The intensive therapies that have been used to treat pediatric and adolescent obesity include very-low-calorie diets, pharmacotherapy, and bariatric surgery. None of these approaches have been reported in sufficient numbers of subjects who have taken part in well-designed experiments with long-term follow-up to demonstrate convincingly their true value for the treatment of pediatric obesity. As the potency of the therapy increases, so does its possible adverse consequences. Of the intensive approaches, only bariatric surgery can be said to have even small studies supporting its ability to induce long-lasting (> 1 year) effects on body weight in severely obese adolescents. The risks and benefits of intensive weight-management therapies should be weighed carefully before they are used with pediatric-aged patients. Until further controlled trials become available, intensive therapies for pediatric obesity should be considered only for children who have not responded to conventional weight-management programs but have significant complications of their obesity. Intensive approaches generally should be restricted to specialized centers that have experience with those treatments and should be carried out in the context of a comprehensive weight-management program.