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

1. Tertiary Prevention of Pediatric Obesity: Individual-Family-Based Interventions Melinda S. Sothern, PhD Director, Section of Health Promotion School of Public Health Louisiana State University (LSU) Health Sciences Center Childhood Obesity Laboratory LSU Pennington Biomedical Research Center

2. What should I do to help my overweight patient?

3. 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

4. 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

5. Childhood Obesity Treatment Long-term Studies Authors Age Intervention Outcome Epstein 6-12 Parent/child -19.7% @ 10 yrs Braet 9-12 Behavioral vs advice -17.3 @ 4.5 yrs. Nuutinen 6-15 Group vs Individual -11.7% @ 5 yrs. Epstein 6-12 Parental obesity NS @ 10 yrs Epstein 6-12 Exercise + diet NS @ 10 yrs Epstein 6-12 Lifestyle exercise -15.3% @ 10 yrs

6. 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

7. Treatment of Overweight Conditions in Childhood Pediatrician Family Behavioral Counseling Nutrition Education Exercise and physical activity

8. Multi-Disciplinary Weight Management Sample Class Schedule

9. What is the Best Dietary Approach for Treating Overweight Children?

10. Recommendations from the American Academy of PediatricsHealth supervision (Nutrition) • Encourage,support, and protect breastfeeding. • Encourage parents andcaregivers to promote healthy eating patternsby offering nutritioussnacks, such as vegetables and fruits,low-fat dairy foods,and whole grains; encouraging children’sautonomy in self-regulationof food intake and setting appropriatelimits on choices; andmodeling healthy food choices. American Academy of Pediatrics. Pediatrics. 2003;112(2):424-430.

11. 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

12. What is the best type of physical activity for overweight children?

13. Recommendations from the American Academy of PediatricsHealth 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.

14. 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

15. 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

16. 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

17. 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

18. 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

19. A lot can happen in 2 years!

20. 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

21. 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

22. 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

23. Evidence-based Recommendations for Physical Activity in School-Age Youth • Intensity 5 to 8 METs (moderate to vigorous) is need to derive most health benefits, such as active outdoor play, brisk walking, cycling. • Duration A total of 60 minutes per day Cumulative, not necessarily sustained • Frequency Daily Strong, Malina, Blimkie, et al, J Pediatrics, 2005

24. 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

25. Evidence-based Recommendations for Exercise in Overweight Youth • Type or Mode Play oriented in younger children Continuous movement games, exercise machines, swimming, aerobic dance, strength training in older children • Intensity 60-80% Max HR (moderate to vigorous) • Duration and Frequency 30-50 minutes per session at least 3 days per week Owens, Handbook of Pediatric Obesity: Clinical Management, 2006

26. 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

27. Strength Training Improves Lean Muscle and Bone Mineral Content • Obese, prepubertal children ~ 10 yrs; randomized to • Diet 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 group Yu, et al, J Strength Cond Res, 2005

28. Initial Physical ActivityStrategies by Medical History, Age & Weight Condition Level Age Physical Activity Approach Family counseling, fitness education, free play, reduce TV, parent training Normal Wt Obese Parent  6 Structured weight bearing activities, free play, reduce TV, parent training >85th BMI 7-18 Alternate non-weight bearing activities, free play, reduce TV, parent training >95th BMI 7-18 >99th BMI *Non-weight bearing activities, free play, reduce TV, parent training 7-18 *Close medical supervision required.

29. University of California, Berkeley Summary: First ADA position paper— • to draw its conclusions from an extensive review of the literature • to use evidence analysis approach

30. 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

31. First ADA position paper on pediatric overweight intervention at each level: • Individual- • Family- • School- • Community

32. University of California, Berkeley Levels for Childhood Obesity Prevention Legislation Media Urban Design & Transportation Systems Food Supply Community Healthcare System Schools Home & Family The Child Developed by Center for Weight and Health, UC Berkeley

33. University of California, Berkeley 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

34. University of California, Berkeley 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 studies

35. University of California, Berkeley Key results Multicomponent family-based tertiary prevention programs for children ages 5 to 12 years – Grade I

36. Components of individual and family based intervention Behavioral Counseling Physical Activity Tertiary Prevention Diet Counsel Nutr. Ed. Parent Training Adiposity Outcomes

37. University of California, Berkeley Key results Multicomponent school-based primary prevention programs for adolescents – Grade II

38. Components of School Based Intervention Nutrition Education Family Environment PA Education Primary Prevention PA Environ Sedentary Behaviors (TV/video) Adiposity Outcomes

39. University of California, Berkeley An added bonus… School-based Interventions at all grade levels have shown effectiveness in changing student knowledge, attitudes, and behaviors around food and activity

40. 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.

41. 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.

42. 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.

43. University of California, Berkeley Practitioners can use the position statement to: • Synthesize the literature • Educate others • Design interventions • Obtain support • Justify programs

44. University of California, Berkeley 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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