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Tertiary Prevention of Pediatric Obesity:

Individual-Family-Based Interventions

Melinda S. Sothern, PhDDirector, Section of Health Promotion

School of Public Health

Louisiana State University (LSU) Health Sciences Center

Childhood Obesity Laboratory

LSU Pennington Biomedical Research Center

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What should I do to help my overweight patient?

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Tertiary Prevention of Pediatric Obesity: Individual-Family-Based Interventions

Designed to slow down or reverse the increase in BMI and to prevent the complications of overweight

Included a measure of adiposity Included children >2 and <18 years of age Intervention of 8 weeks or more Included at least 30 subjects in the

intervention group Surgery or pharmacological interventions

were not evaluated.J Am Diet Assoc. 2006;106:925-945

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What Does the Research Say? Studies from1984 to 2004 were evaluated 44 evidence-based studies were identified

29 were randomized-controlled (RCT); 15 other design

43 contained one or more component (multi-component)

39 included behavior counseling; 6 studies > 2 years

38 studies included dietary counseling w/behavior & exercise

J Am Diet Assoc. 2006;106:925-945

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Authors Age Intervention Outcome

Epstein 6-12 Parent/child -19.7% @ 10 yrs

Epstein 6-12 Parental obesity NS @ 10 yrs

Braet 9-12 Behavioral vs advice -17.3 @ 4.5 yrs.

Nuutinen 6-15 Group vs Individual -11.7% @ 5 yrs.

Childhood Obesity TreatmentLong-term Studies

Epstein 6-12 Exercise + diet NS @ 10 yrs

Epstein 6-12 Lifestyle exercise -15.3% @ 10 yrs

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What Does the Research Say? Family based interventions (Grade I & II):

21 of the 29 RCT 13 or the 15 studies of other design 28 studies - significant weight loss

Parent training within multi-component interventions (Grade I & II): 20 of the 29 RCT 13 of the 15 studies of other design

10 studies evaluated child only versus parent only or parent/child combined

J Am Diet Assoc. 2006;106:925-945

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Family

Pediatrician

Nutrition Education

BehavioralCounseling

Exercise and physical activity

Treatment of Overweight Conditions in Childhood

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Multi-Disciplinary Weight Management Sample Class Schedule

Medicine Nutrition Behavior Exercise

4:00-4:30 Return Calls Set-up

4:30-4:50Nurse

Supervises Weigh-In

Check Food Records

Talk with Parents Review

Charts

Check Exercise Cards

4:50-5:10 Group Group Group Group

5:10-5:30Review Charts Behavior

SessionReturn Calls

Review Charts

Review Charts

Return Calls

5:30-6:00Physician Q&A

or SessionClean-up Nutrition

Session

Set-up Exercise

6:00-6:30Physician Q&A

or SessionClean-up Exercise

Session

6:30-7:00 Clean-up Clean-up

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What is the Best Dietary Approach for Treating Overweight Children?

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Recommendations from the American Academy of Pediatrics Health supervision (Nutrition)

Encourage, support, and protect breastfeeding.

Encourage parents and caregivers to promote healthy eating patterns by offering nutritious snacks, such as vegetables and fruits, low-fat dairy foods, and whole grains; encouraging children’s autonomy in self-regulation of food intake and setting appropriate limits on choices; and modeling healthy food choices.

American Academy of Pediatrics. Pediatrics. 2003;112(2):424-430.

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What Does the Research Say? Dietary Counseling/Nutrition Education

within multi-component (Grade I & II) 38 studies- significant reductions in

adiposity (24 RCTS; 14 other design) 29 nutrition education such as portion

control and reductions of high density foods

12 Traffic Light diet 7 diets based on ADA guidelines 5 balanced hypocaloric

J Am Diet Assoc. 2006;106:925-945

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What is thebest type

of physical activity for overweightchildren?

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Recommendations from the American Academy of Pediatrics Health supervision (Physical Activity)

Use change in BMI to identify rate of excessive weight gain relative to linear growth.

Routinely promote physical activity, including unstructured play at home, in school, in child care settings, and throughout the community.

Recommend limitation of television and video time to a maximum of 2 hours per day.

American Academy of Pediatrics. Pediatrics. 2003;112(2):424-430.

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What Does the Research Say? Physical Activity Interventions

(Grade I & II): 24 RCTs; 13 other design

10 RCTs examined the independent contribution of exercise: 8 showed significant reductions in

adiposity independent of other factors 1 randomized-controlled study examined

sedentary behavior (TV) versus increased physical activity (Grade III)

J Am Diet Assoc. 2006;106:925-945

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What Does the Research Say? Behavioral counseling interventions

(Grade I & II): 25 RCTs; 14 other design

7 RCT’s compared behavioral counseling to standard care All showed significant reductions in adiposity

compared to standard care Many were based on well-established theories Most included basic behavioral techniques Only 2 studies examined the independent

contribution of different techniques J Am Diet Assoc. 2006;106:925-945

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Behavioral Treatment Strategies

Monitoring of Diet and Activity Redirection & Give Choices Positive Attention Cue Elimination & Stimulus

Control Limits Setting & Consistency Goal Setting & Action Planning Goal Review Modeling Relapse Prevention

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Summary Recommendations:Individual-and Family-Based

Tertiary Treatment of Pediatric Obesity

Recommendations:

Family-based, multi-component interventions should be routinely recommended

As part of a family-based, multi-component program the following are recommended:

Parent training Dietary counseling/nutrition education Physical Activity Behavioral Counseling

J Am Diet Assoc. 2006;106:925-945

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Summary Recommendations:Individual-and Family-Based

Tertiary Treatment of Pediatric Obesity

Recommendations:

Limited evidence to support routine recommendation of: Individual-based intervention Altered macronutrient approaches Sedentary behaviors alone

Lack of evidence to support any recommendation of: Individual psychotherapy

J Am Diet Assoc. 2006;106:925-945

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A lot can happen in 2 years!

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Clinic-based Studies 1985-2005 Interventions for Childhood

Overweight: Evidence for the US Preventive Services Task Force

Recommendations: Insufficient evidence for the effectiveness of

behavioral counseling or other preventive interventions with overweight children and adolescents that can be conducted in primary care settings or to which primary care physicians can make referrals.

More quality research is needed.

Whitlock, Williams, Gold, et al Pediatrics, 2005

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Evidence-based Recommendations for Physical Activity in School-Age Youth

School-age youth should participate daily in 60 minutes or more of moderate to vigorous physical activity that is:

Developmentally

appropriate Enjoyable Involves a variety

of activities Strong, Malina, Blimkie, et al, J Pediatrics, 2005

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Evidence-based Recommendations for Physical Activity in School-Age Youth – Type

Pre-school Years:General movement activities (jumping, throwing, running, climbing)

Pre-pubertal (6-9 years):More specialized and complex movements, anaerobic (tag, games, recreational sports)

Puberty (10-14 years):Organized sports, skill development

Adolescence (15-18 years)More structured health and fitness activities, refinement of skills

Strong, Malina, Blimkie, et al, J Pediatrics, 2005

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Evidence-based Recommendations for Physical Activity in School-Age Youth

Intensity5 to 8 METs (moderate to vigorous) is need to derive most health benefits, such as active outdoor play, brisk walking, cycling.

DurationA total of 60 minutes per day

Cumulative, not necessarily sustained Frequency

DailyStrong, Malina, Blimkie, et al, J Pediatrics, 2005

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Evidence-based Recommendations for Physical Activity in School-Age Youth - Type

Physically inactive youth: Incremental approach to reach

the 60 minute per day recommendation

Increase activity by 10% per week

Progressing too quickly is counter productive and leads to injury

Strong, Malina, Blimkie, et al, J Pediatrics, 2005

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Evidence-based Recommendations for Exercise in Overweight Youth

Type or ModePlay oriented in younger children

Continuous movement games, exercise machines, swimming, aerobic dance, strength training in older children

Intensity60-80% Max HR (moderate to vigorous)

Duration and Frequency30-50 minutes per session at least 3 days per week

Owens, Handbook of Pediatric Obesity: Clinical Management, 2006

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Physical Activity Studies

2004 Systematic Review and Meta Analysis

645 manually searched, 45 considered, of which 14 studies included (N = 481 overweight boys

and girls, ~12 yrs). Few studies were robust. Recommendations:Aerobic exercise of 155-180 min/weeks at

moderate-to-high intensity is effective for reducing body fat in overweigh youth.

Effects on body weight and central obesity are inconclusive.

Atlantis, et al, Int’l J Ob, 2006

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Strength Training Improves Lean Muscle

and Bone Mineral Content

Obese, prepubertal children ~ 10 yrs; randomized toDiet alone (n = 41) (control group). Diet plus strength training (n = 41) (training group)

75-minute strength exercise 3 times/wk

After 6 weeks, the children in the training group showed significantly larger increases in:

Lean body mass (+ 0.8 kg [2.4%] vs. +0.3 kg [1.0%], p < 0.05) than control group Total bone mineral content (+46.9 g [3.9%] vs. +33.6

g [2.9%], p < 0.05) than control groupYu, et al, J Strength Cond Res, 2005

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Level AgePhysical Activity Approach

67-18

7-18

7-18

Initial Physical Activity Strategies by Medical History, Age & Weight Condition

Normal WtObese Parent

>85thBMI

>95thBMI

>99th

BMI

Family counseling, fitness education, free play, reduce TV, parent training

Structured weight bearing activities, free play, reduce TV, parent training

Alternate non-weight bearing activities, free play, reduce TV, parent training

*Non-weight bearing activities, free play, reduce TV, parent training

*Close medical supervision required.

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Summary: First ADA position paper— to draw its conclusions

from an extensive review of the literature

to use evidence analysis approach

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Benefits of this new approach

Provides more rigorous standardization of review criteria

Minimizes the likelihood of reviewer bias

Increases the ease with which disparate articles may be compared

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First ADA position paper on pediatric overweight intervention at each level:

Individual- Family- School- Community

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Media

Legislation

Developed by Center for Weight and Health, UC Berkeley

Levels for Childhood Obesity Prevention

Urban Design &Transportation Systems

Food Supply

Schools

Healthcare System

TheChild

Home & Family

Community

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First position paper to include 3 types of intervention Tertiary

Slow down or reverse the increase in BMI and to prevent the complications of overweight

Secondary Identification and intervention of asymptomatic

children who are at risk for overweight Primary

Prevention efforts occurring before individuals are overweight

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Evidence grades Grade I: Good – evidence is consistent

from studies of strong design Grade II: Fair – Evidence from studies of

strong design is not always consistent or evidence is consistent but based on studies of weaker design

Grade III: Limited – evidence from a limited number of studies

Grade IV: Expert Opinion Only – no or limited studies but based on expertise

Grade V: Not Assignable – no studiesc enter fo r

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Key results

Multicomponent family-based tertiary prevention programs for children ages 5 to 12 years – Grade I

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Components of individual and family based intervention

PhysicalActivity

Diet CounselNutr. Ed.

Behavioral Counseling

Parent Training

TertiaryPrevention

Adiposity Outcomes

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Key results

Multicomponent school-based primary prevention programs for adolescents – Grade II

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Components of School Based Intervention

Family Environment

SedentaryBehaviors (TV/video)

PA Education

PA Environ

PrimaryPrevention

Adiposity Outcomes

Nutrition Education

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An added bonus…

School-based Interventions at all grade levels have shown effectiveness in changing student knowledge, attitudes, and behaviors around food and activity

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Dietetic professionals may use this position paper to educate:

• Overweight interventions are more efficacious with young children 6-12 than older children.

• Children can decrease their adiposity without weight loss by maintaining or stabilizing weight over time.

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• Schools based interventions can be efficacious for adolescents.

• Community based and environmental interventions must be developed and evaluated. They have the capacity to reach the greatest number of children and their families.

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Body weight is an imprecise surrogate. Concrete and actionable indicators appropriate for interventions are:• dietary intake/nutritional status;• physical and sedentary activity levels;• self-esteem, body image, and other psychological

markers of health;• blood pressure;• blood lipids; and• blood glucose concentration.

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Practitioners can use the position statement to:

Synthesize the literature Educate others Design interventions Obtain support Justify programs

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and to write grants and advocate for needed research in the areas of: Community-based programs, including

studies of the impact of changes in the built environment, marketing, and policy on children’s eating and physical activity patterns

Intervention studies in ethnically diverse populations

Intervention programs with adolescents

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