive behaviors, such as sitting and watching television, using a computer or playing video games and to do at least 60 min of moderate or greater intensity physical activity each day. The activity can be in 1 session or several sessions lasting 10 min or more [206].

It is important to make the choice of activity with the child and ensure that it is appropriate to the child's ability and confidence, giving children the opportunity and support to do more exercise in their daily lives (e.g., walking, cycling, using the stairs and active play) or to do more regular, structured physical activity (e.g., football, swimming or dancing) [206].

Children affected by genetic obesity (e.g., PWS) often eat more than necessary for anxiety, sadness, boredom: in this case, it is important not only to reduce the amount of foods but also to search for reasons of suffering causing the overeating. It is important, therefore, to recon‐ struct the individual's self‐esteem [206].

There are, however, barriers to parental involvement in the child's treatment: in some families, for cultural or psychological reasons, parents do not perceive their child as obese. In other families, parents may acknowledge that the child is obese but denies that this condition can have consequences.

Therefore, it is crucial to raise awareness among parents of the need to intervene, especially when behavioral changes are needed in the family [207].

Focusing on hyperphagic children, particularly those affected by Prader–Willi syndrome, parents must learn to celebrate each small goal, large or small, and to appreciate the acquisition of any new skill [208].

In these children, there are behavior changes that become more apparent and severe with age: in fact, they are concerned about food, hypersensitive, agitated, aggressive, impulsive, anxious. These behaviors are caused specially by their insatiable appetite that causes physical, emo‐ tional and social problems [209].

For these reasons, it is important to intervene to reduce stress not only for children, but also for the whole family.

However, to control the anxious behavior in children with PWS, the following information may be useful:


**•** create an environment that promotes lifestyle changes within the family and in social settings. Parents (or carers) are responsible of these changes, especially if children are

The initial assessment is important to collect data necessary for diagnosis and subsequent treatment. In particular, these informations regarding patient history (personal, familiar, healthy and social history), food/nutrition‐related history (eating patterns, diet experience, physical activity, beliefs and attitudes about eating, etc.), anthropometric measures (current weight, weight history, etc.), biochemical data and medical tests (e.g., lipid profile, glucose profile, etc.); what the person has already tried and how successful this has been will be discussed, and what they learned from the experience; the person's readiness to adopt changes

Multicomponent interventions are the treatment of choice. Weight management programs must include behavior change strategies to increase people's physical activity levels or decrease inactivity, improve eating behavior and the quality of the person's diet and reduce energy

In particular, nutrition offered to obese children must also ensure the maintenance of adequate rhythms of growth and promote the maintenance of lean body mass (in particular of muscle mass), which represents the metabolically active compartment, and it is the large part of the total energy expenditure. Therefore, it must necessarily guarantee the macro‐ and micro‐

In overweight and obese children and young people, it is important a multidisciplinary intervention that includes dietary recommendations appropriate for age and complies with the principles for a healthy nutrition (in these patients, total energy intake should be below

Dietary changes should be tailored to food preferences and allow for a flexible and individual approach to reducing calorie intake; it is important not to use unduly restrictive and nutri‐ tionally unbalanced diets because they are ineffective in the long term and can be harmful [206]. In these patients, it is also necessary that an intervention about physical activity is important not only for lose weight, but also for other health benefits, such as reduction risk of type 2

Therefore, obese and overweight children must be encouraged to become more active and to reduce inactive behaviors, such as sitting and watching television, using a computer or playing video games and to do at least 60 min of moderate or greater intensity physical activity each

It is important to make the choice of activity with the child and ensure that it is appropriate to the child's ability and confidence, giving children the opportunity and support to do more exercise in their daily lives (e.g., walking, cycling, using the stairs and active play) or to do

Children affected by genetic obesity (e.g., PWS) often eat more than necessary for anxiety, sadness, boredom: in this case, it is important not only to reduce the amount of foods but also

day. The activity can be in 1 session or several sessions lasting 10 min or more [206].

more regular, structured physical activity (e.g., football, swimming or dancing) [206].

younger than 12 years old [206].

246 Adiposity - Omics and Molecular Understanding

intake [206].

and their confidence in making changes will be assessed [206].

nutrients intake in relation to their age [205].

their energy expenditure) [206].

diabetes or heart diseases [206].

**•** speaking to your child in a calm, yet firm matter‐of‐fact tone [209].

In children with PWS, it is essential management food, based also on control food access, to ensure adequate nutrition, weight regulation and appropriate eating behaviors.

Crucial in this regard is the role of parents, who must support their children in these changes by adopting appropriate strategies.

However, each family will find the best way for them and for the specific need of their child.

First of all, it is important to follow an adequate food program that helps parents to monitor their food intake and reassures the child that the food will always be available: therefore, it represents the beginning for him to acquire the habit of eating healthy so that food can be controlled and could become a part of his daily routine [209].

This program is based on three main meals (breakfast, lunch, and dinner) and two or three snacks (mid‐morning snack, afternoon snack, and perhaps evening snack) [209]. It is funda‐ mental to respect scheduled times (food must be given every 2–3 h), avoiding giving food outside mealtimes. Whenever possible, all family members should eat at the same time and others should not eat in front of the child when it is not their scheduled meal/snack time [209].

Portion control is another adequate strategy: it must not be excessive, but appropriate for the child's age to ensure adequate growth [209].

However, food must be healthy considering that in children with PWS, calorie needs are lower due to reduced metabolism. Food must be given only by parents/caregivers and served on the plate prior to being eaten, avoiding other platters/bowls of food visible on the table and to share or offer them other food [209].

At the end of the meal, it is important to remove the empty plate from the table and encourage the child to play away from the table or from the kitchenette until all food has been taken away. It is important to keep food out of sight and reach of children, keeping it under lock and key if necessary [209] (**Figure 8**).

**Figure 8.** Girl with Bardet‐Biedl syndrome. You can see the amelioration of the BMI after the interdisciplinary ap‐ proach to hyperphagia.
