2480.pdf

Interventions to Prevent and Treat Childhood

Obesity:

A Systematic Review

By

Tamaurus

J.

Sutton

A Master's Paper submitted to the faculty of

The University of North Carolina at Chapel Hill

In partial fulfillment of the requirements for

The degree of Master of Public Health in

The Public Health Leadership Program.

Chapel Hill

Introduction

Overweight and obesity are chronic conditions, and over the last decade

many groups of people have been affected by these problems. Both developed

countries, including the United States, Canada, and Europe, and underdeveloped

areas, including parts of Latin America, Africa, and Asia have seen drastic and

continual increases in obesity and overweight, and in many places they now have

reached epidemic proportions (1). This epidemic has affects all ages, almost all

ethnic groups, and people of every socioeconomic status, though often in

disproportionate ways (2).

This paper reviews the prevalence of overweight and obesity in the U.S.,

discusses adverse health and psychosocial outcomes, and reviews the

effectiveness of various interventions in preventing and treating childhood

overweight and/or obesity. A previous systematic review conducted on this topic

by Summerbell et al in 2003 (3) concluded that there is limited data on the

effectiveness of obesity prevention and treatment programs and no generalizable

conclusions can be drawn from the studies to date.

Thus, a new review examining this topic is needed for several reasons.

One, the Summerbell et al. review was last updated in January of 2002. Also, the

Summerbell et al review included all children from age 0 to 18 years, which is a

very wide age range. In this review, I have narrowed the age range to 6 to 12

years to include only elementary

j

t-school aged children because I feel that children are easier to reach at this age for

the following reasons: 1) they all are required by law to go to school, and 2)

younger children are often more accepting of change than teenagers. However,

the most important reason for doing another systematic review is that childhood

overweight/obesity is huge problem and we need to find an answer to this

question.

Childhood Overweight/Obesity

Defining Obesity/Overweight

In children, overweight and obesity are determined by using BMI growth

charts. Overweight is defined as BMI greater than the 85th percentile of normal

BMI, and obesity is defined as a BMI greater than the 95th percentile of normal

BMI (Appendix 1) (4).

The BMI growth charts consist of a series of percentile curves that

illustrate the distribution of selected body measurements in U.S. children.

Percentiles are the most commonly used indicator to asses size and growth

~

}--patterns of individual children. Percentiles rank the position of an individual by

indicating what percent of the reference population the individual would equal or

exceed. The charts were first developed in 1977 by the National Center for

Health Statistics as a clinical tool for health care providers to determine if the

growth of a child is adequate. The 2000 CDC growth charts represent the revised

version of the 1977 NCHS growth charts. The data used to construct these charts

comes from the National Health and Nutrition Examination Survey (NHANES),

American population since the early 1960's (5). Because this data was collected

mainly from those persons seeking routine health care, it may not be

representative of those groups not seeking routine health care.

Prevalence of Overweight/Obesity

The percent of overweight or obese children in the US has nearly tripled

over the last two decades, with absolute numbers currently well over 9 million

(6). The increases in prevalence of overweight and obesity are constant across

racial and ethnic groups, and both genders. Today, approximately 15% of children

in the US are overweight or obese (Table 1) (7) according to numbers from the

latest NHANES data.

·:rabie'i; ·o:;e~eigbt -chiidren and·a·ttOkSceuts ~19 years or'a·ge, aromting to sex. age. a·~d'iiispanic origiilinuniiect States. seifi:-tetfYearS

I96j.6S·u.·rou·gh-I.

1999-2000

Age, se~t, race, and Hispanic origin

I

i963-65 1966-70 1971-74

I

1976-80

r

1988-94

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1999-2000

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6-11 years of uge I Perc~t;i of Population (St~ard ~rro~) _I.

Both-~~d~-- _I 4.2 I 4.0 I 6.5 l 11.3 (1.0) I 1s.J o:7) I

!loY' _i 4.0 I 4.3 I 6.6 I 11.6(1.3) _l 16.0 (2.3) _I

\.Vrnte I 44 I 4.1 I 6.7 I 11.3(1.7) _{I I}

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I L6 I 5.3 _I 6.7 _I Ji.'3 {1.4) _{I I}

White, n;n~Hi;punic _{I I I} 6.1 I Jb?J (z:O} I i2.0'(3.0) I

BlOCk, ixui~HisP:mic _I I I 6.8 _I 12.3 (1.4) _I n: ,-(2.7)" _I

Mexican _I .. I I 13.3 I ··11:s ciAJ .T -iiJ·d:n I

Gkls _I 4.5 _I 3.6 _I 6.4 I 1\.0(1.4) T 14.5(2.4) _I

White I '4.5 I 3.7 _I 5.7 _J 9.8(!.'7)'' _I j

Block _I 4.5 I 3.3 I 11.1 _I 16.7 (1.5) _I I"

White, ooU-Hi~Pani~-- _I I I 5.2 I 9.8(2.0) _I I

at:ick-r10n-Hisj,'~c _{I I I} 11.2 I I7.od.6} T 2i:f('3.3) I

Md~icmi I. _{I I} 9.8 I 15.3 (2.5) _I 19.6 (3. \) _I

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Boys _I 4.5 I 6.1 I 4.8 _I li:3ct.3-> 15:5'(£.6) _I

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BJa'ck _I .. 3.1 I j'j I 6:"i' I . w.4~ci.4) _I I

white~ ·;;;:;~-Hisranic _{I I I} 38 I '1'(6'(1:9) _I 12:8 (2:4)' _I Block, non-Hispani~ _{I I I} 6.1 l 10.7 (1.4) _I 20.7 (2.6) _I Mellican _{I I I} 7.7 _I 14.1 (1.8) _I 27.5 (3.0) _I Girls I 4.7 I 6.2 I 5.3 I. 9.7 (1.1) _I 'i"S."s'(\.66 I White j 4.5 I 5.4 I• 4.5 _J 9.'o.(t~i) _{I J}

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I M _I 10.1 _I \0.7 _I 16.3 (2.0) _{I I}

Consequences of Overweight/Obesity

Adverse Health Outcomes

Some of the conditions, once only thought to occur in adulthood, are now

starting to appear in America's children (Figure 1). Type 2 diabetes, once

practically unrecognized in adolescence, has seen a 10-fold increase in incidence

since 1982 (2,4). The emergence of type 2 diabetes in children represents an

ominous development given the disease's macro-vascular (heart attack, stroke,

amputation) and micro-vascular (kidney failure, blindness) complications (2).

Moreover, research done by the American Academy of Pediatrics

indicates that nearly 1 million American children suffer from a condition called

metabolic syndrome, which includes excessive abdominal fat, high blood

pressure, high trigylceride levels, low HDL levels, and high blood sugar (4).

These are all proven risk factors for heart disease in adults. According to former

Surgeon General Dr. David Satcher, Americans will risk nullifying some of the

gains made in the treatment of heart disease, cancer, hypertension, and other

chronic health problems if we fail to confront the health problems caused by

obesity (1).

Adverse Psychosocial Outcomes

Among children, obesity is one of the most stigmatizing and least

acceptable conditions. Obese children are stereotyped as unhealthy, academically

unsuccessful, socially inept, unhygienic, and lazy (2). In a decent study by

Schwimmer, Burwinkle, and Varni (4), obese children were found to be 5.9 times

I

l ;

"---more likely to self-report impairment in psychosocial health than normal weight

children. The most immediate consequence of overweight and obesity, as

perceived by children themselves, is social discrimination. This discrimination

often leads to low self-esteem and depression (Figure 1)(4).

Figure 1: Consequences of Childhood Obesity, Taken from ref 8

Psychosocla!H·1°

POOl selfest.o-em

-+

DepresSion

Eating dlsc,ders

Sleep apnoea Asthma Exercise rnt~erance

Gallstooes Steatohepatitis

Slipped capital femoral epiphysis Blount"s disease Forearm fracture Rat feet

CardlovaMular10-N Oyslipi~mia

Hyperle.nsion Coagulopalhj Chronic Inflammation Endothelial dysfunction

Endocrinetl Yi

Type 2 diabetes Precocious puberty

Polycystic 01~ry syndrome (girls! flypogonadrsm (boys)

Relationship Between Childhood and Adult Obesity

Tracking

Obesity in childhood is a significant predictor of obesity in adulthood and

adolescent obesity is a better predictor than obesity at earlier ages (9).

Overweight adolescents have a 70% chance of becoming overweight or obese

or obese (10-12). Several studies have validated these findings. A good study

conducted by Whitaker et al showed that the odds ratio for obesity in adulthood

associated with childhood obesity

~

Onos &\nos !OR OBm n< YoUNG ADuLTHooD

ranged from 1.3 for obesity at ages ~JNG m SuBJEcm' OBES!I'I S'rArus JN CHilDHooD

AND TllEIR PAlilliiS' OBES!I'I S'rA"IUS, !ROM MUL1lVAR!A1!

1 to 2 to 17.5 for obesity at age 15 Lommc-REG=oN Monru.'

to 17. All of these numbers

increased for children with one or

more obese parents (Table 2)(13).

Moreover, the human gene

map has identified over 300 genes,

markers, and chromosomal regions

that are associated with human

obesity (14). What complicates this

AGE(ml 1-J 3-5 6-9 10-14 15-17 Sl8.ECT OBESE }.SA.CIILD YESVS.lfO

No. oF OsEsE PJJlENrs

lvs.O lvs.O

odd~ ratio (95% confidence interval)

1.3 (0.6-3.0) 4.7(25-3.3) 3.3(47-16.5) 22.3 (10.5-47.1) 17.5(77-39.5)

31(12-5.7) 13.6 (3.7-50.4) 3.0(17-5.3) 15.3 (5.7-41.3) 2.6(1.4-4.6) 5.0 (2.1-ll.l) 22(!1-3.3) J.O (0.3-5.2) Jl(ll-4.3) 5.6 (25-12.4) *Young -adulthood was defined as 21 to 29 yem of ~e. The v31'iables induded in the model wm childhood obecity tatus (obese or not obese) md the number of obe!>e puents (0, 1, or 2). See the Methods seaion for

m explm<tion of adjusnnents for iblings.

issue even more is the fact that the genes relevant for weight regulation are not the

same throughout life (15). According to a large longitudinal twin study, only 40%

of the genetic factors that influence BMl at age 20 continue to do so at age 48

(16). Despite these recent advances in genetics, these genes have only been

proven to be responsible for only a small proportion of human cases of obesity

(17).

Individuals become obese as a result of a unique mixture of inherited

genes that confers susceptibility and years of complex interaction with an

environment that is increasingly more "obesigenic." In other words, certain

environmental factors are needed in order for genes conferring for obesity to be

I

I

i---expressed. In conclusion, since manipulating the environment is currently easier

than altering genetic make-up, we will not discuss genetics any further for the

time being.

Consequences of Overweight/Obesity in Adults

Obesity and overweight are chronic conditions that bring serious risk.

Health risks are better established for obese persons than for overweight persons;

however, overweight status carries

~

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some risk (8). The observed 0

Cl 0

~

.

relationship between body mass index

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0

>

-~

•

and mortality has been described as J- ~

shaped or U-shaped with higher

mortality as a result of underweight,

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overweight, and obesity (Figure 2) ;; >

Cl

0

~

(18,19). •

"'

0

.~

"

Using data from the CDC's

-.

~

1999 and 2000 National Health and

Nutrition Examination Surveys

3.2 3.0 2.8 2.6 2.4 2.2 2.0 1.8 1.6 1.4 1.2 1.0 0.8 0.6 2.4 2.2 2.0 1.8 1.6 1.4 1.2 1.0 0.8 0.6 Men Cardiovascular diseast> - - Canc<>r

- Ai! o!har causes

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Women

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Body-Mass Index

Figure 2: Taken from ref 20

rnrVf~S for ~rlnlts

(NHANES), the American Obesity Association estimates that obesity is a

contributing factor in 300,000 to 400,000 deaths per year and obesity-related

problems account for around 62 million doctors' visits per year (Table 3) (1).

Given the similarity of these numbers to the numbers obtained in six major

population-based studies using hazard ratios to compute annual deaths, the

County Health Study, the estimated number of overweight-attributable deaths in

2000 was 567,683; Framingham Heart Study, 543,981; Tecumesh Community

Health Study, 462,005; American Cancer Society Cancer Prevention Study,

451,708; Nurses Health Study, 504,602; and the National Health and Nutrition

Examination Survey I Epidemiologic Follow-up Study, 439,548 (21,22).

Table 3 • Actual Causes of Death in the United States in 1990 and 2000

Actual Cause No. (%) in 1990* No. (%) in 2000

Tobacco 400000 (19) 435000 (18.1)

Poor diet and physical inactivity 3000CO (14) 400 000 (16.6)

100000 (5] 85000 (3.5)

Ml'crobial 90000 75000

Toxic agents 60000 (3) 55000 (2.3)

Motor vshicle 25000 (1) 43000 (1.8)

Firearms 350CO (2) 29000 (1.2)

Sexual behavior 30000 (1) 20000 (0.8)

Illicit drug use 20000 (<1) 17000 (0.7)

Total 1 060 000 (50) 1159 000 (48.2)

Obesity is associated with heart disease, diabetes, cancer, breathing

problems, arthritis, reproductive complications, and many other health

complications (18). Over 80% of people with diabetes are obese. There is an

approximately 10% increase in the risk for developing arthritis for every 2-pound

increase in weight over normal body weight. Obesity during pregnancy is

associated with high rates of Cesarean section delivery, increased risk of

gestational diabetes, and increased risk of birth defects, namely neural tube

defects (10-12).

The most recent estimated health care cost of obesity in the US is in

excess of $115 billion dollars per year (10-12). In addition, it is estimated that

weight loss programs (1). Obesity also has several non-monetary costs. Perhaps

one of the largest of these costs is missed workdays. According to Spence-Jones,

the National Task Force for the Prevention and Treatment of Obesity noted that

there are 39.3 million missed workdays related to obesity each year (1).

Purpose of the Systematic Review

This review examines the effectiveness of the various interventions and

treatments that have been tried to determine if any are effective in reducing and/or

treating childhood overweight/obesity. I conducted a systematic review that

included all studies in which the main focus was on the effectiveness of

interventions in reducing and/or treating childhood obesity.

I chose to target children for several reasons. First, childhood obesity is

potentially preventable. Second, persons at high risk for obesity can be identified

at a young age (18). Third, childhood obesity has been linked to adult obesity

(13). Fourth, several studies have shown that once they become obese, adults

rarely sustain weight loss (13). Fifth, adult obesity is linked to increased

morbidity and mortality (20). Thus, prevention of obesity in childhood and

effective treatment of overweight children should be a priority.

Methods

Literature Search

Relevant articles from January 1985 to the present were identified using

MEDLINE, the Cochrane Collaboration, and the systematic review and

Services. In addition, an expert in the field of childhood obesity was consulted

and her recommendations for retrieving relevant articles were taken into account.

Search terms used included interventions, prevent, prevention, childhood, child,

obesity, overweight, and human. Only articles classified as randomized controlled

trials conducted with human subjects that included children ages 6 to 12 were

retrieved. Again, this age group was targeted because I feel that children are

easier to reach at this age. They all are required by law to go to school, and

younger children are often more accepting of change than teenagers. All

literature searches were done in collaboration with a research librarian to ensure

that a complete systematic search had been conducted. The initial search yielded

260 articles (Appendix 2).

i

Inclusion Criteria

All potentially relevant articles identified by the search were reviewed for

inclusion in the analysis. To be included, studies had to have 1) been conducted

using children ages 6 to 12; 2) provided information concerning participant

oriented outcomes (weight/BMI change); 3) been randomized controlled clinical

trials; 4) lasted at least six months; 5) contained an appropriate control group; 6)

included both pre-intervention and post-intervention results for both the treatment

and control groups; 7) been available in the English language. Because there are

no FDA approved drugs for the treatment of childhood overweight/obesity,

A summary of the articles, with study design, subjects, intervention

evaluated, outcomes measured, and study quality, is presented in the evidence

tables. Any article that failed to meet the stated inclusion criteria was eliminated.

Article Review

Studies that met the inclusion criteria were reviewed using the revised

CONSORT statement presented in an article by Moher et al (23) in JAMA in

2001. This revised statement incorporates new evidence and gives a checklist of

items pertaining to the content of the title/ abstract, introduction, methods, results,

discussion/comment (Appendix 3) (23). Each article was assigned a grade of

"pass" or "fail" for each of the five sections appraised. A second reader would

have been used but was not due to time and financial constraints. Articles were

rated as "good" if they received a grade of pass for all five sections, "fair" if they

received a grade of pass for at least four of five sections, and "poor" if they

received a grade of pass for three or less of the sections. Moreover, the quality of

the studies was evaluated using the following quality assessors: 1) drop-out rate of

no more than 25%, 2) minimal crossover during the study, 3) quality of

randomization, and 4) use effective measurement tools and procedures.

Results

Of 260 articles identified in the initial search, five met the inclusion

criteria and were internally valid. Of these five studies, two found significant

reductions in BMI/weight between intervention and control groups (Robinson TN,

Gortmaker SL et al)(24, 25), and three did not (Warren JM eta!, Cabellero JM et

A summary of the included studies can be found below and in Table 4. A

summary of other studies evaluated can be found in the table in appendix 4.

Warren JM et al (26)

This study described a school and family-based intervention to prevent

obesity in children ages 5 to 7 years. There were 218 subjects recruited from

three primary schools in Oxford, England. The subjects were randomly assigned

to a control group or one of three interventions groups: nutrition group, physical

activity group, and combined group. The interventions took place during

lunchtime clubs and were composed of an interactive, age-appropriate nutrition

and/or physical activity curriculum. The interventions lasted for 14 months. The

study did not find any significant changes in the rates of overweight/obesity;

I

j

however, significant changes were found for improvements in nutrition in

knowledge (P<0.01) between baseline and post-intervention for all children, and

the results were highly significant for the nutrition and combined group

(P<O.OOl). Overall, fruit and vegetable intake increased significantly (P<0.01 and

<0.05, respectively), with significant changes seen for the nutrition (P<O.OS) and

control groups (P<O.OS). Also of note, the study indicated that schools are a

suitable setting for this type of intervention.

Of the 218 participants who originally started the study, a total of 46 were

loss to follow-up (22% ). Also, there was no crossover during the study and all

measurements tools and procedures used were discussed and appeared adequate.

On the other hand, the method of randomization was not discussed therefore no

Cabellero Bet al (27)

This study described a school-based multi-component intervention for

reducing percentage body fat in American Indian schoolchildren. It was a

randomized control trial involving 1704 children in 41 schools and was conducted

over 3 years, from 3'ct to 5'h grades, in schools serving American Indian

communities in Arizona, New Mexico, and South Dakota. The intervention had

four components: 1) change in dietary intake, 2) increase in physical activity, 3) a

core classroom curriculum focused on healthy eating and lifestyle, and 4) a

family-involvement program. The main outcome was percentage body fat. The

intervention resulted in no significant reduction in percentage body fat between

intervention and control schools. On the other hand, the results do document the

I

feasibility of implementing a multi-component program for obesity prevention in

elementary schools serving American Indian communities.

Ofthe 1704 children (879 intervention, 825 control), a total of 295 (152

'

intervention, 143 control) were lost to follow-up for an overall dropout of 17%

L

(17% intervention, 17% control). There was no reported crossover during the

study and all measurements tools and procedures used were discussed and

appeared adequate. The method of randomization discussed elsewhere and also

appeared adequate.

Sahota Petal (28)

This study evaluated a school-based intervention that targeted reducing

risk factors for obesity. Ten primary schools in Leeds were recruited and paired

numbers of free school meals). The schools were randomized to received the

intervention or serve as control schools. A total of 634 children age 7 to 11

participated in the study. The intervention schools received the active program

promoting lifestyle education in schools (APPLES). The program consisted of

teacher training, modifications of school meals, and development and

implementation of school action plans designed to promote healthy eating and

physical activity over one academic year. The control schools continued with

their usual health curriculum. The study found no significant differences in BMI

between schools. However, the study did find a significantly higher vegetable

consumption by 24-hour recall in the intervention schools when compared to the

control schools. The also found that fruit consumption was lower in obese

children in the intervention schools than those in the control schools. Moreover,

they found that sedentary behavior was higher in overweight children in the

intervention schools and global self worth was higher in obese children in the

intervention schools.

All 10 schools completed the project. Over the year, a total of 42

participants left the study and 40 joined. In all, 613 of 636 (97%) children were

measured at baseline and 595 of 636 (94%) at the end of the intervention. Also,

there was no crossover reported during the study and all measurements tools and

procedures used were discussed and appeared adequate. The method of

randomization was also discussed and was adequate.

This was a school-based intervention that targeted reducing sedentary

behavior through reducing television, videotape, and video game use. Two public

elementary schools in a single school district in San Jose, California were eligible

to participate. The schools were sociodemographically and scholastically

matched by district personnel. School principals agreed to participate prior to

randomization. One school was randomly assigned to receive the intervention

and the other school was assigned to be an assessment s only control. The

intervention curriculum consisted of 18 hours a classroom time and newsletters

designed to motive children and parents to limit television, videotape, and video

game use. Electronic television time mangers were sent to each household with

additional units available for every television in the home at no cost. One

hundred ninety two students with a mean age of 8.9 years participated in the

study. The groups were followed for six months. Compared with controls,

children in the intervention group had statistically significant relative decreases in

body mass index (intervention vs. control change: 18.38 to 18.67 kg/m2 _{vs. 18.10}

to 18.81 kg/m2, respectively; adjusted difference -0.45 kg/m2 _{(95% CI, -0.73}

to-0.17); P=0.002). Triceps skin fold thickness, waist circumference, and

waist-to-hip ratio also all decreased significantly (P=0.002, P<0.001, P<O.OOl

respectively). Relative to controls, intervention group changes were accompanied

by statistically significant decreases in reported television viewing and meals

eaten in front of the television. Overall, the study found that reducing television,

videotape, and video game use might be a promising intervention for preventing

Of 95 children in the intervention group, only 3 (3.2%) were lost to

follow-up. Of 103 children in the control group, only 3 (2.9%) were lost to

follow-up. There was no reported crossover during the study and all

measurements tools and procedures used were discussed and appeared adequate.

The method of randomization was discussed and also appeared adequate.

Gortmaker SL et al (25)

This study evaluated a school-based health behavior intervention known

as Planet Health on obesity among boys and girls in grades 6 to 8. Planet Health

was designed to reduce obesity by increasing energy expenditure while promoting

key dietary behaviors consistent with dietary guidelines. The intervention focuses

on 4 behavioral changes: reducing television viewing to less than 2 hours per day,

i

increasing moderate and vigorous physical activity, decreasing consumption of

high fat foods, and increasing consumption of fruits and vegetables to 5 a day or

more. The intervention was implemented as 16 core classroom lessons each year.

Classroom lessons were designed to last approximately 45 minutes.

~-Ten schools were randomized to receive or not receive the Planet Health

intervention. A total of 641 students were included at the intervention schools

and 654 were included in the control schools. The study found that the

prevalence of obesity among girls in the intervention schools was reduced

compared with girls at the control schools (OR 0.47, 95%CI 0.24-0.93, P=0.03)

with no differences found among boys. The intervention also reduced television

hours among both girls and boys, and increased fruit and vegetable consumption

outcomes were assessed using a Food and Activity Survey completed

independently by each student in a classroom under the supervision of teachers

who were trained to administer the survey. Lastly, this study indicated that a

school-based approach is feasible in preventing childhood obesity.

For girls, follow-up data were obtained for 82% of control and 81% of

intervention students. For boys, follow-up data were obtained for 86% of control

and 83% of intervention students. The main reasons reported for loss to

follow-up were school transfer (52%), school absence (27%), and child refusal (10%).

No information concerning crossover was reported. However, all measurement

tools and procedures used were discussed and appeared adequate. The method of

randomization was discussed and also appeared adequate.

,_ ... , __ "_ ... , .. ,L~I!U~JJIIillllllllt ... " - _____ , ___ J," .. L .. _{··· I '"''I-··}

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1 Study, Year U Study

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Groups Sample Race Sex Age Baseline Study Follow- P Value Patieu Study •

~ (Reference) & Design

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Size M/F BMI Duration upBMI ts Lost Grade

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or

5 ~ Change Follow

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inBMI -up

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6 ~(~~) 16.1(2.7) 14mos

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NR 14 Fair

2003 (26) ySICa Ct!VIty 6.1(0.6) 16.0(2.0) NR 8

School~ Based Combined 54 200 6.1(0.7) 15.8(2.0) NRINS NR 12

Target: C Control 54 29•25 6.1(0.6) 15.5(1.6) NRINS NR 12 Intervention: D, Total 218 I !1•107 6.1(0.6) 15.9(2.1) NRINS NR 46 PA

Conclusion: There were no significant differences in BMI between groups at baseline and overall. Small changes in incidence of overweight and obesity were noted in some groups but subject numbers were ... t~-~,t;JJ~}t!?r--~-~--~,~~-~t~;~J--.~~;!~~~~:, !i.?,~_;y~,~-'~}»~ .,P.~~~-~-ti,~_1,.~!-~.72.~!-!~--~""~~~,~~~~,--~~t!i.~p_l~!,!~S._B!-~~~5~~e .?-f -~-~~,~~~X}.~!~~~-Y}~~}~--~~}, ~~~~~,-~~~,.~"~~~~~9:!~-~~; ._, ''"'--'~ :---.-. /"'/ '/4 ·"' -y., /•:.r_,,,n·-•"" ,, .. ""'/'F•P.·JC-/C• i'i''·'

Cabellero, B et al, RCT PATHWAYS 879 All NR 7.6(0.6) 32.8% 3 years 40.3% 0.2 (-0.84 to !52 Good

2003 (27) (Intervention) Americ 1.31)

School-Based an P=0.664

Target: C Control 825 Indian 33.3% 40.0% between 143

Intervention: D, groups

PA %Body fat

Conclusion: The PATHWAYS intervention did not result in a significant reduction in percentage body fat between the two groups. However, the study does indicate that it is feasible to implement a multi-component program for obesity prevention in elementary schools serving American Indian children, which could extend to other ethnic groups.

' c. ···.· 42left ....

" ' ;-; ·,-. ;'-'"'"'./·0:·' .··,- ;, - '::::-:.::::;;:.:· .,, .. •,;·;-. .--"'.//."''!//,/-",i//•W'/;C·'·' i'//· . .'"',;/-:::. ··- "; .·• <-"·::·::.· · ,,.,, · '" ;.•;--:,"•/:"'·""/!''-'/-' ,,. ·.:-·;-.-·••"':<'/"''·'_,;· ;".;.·;-·;;,"/ • ;·.::",C'/•"/; ;·:·;·•; "•

NR Good

Sahota,Petal, RCT APPLES(Active 314 NR 153M 8.36(0.64) 0.12(1.01) 12mos 0(-0.Ito

2001 (28) Program Promoting !61F 0.1) 40 joined

School-Based Lifestyle in Schools) No

Target: C significant Numbers

Intervention: D, difference for entire

PA Control 322 189M 8.42(0.63) 0.04 (Ll7) 12mos between study

133F BM1SD

BMI SD score score between

. _schools

Conclusion: Overall, there was no difference in BMI SD score between the intervention and control schools at the end of the year although it was successful at changing the ethos of the schools and the attitude of the children.

;--.; . .,_;.;·;.-;;,--.-,-,-.... , : - ' ' : / ' / ' " - . - " ;,o-.--.:./<;/(/-!·,/"

95

'C"•, ;;,o;q; P//'-'" ,-;-• · : · ; " --·-.;;• / ' , '----"·;, /,';-;";--··-·:.::·;-.---- ...

Robinson, TN RCT Decrease Television NR 44.6%f 8.95(0.69) 18.38(3.67) 6mos 18.67(3.77) -0.45(-0.73 3 Good

1999 (24) to-0.17)

School Based significant

Target: C Control 103 48.5%F 8.92(0.70) 18.10(3.77) 18.81(13.76) relative 3

" """ ""' ." .. "J.,"I ·"J , .. ,"" . "'""l.lll,t.Jm•IIIL" ''""'''""J .• "',J,., _'"J

vie win

Conclusion: Children in the intervention group (decrease television) had statistically significant relative decreases in BMI when compared to the control group. Reducing television, videotape, and video game

"~7~~k~st~~;(!~~~~~!!';~~?;~~:~~ft!~~~}~£~~v~~l*\~!)~s~rt:::

d

48%F~

r n•

'i

1~7(o:7)"''''If~:~·d· /YI<2';;~;~--

F'r "'

'"'/q/~~:·~-:~~·

,, //'//

-~~~ff:

P;/'""'''•

'f'r~·:·•'././T'G~~~r····

School Based 11 %H %Obese %Obese (0.24 to

Intervention: D, 9%API 0.93,

PA 2%AI P=0.03)

5%0

Control I 654 I 63%W 48%F Il.7(0.7) 21.5%F 23.7%F -2.3 _118%F

15%Aa 34.7%M 3!.8%M -!.5 14%8

16%H %Obese %Obese (0.52 to

7%API !.39,

2%AI p=0.48)

9%0

Conclusion: The prevalence of obesity among girls in the intervention schools was significantly reduced (OR 0.47(0.44-0.93), P=0.03) compared with controls, with no differences found among boys (OR

0.85(0.52-1 .39), P=0.48).

n---" -,'"''""-'"•"'''•' '"'"'-""'"'"'"·"·'/·"-'''' ' '"""'"•"'::C'>:<>'W"P /-~/. •r/'"-"''-"h 'pO'•R71'·-~·

D

p NR

RCT

Diet Parent Not Recorded

Randomized Control Trial

0

H

AI

CCT

Other Hispanic American Indian

Controlled Clinical Trial

c

PA

PT

Child

Physical Activity Physical Training

w

AA API

White

Discussion

In conducting this systematic review, I found two high quality studies that

found that showed significant differences in weight loss or BMI change between

intervention and control groups. One evaluated reducing sedentary behavior

(physical activity) verses control and lasted six months (24), and the other

evaluated a multi-disciplinary intervention (diet and physical activity) verses

control and lasted two years (25). Both were school-based interventions. On the

other hand, I found three high quality studies that did not show significant

differences in weight loss or BMI change between intervention and control

groups. All three evaluated multi-disciplinary (diet and physical activity)

interventions verses control (26, 27, 28). All three also lasted at least a year with

the longest one lasting three years. Also, all three were school-based

interventions. Given these findings, I conclude that research currently lacks the

capacity to set clear directions for obesity prevention or treatment in children.

This review has several limitations. One, the review was restricted to

include only articles that were available in the English language which could have

led to a lot of quality studies being left out. Two, the review included such a

small number of studies that no definite conclusions could have been drawn in

any case. Three, the included studies likely lacked external validity because they

were conducted among highly selected populations i.e. American Indians in the

PATHWAYS study (27).

This review highlights a troubling situation. At a time when obesity is at

capacity to set clear directions for obesity prevention across a range of at risk

groups, in particular children. While it seems reasonable to suggest that we

concentrate on strategies that focus on reducing sedentary behaviors and

increasing physical activity, the need for well-designed studies, which examine a

range of interventions remains a priority. Research suggests that multifaceted

behavioral treatment programs seem to be the most promising interventions

available for children (29).

Current efforts at obesity prevention and treatment need to continue to

build the evidence base to determine the most cost-effective and health-promoting

strategies to achieve the goal of a healthy weight for all children. Particular

attention must be paid to undertaking studies with sufficient subject numbers to

ensure adequate power, appropriate follow-up of participants, reliable outcome

measures (BMI), sufficient process indicators, indications of cost effectiveness,

appropriate and adequate statistical analysis, sustainability, and genralizability

(3).

Several things must be kept in mind when approaching the issue of

childhood obesity. Programs addressing this issue should focus on the whole

child, mentally, physically, and socially because it is accepted that obesity, eating

disorders, hazardous weight loss, size discrimination, and body hatred are all

interrelated and need to be addressed in comprehensive ways (30).

Several barriers exist to finding a solution to this huge problem facing

America today. In conducting this review, I was faced with one issue in

can be measured in several ways including BMI, percent body fat, and total body

weight, we must come to a consensus on an ideal measure to be used in future

research. In doing this, we may be able to extrapolate data across studies to come

up with an answer as to what interventions are effective in reducing childhood

obesity. As it currently exists, the outcomes measured are so diverse that it is

hard to determine what is actually the best intervention.

Another aspect of these studies that make it hard to generalize the results

is the wide range of ages of the children included the studies. Given this range of

ages, it was difficult to determine which intervention is the best for what age

group. This was the main reason for narrowing the age range in the initial search

but unfortunately I still ran into the problem of wide age range.

One positive finding that was evident in several of the studies was the

i

potential for schools to be the setting for obesity prevention programs. It is my

opinion that schools are an ideal place to implement programs aimed at children

because of frequent and long-term contact with children, resources and personnel

to support eating and physical activity, and the ability to reach almost all children

despite not knowing what interventions work best.

In conclusion, preventing and treating obesity require persistence,

patience, and understanding. Any person who has ever struggled to lose weight

recognizes this very well. However, until we can find a viable solution to this

problem we must continue to evaluate programs and interventions aimed at

Appendix 1

What's Your Child's BMI Percentile?

1. Find your child's age along the horizontal (across) axis and your child's BMI along the vertical (up-down) axis.

2. You'll find your child's percentile (between 5 and 95) where these two points meet. A child's BMI percentile indicates how his or her measurements compare to other boys or girls in the same age group:

• Underweight: Less than the 5th percentile

• Ideal weight: Between the 5th and the 85th percentiles (50th percentile is average)

• At risk for overweight: Between the 85th and 95th percentiles

• Overweight: Higher than the 95th percentile

GIRLS

Body

Mass Index

32

31

30

29

28

27

26 25

24

23~

22

21

20

19

18

17

16

15

14

13

2 3 4 5 6 7 8 9 10 11 12 13 1415 1617 18 19 20

age In years

I

•

Appendix2

Appendix 2: Steps A-D carried out using abstract only

A. 260 articles identified in the initial electronic database search

t

B. 7 8 articles remaining

t

C. 69 articles remaining

t

D. 55 articles remaining

t

E. 51 articles remaining for full manuscript review

F. 5 articles included in the

systematic review.

182 articles eliminated because they

did not measure the primary outcome

or evaluate drug therapy

9 articles eliminated due to language

14 articles excluded due to date

4 articles eliminated due to study

duration

46 articles eliminated due to not

meeting inclusion criteria after manuscript review

i

f-Appendix 3: Revised CONSORT Statement from ref 24

Title and abstract

1 How participants were allocated to interventions (e.g. "random allocation", ·'randomized", or '·randomly assigned")

Introduction

Background

2 Scientific background and explanation of rationale Methods

Results

Participants

3 Eligibility criteria for participants and the settings and locations where the data were collected

Interventions

4 Precise details of the interventions intended for each group and how and when they were actually administered

Objectives

5 Specific objectives and hypotheses

Outcomes

6 Clearly defined primary and secondary outcome measures and, when applicable, any methods used to enhance the quality of measurements (e.g. multiple observations, training of assessors, etc

Sample size

7 How sample size was determined and, when applicable, explanation of any interim analyses and stopping rules

Randomization Sequence generation

8 Method used to generate the random allocation sequence, including details of any restriction (e.g. blocking, stratification)

Allocation concealment

9 Method used to implement the random allocation sequence (e.g. numbered containers or central telephone), clarifying whether the sequence was concealed until interventions were assigned

Implementation

I 0 Who generated the allocation sequence, who enrolled participants, and who assigned participants to their groups?

Blinding (masking)

I I Whether or not participants, those administering the interventions, and those assessing the outcomes were aware of group assignment. If not, how the success of masking was assessed

Statistical methods

12 Statistical methods used to compare groups for primary outcome(s); methods for additional analyses, such as subgroup analyses and adjusted analyses

Participant flow

13 Flow of participants through each stage (a diagram is strongly recommended). Specifically, for each group, report the numbers of participants randomly assigned, receiving intended treatment, completing the study protocol, and analyzed for the primary outcome. Describe protocol deviations from study as planned, together with reasons

Recruitment

14 Dates defining the periods of recruitment and follow-Ltp

Baseline data

15 Baseline demographic and clinical characteristics of each group

Numbers analyzed

16 Number of participants (denominator) in each group included in each analysis and whether the analysis was by "intention to treat". State the results in absolute numbers when feasible (e.g. I 0/20. not 50%)

Outcomes and estimation

17 For each primary and secondary outcome. a summary of results for each group, and the estimated effect size and its precision (e.g. 95% Cl)

Ancillary analyses

! 8 Address multiplicity by reporting any other analyses performed, including subgroup analyses and adjusted analyses, indicating those pre-specified and those exploratory

Adverse events

19 All important adverse events or side effects in each intervention group Discussion/Comment

Interpretation

20 Interpretation of the results, taking into account study hypotheses. sources of potential bias or imprecision and the dangers associated with multiplicity of analyses and outcomes

Generalisability

Overall evidence

22 General interpretations of the results in the context of current evidence

Overall Grade: Good Fair Poor

Article T i t l e :

-Author: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

Date Appraised: _ _ _ _ _ _ _ _

I

l

l

. " .. ~,.,,,,l,iiliLI~JJIIiJIJIIIIli,,_,. , ---.. u~ - - · · • • • , ... ,J,,,J .. N ... .L

A]

4: Other

~Studies

Study, Year Study GroiJpS Sample Race Sex Age Study Follow- P Value Patien

l

Study

(Reference) Design Size MIF BMI Duration upBMI ts Lost Grade

; or to

Change Follow

i

iuBMI -up

~~i~~i~: A et al, CCT Control 25 l5•M 10•15 10.7(0.6) 25.2(1.4) 6mos 0.72(0.17) P<0.05 NR Fai<

2002 (31)

Clinic~ Based 6-month intervention 65 47•10•8 31>34 10.1(0.3) 25.9(0.4) -1.07(0.23) NR Target: C

Intervention: D, (Ashke

PA nazi:

Sephar adic: mixed)

Conclusion: A combined, structured multidisciplinary (diet and physical activity) intervention for childhood obesity resulted in a significant (P<0.05) decrease in BMI when compared to controls.

Y'V'• ·vxx.~/df//'PWF'/~/'"'"-'' >', r•:-:-."/'''·"· "-,-, · --''"'iC/-"'//''l r•-;-F;W/F/d'/' •·/.•·; -- ···-• r.-r ;_,.,•.,·:;.<;'<'- / ' /• -,;, ,,,., •";w;o • ,_._._., .. ·•o·c; ·-e,;,• ·;;•·o;-.-:-o-~'"'''''/, ;~_-_f-;c· ">''>''·''';',•-' '' -·-/:'-'''""''''/.·:_,-... -;-_ ... _.,_--.;,-w rrx-·-'-'-";/-0"/c"~""-·''!Y'Y'/'. // Y/7'/-1"7' -"'-"' .,_. ... ,., •--•·;•.;;·-r-M"N-'/'-, ··---n-"W" c:0<-7"''''-'>'''/ ;· (' ·:,_: .. -_,.,

Epstein, LH eta!, RCT Increase Activity 29 NR 15M 10.8(1.1) 27.3(3.8) l2mos 0.65(1.37) NR NR Fair 2001 (32) l4F(Co) 10.2(1.4) 26.9(3.6) 0.27(1.37)

Family-Based

Target P, C Increase Activity & 27 14M 10.4(1.2) 27.5(2.5) l2mos -1.76(1.86) Intervention: PA Decrease Sedentary 13F(Co) 9.9(l.l) 27.9(4.7) 1.00(1.73)

Conclusion: Despite the fact that there were no reported differences in BMI between baseline and follow-up between boys and girls for either group, boys showed significantly better percentages of overweight changes (-15.8%) for the combined group than girls (-1.0) (P<0.001), with no significant differences for the increase activity group. The study does show however that child sex may influence weight control in _ --t~~t'~.:~~s--~d i_~-t~~~~!l!_i~e~---~-~~i-~-~~,~?--~5!~!XJ.-~~~s,~-~;~! ,~;.!_i_y~ .. !~;-.... --- •c,-·;c·;;p, '/'-/'"'-" •"\'i;;;.-.-,r'/,_.';''' '''/-"''/'/• F ' / F / ''"/,.'/-' //-'/' ' ' ; · N C ' ' • ' " • ' / ' ' " /"/7;"'• , ... " ~ ., .

,.,."

.. '" (

Epstein, LH et a!, RCT Parent + child 17 97%W 8MJ9F 10.7(0.9) 2.8(0.9) 24mos 2.3(l.l) Standard 15% Fair 2000(33) Child only 18 2%AA 9M/9F 10.3(1.2) 2.6(0.9) 1.7(0.9) group had overall Family-Based Standard (control) 17 2%H 8MJ9F 10.0(1.2) 2.7(0.8) 1.6(1.0) larger BMI

Target: P, C Children (All Z-score Z-score decreases

Intervention: D only, particip (p<0.2)

parents not ants) when

included compared to

othcr gwups

Conclusion: No advantages for weight control or loss when parent and/or child is provided problem solving training in addition to standard treatment which included diet and physical activity counseling and

---~~~}~~~~--~ ~~----~~~,~---~~---~~'"~!Y-1_,?r

___ ~~-~~§.:.,!~-~~-~~9~~~;--"~?~-~~AI!;l_,S,~1~_i,~~--~~X--~-~-~~!~~--~~-~R-~-~"'~~--:,},h,;<~-~-~--~---~E~,,t~~~--t--~~~~:.," .. _."":-.-. .---.---·--- ' •f','•"/C,"/A/•'/- :-~/P/'/" "/< ;-;-,/' ---r.;----· .. ;,-·• '/' ;·;,-· ,_,..,

Epstein, LH et a!, RCT Increase Activity 37 NR L(5>l3) 10.7(1.3) 62.7(21.2) 24mos -12.4(13.3) Significant 4 Good

2000 (34) (low intensity & high H (6>13) 10.0(1.3) 62.3(13.4) -13.2(16.4) (P<. 001) 4

Family Based intensity group) decreases in

Target P, C

'~~ J;,l,,.,l ,, ~~• •••H·~ " ' '""' '""''"' "' ,,l,.l~i:<Jt,.lJIIilllmll.«

PA

Decrease Sedentary 139

I

I

L (5:14) 10.7(1.0) 55~8(18.1) -11.6(21.9) form

I

~

(low intensity & high H (8:12) 10.6(1.1) 66.6(14.3) -14.3(16.) baseline for

intensity group) both groups.

24:52 10.5(1.2) 62.0(17.1) -12.9(17.0) No % Overweight difference

between

~-wf~~:~;;;i,~~~;j\_!;~~¥~-~~-,~9-.~"'el1~~~1;;~;~~z;!!;!~-~~~~~~~~~-~~.~~r~1;~:rr~lf"~f~,i~i'4!r!~~~~~~-~~?!~~g~~"?2~~\~x;r;;;.~~~!~~r~~~~~~d~i~~r~:i~~i''·!~.~f:f~l?;'.~~1i~~

Family Based Control (child led) 30 9.2(0.2) 39.1(3.8) 31.0 P<O.OI 9

Target: C Intervention: D,

PA

%Overweight Between

groups P<0.03

Significa nt differenc

e P<0.02 Conclusion: The family-based experimental approach (parents as the sole agents of change) was more effective in treating childhood obesity than the conventional approach (children as the main focus of

.

~~?J~!~;~:·~nTF.~:l~ :T~;~f;W;~! 1:d'T!~' ,~~~~~!~~r:v!~::~gTt~y~=,;~R]~J.;i~~*~l28

4(6 2o) ..•.

···r

8;]l~;

. ... ..

.1. NR

·r~:E;~~P'

Workout Facility Target: c·

Intervention: PA Group 2 (no PT then PT) 39 OAsian 16W 22Aa I Asian 13M 26F

9.4(1.00) 28.0(6.59) 8mos NR

significant decline in %BFwhile engaged in PT (P<O.OOI) but not during periods of PT.

5 Fair

3

~~1~~~~~~~;:~ ~~'"~~Jr~·~H~~~[·~Bi;~~·~~~!~~:,!i~~(~ f~lr1~i,~

..

~u~n&,R\.~~1·~

?UJI

··;;;~·i~-~.t?~r.l.s~~':I&·~i;t-~1.:·~6t:iJ6~}ll_()·~-~, ~?~

..

~~.~~~~~/f~.Y?~~.~~¥.~f3~i;~·~}.~.,tt~~6b%-9~~!il~:

NR

Clinic-Based Control 7 4:3 10.8(1.2) 28.8(4.2) 0.2(0.9)

Good

Target: C Intervention: D,

PA

Conclusion: Protein-sparing modified fast diet and a hypo caloric balanced diet appear to be effective in a group of age-school-age children in a medically supervised clinic-based program implemented in a

14M31F NR !year

-···mw.·r ... .

-13.08 1 P<O.OOI

school setting over a 6-month period.

''f~;;:(·~~~~-:--"-·'•"'·''•''-'l:--ccT/'/"~/fi"'''l"'•G;~~p-/· Y•·;~~-;·w-/,O'/(<'

/'/''T"45

r---~~----

_{.. '!"}

_Ism

_-~··

_{F;;; ·}

(int'lnr'IP<:

11.7(3) All

... ,.l.iillcl. .. lm:lllllllll .••.

57 20M37F

~YCli;ti;'B;~;d'",,_'"A"/c"'l~--, 'F"·'/fl'"/-/fT?:xluJ~di~id~;J"

·'"''

'/W?A"''"""r48/4''~ d·''/-'C'''"T~/AF//F/-~/--T/21M27f--T/JYr9(3)'l?'"/#rNit

Target: C

Intervention: D, Advice I 1.2(2) NR

PA

Camp 55 23M32F I2.I(2) NR Control 54 I9M35F 10.5(I) NR

-9.84 -6.84 -14.67 +2.52 Mean weight loss P<O.OOI P<O.OOI P<O.OOl P<O.OO! All above P-values are within groups. Overall each group lost significantly more weight than the control group (P<O.OOI) both group and individu a!) 13 IO

1 I2

Conclusion: Treatment results in significant (P<O.OOI) reduction in percentage overweight for all therapeutic conditions, even without strict dietary restrictions. months. Treatment consisted of cognitive behavior therapy applied in different manners.

Weight reduction was noticed in a little as three

-. "''"·· Y·">-'''4"'''"''""''""''"'V'- /' /"'"'-'"'·j·/-· .,.-.:;--. ,-.;·"·---·----" "'''·. '":?:./'/'//"//' ,r-.

1--/- ''""'"_,. // k •... .,/.'f'-"/4// "'"""'''''''""'"·'-'r"":r-/·· ., ,,.,,.:- "/- " :''"'"'"'"'' .. _ .. "'

Epstein, LH eta!, RCT Experimental I7 NR

I

4,13

I

10 3(1.3)

I

60.6(25.3) 1994 (39) (mastery criteria and

Clinic-Based contingent Target C, P reinforcement) intervention

Control (behavior change strategies and non-contingent reinforcement)

22 6'I6 10.2(1.0) 58.8(19.6)

(percent over 50th percentile for BMI)

24mos (intervention lasted 6 mos but patients followed for 2 years)

-15.4

-10.6

Si;tr.~;;;;v-

''(NR '"'"''''. (

p;j;~

-'"•'

changes in percent over weight at 6 and 12 mas

p < 0.05

No

significant difference at 24mosp=

. . . ' ' ' ' 0.29

Conclusion: Results showed significantly better relative weight change at 6 months and I year for children in the experimental compared to the control group, but these effects were not maintained at 2 years.

-.. -Je:~e,-,~~~~l~.,-S..':I.?J~-~-?~--~'~}~!-~~st,ie_!\?,!,~:~,~~~~,,~-~-~~~<;,~~~ :S?~~~~-~;}~-~:7eJ.~X~~£er~~;~~

..

f~~,~~~~~~-IJ. ~~-~ i~p~~~; -~~t~?~T,~--~~~~~"t;~~~~~ .. t}~.!!;~-~~!?,~~1 }!,~;tT;!!~l~~-c_~}_t_~-~~-,~-~~~~-t~-:

Israel, ACetal,

I

RCT

I

Standard Treatment

III

I

NR

I

NR

,8-13

145.94(17.11)

r

Treatment

I

TX I NR I NR I Fair 1993 (29) (parent controlled) years old (TX) 6.5mos 33.43(17.00)

Office Based 52.30(24.37)

Target: P, C Intervention: D,

PA F.nh~nrf'fi rhilrl 9

48.10(18.3I) Follow-up

(fu) 3vrs

Fu

. ,M.Jci,.,L« ... ,,.,. • • • • • • . M . . . . UI,I.Jm-lllL. . ... L ... I .. I

controlled) t (child 43.29(21.18)

%0verweiJJ:ht

Conclusion: This study examined the effect of a multi-component self-regulation intervention, which had four components: goal setting, self-monitoring, self-evaluation, and self-consequence. The study was not adequately powered to determine statistical significance between groups although it was noted that 44% of the ECI children verses 0% of the ST children were below post treatment (6.5mos) %overweight level~ at_the.~~year follow~up.

~.-;S~Jlis:'·Jp·;; ~~/,"-?xnvRCT'''' ''•"''?'/c

'SPARK

('f;;~i~;l ''T'r"' '745.~(T;~J)v-~85%W0" NR 7·'--'\v .

.Jv.

NR 2Ye~~· NR GirtS had

no ..

NR Fair

1993 (40) Education & Self 6%API Difference

School Based Management) 7%H in BMI at

Target C 1 %Aa 2years.

Intervention: PA 1%0

Control Boys at the

control schools decreased

BMI

significantly

(p<O.OI)

more than

SPARK

schools

Conclusion: Two years of participation in a special physical education activity program did not produce significant reductions in children's BMI or adiposity. It was noted however, that SPARK was not designed to be an obesity prevention program.

~'0/t/"//'~p~/'""~~~r~~;/t//'-/'''" ,,,.,_ '/"'•''~· :""''" '/" , ' / 0 / " · / • / ' 0 / ' ' /•':<Y/<''' ' ·;;, • ~'//" / Tk'/0''~ ' " ~'"' / -~ ,•- ,. ' ~-; /" · ·;--/-"~" .,. ~·••;.-;--" ""'.<"/' " •' ; / -~ '• "/•"-" -,· " " / " ' "

Duffy & Spence, RCf Behavior Therapy 28(total) NR 6 M 118.71(20 46.28(19.32) 6mos 37.09(21.71) NR ll(total) Fair

1993 ( 41) plus Placebo Control 22 F .16) mos There was

Clinic Based (Total) no apparent

Target C Cognitive Self 45.96(18.55) 37 .02(24.58) difference in

Intervention: D, Management plus response

PA Behavior Therapy between the

%Overweight two groups

Conclusion: The two procedures were effective at reducing obesity; however, there were no differences noted between groups. Average reductions of around 9% in percentage overweight adjusted for age, height, and sex were noted fro both groups.

;-".;' ;--··''''"'"''-;";·<•'0<"'/';;--c'''•'':;•~-,._,~vo; '•'//'·'//'/"''/-':/'t':/-/o•",/''' '";-''/,'''' ? / / "~~-;j -~'; ·""", ---;;-~-;~ ·, -~ -'" --/--'o• ';",;

;--;~-,--FJOdffiark,CEet CCT Treatment Group "NR -~IQM 10-11 at 25.5(0.53) 12mos 27.1(0.88) BMiof 0 Fair

al, 1993(42) !(conventional) 9F start (all family

Family Based participan group is

Target C Treatment Group 25 liM ts) 24.7(0.36) 25.8(0.53) significantly 4

Intervention: D 2(family therapy) 14F less than

that of

Control Group 50 16M 25.1(0.35) 27.9(0.61) control 2

31F group

~~ ~ ~1.: •. 1 .•. ~1' L.v • • • • ·~· •..•. , •. 1 .• 11~t .. 1m,1111111111 •• ~·

I I I I I I I I I I I

Conclusion: Family therapy is effective at preventing the development of severe obesity during childhood. Using the intent-to-treat principle, increases in BMI in the family therapy group was less than both of

_,,J-'~/~~~!!;~4~2/~p~j~~~!;':-:;.~~!?Se!x,~~ r2.~~~~~;,2;;,~.~~-"!~_;,!~)~~Jx,;~/~~~~x.~~~v~e~,~?!:l%2/~~!'!~r~/~!t!~&~~~-~l~~~~e/~J;,/,'---~~Mv·-·· ,-c~.,,._./'" ··rm/>X''''' w/·'/·7/nni'Y/Mff/YYPYP•A'•~/?Nrd:/,'IN'·fts:> • ,.-,x-r/Y/ •~·~·••/• ---/-/-~•/'" .,,,7;0

Epstein, LH et at, RCT Child & Parent 20 NR 6MI4F 9.4(1.8) 41.7(16.3) 10years -7.0% Children in NR Fair

I 990 (43) the child

Family Based parent group

Target: P, C Child 16 7M9F 10.4(1.2) 43.5(16.1) +4.7% had

Intervention: D, significantly

PA (P<0.05)

Nonspecific Control 19 6MI3F 9.9(2.3) 46.2(15.4) +13.6% greater reduction in %Overweight Changes in percent

% overweight Overweight than

children in control with children in child only group between.

Conclusion: The results fro this study provide evidence for long~term treatment of childhood obesity. This study implies that if behavioral, family based treatment is initiated when the child in between the ages

~:ve!~~~~~~·~1_{rt~~~!~·,/!~y~-~~~~;~"'~!~)!~~-~~~,,~-~~~~r~~~~~,.e~~.!!~-~.9:.,.,/ ~'}

" ' ? /

l.EGEND

D Diet 0 Other c Child w White

p _Parent H Hispanic PA Physical Activity AI} African American

NR Not Recorded AI American Indian PT Physical Training API Asian/Pacific Islander

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