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
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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.
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J Am Diet Assoc.
2006;106:925-945
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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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
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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
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J Am Diet Assoc.
Treatment of Overweight Conditions
in Childhood
Pediatrician
Behavioral
Counseling
Family
Nutrition
Education
Exercise and
physical activity
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Multi-Disciplinary Weight Management
Sample Class Schedule
Medicine
Nutrition
Behavior
Exercise
Return Calls
Set-up
4:00-4:30
4:30-4:50
Nurse
Supervises
Weigh-In
Check Food
Records
Talk with
Parents Review
Charts
Check Exercise
Cards
4:50-5:10
Group
Group
Group
Group
Review Charts
Behavior
Session
Return Calls
Review Charts
Review Charts
Return Calls
5:30-6:00
Physician Q&A
or Session
Clean-up
Nutrition
Session
Set-up Exercise
Clean-up
6:00-6:30
Physician Q&A
or Session
Exercise
Session
6:30-7:00
Clean-up
5:10-5:30
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.
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American Academy of Pediatrics. Pediatrics. 2003;112(2):424-430.
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
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J Am Diet Assoc.
What is the
best type
of physical
activity for
overweight
children?
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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.
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American Academy of Pediatrics. Pediatrics. 2003;112(2):424-430.
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)
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J Am Diet Assoc.Jump
2006;106:925-945
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
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J Am Diet Assoc.
2006;106:925-945
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, multicomponent program the following are
recommended:
 Parent training
 Dietary counseling/nutrition education
 Physical Activity
 Behavioral Counseling
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J Am Diet Assoc. 2006;106:925-945
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
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J Am Diet Assoc. 2006;106:925-945
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.
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Whitlock, Williams, Gold, et alJump
Pediatrics,
2005
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
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Strong, Malina, Blimkie, et al,
J Pediatrics,
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,JumpJ Pediatrics,
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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
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Strong, Malina, Blimkie, et al,
J Pediatrics,
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
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Strong, Malina, Blimkie, et al,
J Pediatrics,
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
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Owens, Handbook of Pediatric Obesity: Clinical
Management,
2006
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.
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to Ob,
first page
Atlantis, et al, Int’l
2006
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
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to firstRes,
page 2005
Yu, et al, J Strength
Cond
Initial Physical Activity Strategies by
Medical History, Age & Weight Condition
Level Age Physical Activity Approach
Normal Wt
Obese Parent
6
Family counseling, fitness education, free
play, reduce TV, parent training
>85th
BMI
Structured weight bearing activities, free
7-18 play, reduce TV, parent training
>95th
BMI
Alternate non-weight bearing activities, free
7-18 play, reduce TV, parent training
>99th
BMI
7-18
*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
c
enter for
eight &
ealth
h
University
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to firstof California,
page Berkeley
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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Levels for Childhood Obesity Prevention
Legislation
Media
Urban Design &
Transportation Systems
Food Supply
Community
Healthcare System
Schools
Home
& Family
The
Child
c
enter for
eight &
ealth
h
Developed by Center for Weight and
Health, UC Berkeley
University
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page 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
c
enter for
eight &
ealth
h
University
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page Berkeley
Evidence grades
c
 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
enter for
eight &
ealth
h
University
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Key results
Multicomponent family-based tertiary
prevention programs for children
ages 5 to 12 years – Grade I
c
enter for
eight &
ealth
h
University
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page Berkeley
Components of individual and family
based intervention
Behavioral
Counseling
Physical
Activity
Tertiary
Prevention
Diet Counsel
Nutr. Ed.
Parent
Training
Adiposity Outcomes
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Key results
Multicomponent school-based
primary prevention programs for
adolescents – Grade II
c
enter for
eight &
ealth
h
University
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Components of School Based
Intervention
Nutrition
Education
Family
Environment
PA Education
Primary
Prevention
Sedentary
Behaviors
(TV/video)
PA Environ
Adiposity Outcomes
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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
c
enter for
eight &
ealth
h
University
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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
c
enter for
eight &
ealth
h
University
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to firstof California,
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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
c
enter for
eight &
ealth
h
University
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www.adaevidencelibrary.com/
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