What Dietitians Can Do about Pediatric Overweight
Position of the ADA
--Introduction, Methods, and Schooland Community-based Interventions-Pediatric Weight Management Teleconference
November 14 & 17, 2006
Lorrene D. Ritchie, PhD, RD1
Deanna M. Hoelscher, PhD, RD2
Melinda S. Sothern, PhD3
Patricia B. Crawford, DrPH, RD1
1
Center for Weight and Health, UC Berkeley
2 Michael & Susan Dell Center for Advancement of
Healthy Living, Univ of Texas School of PH
3 Louisiana State Univ Health Science Center
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Outline
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Why this topic?
What was done?
What was found?
 Community-based
interventions (1º prevention)
 School-based interventions (1º & 2º prevention)
 Individual- and Family-based interventions
(3º prevention)

What was recommended?
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Main Objective:
Describe recommended
approaches for overweight
prevention and treatment
in children
www.adaevidencelibrary.com
J Am Diet Assoc. 2006;106:925-45
Tables at www.eatright.org/ada/Appendices_A-B-C.pdf
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Dietitians Integral
to Intervention Efforts
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Leadership role in both
prevention and treatment
programs
Rely on empirical
evidence from research
studies to inform best
practices
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Childhood Overweight is Increasing at a
Staggering Pace
20
15
1963-70
1971-74
1976-80
1988-94
1999-2002
Percent
10
5
0
2-5 Years
6-11 Years
12-19 Years
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High blood
pressure
Dyslipidemia
Tracking of
Overwt
Psychosocial
problems
Advanced
maturation
Insulin
resistance
Health
Concerns
Joint/bone
stress
Breathing
difficulties
GI
problems
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Obesity Related Annual Hospital Costs
for Youth
(in millions of dollars)
$140
$120
$100
$80
$60
$40
$20
$0
1979-81
1997-99
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As overweight among children tripled…
“Do no harm”
What to do first?
What has
been tried?
What works?
How old should
child be?
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ADA Evidence Analysis
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Since 2000, evidence-based approach used
to develop clinical practice guidelines for
nutrition care
This is first of new position papers developed
using ADA’s EA protocols
Maintain an ADA Evidence Analysis Library
website (http://www.adaevidencelibrary.com)
Method overview paper in JADA coming soon
Evidence-based practice guide on pediatric
weight coming soon
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Steps in Evidence Analysis
1)
2)
3)
4)
5)
Select the evidence analysis project team
Formulate the problem as a question
Search for and identify relevant evidence
Analyze and evaluate evidence
Formulate and evaluate the strength of
summary and conclusion statements
6) Develop recommendations
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Steps in Evidence Analysis
1) Select the evidence analysis project team
2) Formulate the problem as a question
3) Search for and identify relevant
evidence
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Selection Criteria for Studies

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Studies published 1982 – 2004
Identified using Pubmed, other primary research
articles, or literature reviews

English language

Involving children (2-12 y) &/or teens (13-18 y)

Healthy population

Intervention studies only

1º, 2º, or 3º prevention

Any design (RCT, non-randomized, non-controlled)

Included outcome measure of adiposity
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Exclusion Criteria for Studies
 Conducted in developing country
 Published in journal/books not peer-reviewed
 No outcome measure of adiposity
 Involving exclusively children <2 y or teens >18 y
 3º prevention trials:
 < 8 wk duration (not including follow-up)
 < 30 subjects total (or <15 in intervention group)
 Involving surgery or medications
 1º/2º prevention trials:
 < 6 mo duration (not including follow-up)
 < 60 subjects total (or <30 in intervention group)
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Steps in Evidence Analysis
1)
2)
3)
4)
Select the evidence analysis project team
Formulate the problem as a question
Search for and identify relevant evidence
Analyze and evaluate evidence
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Abstraction of Studies
 Study Design/Class
 Inclusion Criteria
 Exclusion Criteria
 Study Protocol
 Recruitment methods
 Blinding used
 Intervention
 Study protocol
 Statistical analysis
 Data Collection
 Variables
 Timing
 Study Population
 Sample size
 Demographics
 Location
 Results
 Author Conclusion
 Reviewer Comments
 Strengths
 Weaknesses
 Quality Rating
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Rating Study Quality
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Research question clear?
Selection of subjects free from bias?
Study groups comparable?
Withdrawals?
Blinding?
Intervention described in detail?
Outcomes clearly defined?
Measurements valid and reliable?
Statistical analysis appropriate?
Conclusions supported by results?
Funding or sponsorship?
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Categorization of Studies
Unit of Intervention

Community-based

School-based

Family-based

Individual-based
44 - 1º/2º
prevention trials
44 - 3º
prevention trials
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Steps in Evidence Analysis
1)
2)
3)
4)
Select the evidence analysis project team
Formulate the problem as a question
Search for and identify relevant evidence
Analyze and evaluate the evidence
5) Formulate and evaluate the
strength of summary and
conclusion statements
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Grading Conclusion Statements
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
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Steps in Evidence Analysis
1)
2)
3)
4)
5)
Select the evidence analysis project team
Formulate the problem as a question
Search for and identify relevant evidence
Analyze and evaluate the evidence
Formulate and evaluate the strength of
summary and conclusion statements
6) Develop recommendations
Intervention
Type or Component
Recommendation
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Community-Based Interventions:
Definition

Goal of intervention:
Overweight prevention
 Include outcome adiposity measure
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
Methods of behavior change:
Policy
 Social marketing
 Environmental change
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Targets of intervention:
Members of certain community groups (ad hoc or formal)
 Community members at large
 Excluding schools

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Community-Based Interventions:
What was Found
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Many community-based
interventions
BUT not designed for
overweight prevention
and/or adiposity
measures not included
Adults only

Youth included

Reviews
EXAMPLES:
Minnesota Heart Health Program (Kelder,
1993;1995)
Pawtucket Heart Health Program (Carleton,
1995)
Salud para su Corazon project (Alcalay,
1999)
Sandy Lake Health and Diabetes Project
(Hanley, 1995)
Stanford Five-City Project (Farquhar, 1990)
EXAMPLES:
CardioVision 2002 (Kottke, 2000)
FitWIC (Crawford, 2004)
Hearts N’ Parks (Moody, 2004)
EXAMPLES:
Communities
of color (Yancey, 2004)
Physical activity (King, 1998)
Nutrition and PA in youth (Pate, 2000)
Food marketing to children (IOM, 2006)
Social marketing campaigns (Alcalay, 2000)
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Community-Based Interventions:
What was Found
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Community interventions are feasible
Can alter eating and physical activity behaviors
Only ONE included adiposity outcome in ADULTS:
Heart to Heart Project (Goodman, 1995)
1986-1990
 Aim to reduce CVD risk
 ≈600 community activities
 Change in overweight: +0.3% in intervention vs. +3.2%
in control community (P=0.0002)
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Several other interventions underway, but results
not yet available
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Community-Based Interventions:
Recommendation
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(Evidence Grade IV)
Research priority: communitybased programs, including studies
of built environment, marketing and
policy on children’s eating and
physical activity patterns
Intervention: although not yet
evidence-based, community-based
interventions recommended as
among the most feasible ways to
support healthful lifestyles for
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greatest numbers
Overview of School-based Studies
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44 total papers identified
 37
were primary prevention
 23 were RCT
 14 were studies of other design
 7 were secondary prevention
 Targeted high-risk students through the school setting
 1 was RCT
 Several articles described the same study & so were
combined for the evidence analysis (final n = 28 studies)
 CATCH, SPARK, Know Your Body New York,
Washington, Crete, Zuni Diabetes Prevention
Program
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Primary Prevention Studies
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Multi-component programs
 Evidence
Grade II (Fair)
Include multiple coordinated units, with both
nutrition and physical activity
Examples of studies with positive effects:
• Vandogen, 1995;
• Sallis, 2003 (M-SPAN);
• Gortmaker, 1999 (Planet Health);
• Killen, 1989;
• Muller, 2001 (KOPS);
• Manios, 1999 (Know Your Body in Crete)
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Primary Prevention Studies

Behavioral Counseling
 Evidence
Grade II (Fair)
 Use
of theory to change individual
health behaviors
 Social Cognitive Theory was most
widely used, as it incorporates
individual and environmental level
constructs
 Often see changes in behavioral
constructs prior to actual
behavioral change
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Primary Prevention Studies
Nutrition Education
 Evidence
Grade II (Fair)
 In
most studies, nutrition ed.
and dose were not described
 Most were combined with
multi-component programs
Physical Activity Education

Evidence Grade II (Fair)
Included in most multi-component programs
 One study showed a total of 1 ¼ hours of physical
activity/school day compared with 3 ½-hour
periods/week
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 Optimal level of PA not known

Primary Prevention Studies
Physical Activity Environment

Evidence Grade II (Fair)
Includes increasing PA opportunities
or restructuring PE classes
 Most linked with PA education programs

Sedentary Behaviors

Evidence Grade II (Fair)
Targeted TV and video watching
 Strong studies, but few

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Evidence Grade V (Lack Evidence)

No studies on sedentary activities such as homework,
reading or computer use
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Primary Prevention Studies
Parent/family involvement
 Evidence
Grade II (Fair)
 Generally
not well described
 Dose was difficult to determine
Delivery of program: Grade level
 Evidence
Grade II (Fair)
 Although
successful programs were seen at
both elementary and secondary levels, a
greater percentage of secondary school
prevention studies (71%) found effects
compared to elementary level studies (33%)
 No preschool-age trials
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Primary Prevention Studies
Media influences
 Evidence
Grade III (Limited)
 TV
or video watching time was
targeted, but not other forms of
influence
(e.g., commercials, ads, etc.)
School food environment
 Evidence
Grade III (Limited)
 Usually
linked with nutrition education
 Most studies have looked at nutrient
intake rather than body size as an
outcome
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Primary Prevention Studies
Delivery of program: Individual versus multi
component
 Evidence
Grade III (Limited)
 Virtually
none of the studies were conducted in way that
effectiveness of individual components could be
compared
 Coordinated multi-component programs are effective,
but which components are most effective is not known
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Primary Prevention Studies
Delivery of program: Personnel
 Evidence
Grade V (Lack Evidence)
 No
comparison of teacher-delivery
versus study personnel delivery
Delivery of program: Length of time
 Evidence
Grade V (Lack Evidence)
 No
study that examined optimum length of
time—varied from few months to years
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Key results
Multicomponent school-based
primary prevention programs are
effective, particularly for
adolescents
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Added bonus:
School-based interventions are effective in
changing student knowledge, attitudes, and
behaviors around food and activity.
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Recommended Components of SchoolBased Interventions
Nutrition
Education
Family
Environment
PA Education/
Environment
Primary
Prevention
Sedentary
Behaviors
(TV/video)
c
Behavioral
Counseling
Adiposity Outcomes
enter for
eight &
ealth
h
University
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to firstof California,
page Berkeley
Summary and Recommendations for
School-Based Programs –
Primary Prevention
Of the large number of school-based studies
About half are strong design
About half showed positive effects on body size
Fewer secondary school studies
May be more difficult to conduct
More likely to show effects
Why so many non-significant studies?
 Relatively
low prevalence of overweight at time study
was conducted (prior to mid-1990’s)
 Inadequate dose or length of intervention
 Lack of standardized definition of child overweight
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Summary and Recommendations for
School-Based Programs –
Primary Prevention

Future studies
 Optimal
dose and duration of intervention
 Most effective mode of delivery
 How program elements can be tailored to
meet needs of various age, cultural and SES
groups
 Replication of successful programs
in other high-need groups
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Secondary Prevention Studies

All but one of seven studies saw a significant
effect on some measure of adiposity
 Evidence
grade III (Limited Evidence)
 Only
one was a RCT
 One targeted junior high; two additional studies
targeted children of multiple ages
 4 were conducted outside the U.S., one was a
parochial school, and 2 were U.S. public schools
 Did not address effects of stigmatizing children in
these studies
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Summary and Recommendations for
School-Based Programs –
Secondary Prevention
 As effective or more effective than primary
prevention studies
 Contraindications for implementation:
Increasing rates of overweight
Stigmatization of children
 Recommended approach:
Secondary prevention within a primary
prevention program for all children
Conduct population-level program, but base
outcome on high-risk population.
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Conclusions:
Critical to Prevention Interventions
Early & often
 Long-term
 Family involved
 Specific behaviors targeted
 Comprehensive & multi-component
 Community-wide
 Environmental emphasis

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Contact Information
Lorrene Davis Ritchie
Director of Research
Center for Weight and Health
9 Morgan Hall
University of California
Berkeley, CA 94720
Lorrene_Ritchie@sbcglobal.net
www.cnr.berkeley.edu/cwh
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