Childhood obesity. Treatment options

Role of Parents in Body Mass Reduction in Children with Obesity-Adherence and Success of 1-Year Participation in an Intervention Program

Background and Objectives: Obesity in children and adolescents results in a number of serious health-related consequences necessitating early treatment. Support from family members and family-focused lifestyle interventions can improve effectiveness of the treatment. The aim of the study was to assess the effects of parental characteristics and family-based dietary habits on the adherence and success of a body mass reduction program in children with obesity included in a lifestyle intervention program after 1 year. Materials and Methods: The program included dietetic, psychosocial, and endocrine counseling given to individuals either alone or in groups and was conducted by a multidisciplinary team (consisting of endocrinologists, nurses, psychologists, social counselors, dietitians, and physiotherapists). A total of 113 children aged 10-17 years (mean age 12.9 ± 2.0; 60 girls, 53 boys) were included in the program. After 1 year of participation, the rate of adherence and success were assessed. The effect of the participants' general characteristics, including anthropometric data, as well as parental characteristics (marital status, employment, education, body mass index (BMI), duration of breastfeeding) and the circumstances of meal consumption (eating at home or outside, fast food consumption), was analyzed. Results: The most important factors predicting body mass reduction success were baseline BMI (p < 0.0001) and waist-hip ratio (WHR) (p = 0.04), but they did not predict body mass reduction adherence. Conclusions: The meal consumption habits and support from family members may be among the determinants of adherence to a body mass reduction program for preadolescents and adolescents with obesity. However, the results of the presented study suggested that baseline BMI and WHR are the most important determinants of the body mass reduction success.

The prevalence of overweight/obesity in high school adolescents in Jeddah and the association of obesity association with dental caries

BACKGROUND

The prevalence of overweight/obesity in children in Saudi Arabia is among the highest in the world. The prevalence of dental caries is also high in Saudi children. Studies on the relationship between caries and obesity in Saudi adolescents are lacking.

OBJECTIVES

To study the prevalence of overweight/obesity in adolescents, and determine any association between obesity and caries.

DESIGN

An analytical cross-sectional study.

SETTING

Private and public schools in Jeddah.

PATIENTS AND METHODS

The study sample comprised high school children from public and private schools selected by multistage stratified random sampling. Height, weight, waist circumference (WC), and body mass index (BMI) were measured for all children, who were then classified as underweight/normal, overweight, or obese according to their BMI values, and nonobese or obese according to their WC values. The presence of caries was assessed using the Association of State and Territorial Dental Directors criteria.

MAIN OUTCOME MEASURE(S)

The prevalence of overweight/obesity and the association of obesity with the number of decayed permanent teeth.

RESULTS

801 high school children (48% boys, 49% from public schools) with a mean (SD) age of 16.5 (0.9) years. When the BMI classification was used, 24%, 16%, and 60% adolescents were obese, overweight, and underweight/normal, respectively. When the WC classification was used, 19% and 81% were obese and nonobese, respectively. Obesity was more prevalent in boys and in students attending private schools (P < .05). The number of decayed permanent teeth showed a very weak and insignificant correlation with BMI and WC.

CONCLUSION

One in every four adolescents residing in Jeddah was obese, with a high obesity prevalence in boys and in children attending private schools. The prevalence of caries in the permanent dentition was not associated with BMI or WC.

LIMITATIONS

It was difficult to establish temporality in this cross-sectional study. Data on common risk factors were not adjusted for in the analyses.

Principles and pitfalls in the differential diagnosis and management of childhood obesities

Obesity is currently the most prevalent chronic childhood disease in Western countries. It is one of the most frequent consultations in general pediatrics and is even more common in pediatric endocrinology. As might be predicted, the prevalence of obesity-associated comorbidities is also increasing in children and adolescents. It is widely accepted that this increase in obesity results from an imbalance between energy intake and expenditure, with an increase in positive energy balance being closely associated with the current lifestyle in Western countries. However, there is increasing evidence indicating that an individual's genetic background is important in determining obesity risk. The physiologic mechanisms controlling appetite and energy expenditure are being revealed in part because of the identification of new causes of human monogenic, syndromic, and endocrine-related obesity. Thus, it is no longer appropriate to talk about obesity, but rather about "obesities" or "different diseases causing obesity," because their pathophysiologic bases differ. Moreover, these obesities require different diagnostic and management approaches. The pediatrician must be aware of this issue and focus the clinical history and physical examination toward specific clinical signs and symptoms to better exploit the available diagnostic and therapeutic resources when facing a child with obesity. Genetic, genomic, and metabolomic studies are often necessary to obtain a more appropriate diagnosis. Cognitive behavioral therapy is fundamental in obese children. The identification of potential targets will hopefully result in new pharmacologic approaches for translational and personalized medicine for obesity in the near future.

Barriers and enablers for participation in healthy lifestyle programs by adolescents who are overweight: a qualitative study of the opinions of adolescents, their parents and community stakeholders

BACKGROUND

Overweight or obesity during adolescence affects almost 25% of Australian youth, yet limited research exists regarding recruitment and engagement of adolescents in weight-management or healthy lifestyle interventions, or best-practice for encouraging long-term healthy behaviour change. A sound understanding of community perceptions, including views from adolescents, parents and community stakeholders, regarding barriers and enablers to entering and engaging meaningfully in an intervention is critical to improve the design of such programs.

METHODS

This paper reports findings from focus groups and semi-structured interviews conducted with adolescents (n?=?44), parents (n?=?12) and community stakeholders (n?=?39) in Western Australia. Three major topics were discussed to inform the design of more feasible and effective interventions: recruitment, retention in the program and maintenance of healthy change. Data were analysed using content and thematic analyses.

RESULTS

Data were categorised into barriers and enablers across the three main topics. For recruitment, identified barriers included: the stigma associated with overweight, difficulty defining overweight, a lack of current health services and broader social barriers. The enablers for recruitment included: strategic marketing, a positive approach and subsidising program costs. For retention, identified barriers included: location, timing, high level of commitment needed and social barriers. Enablers for retention included: making it fun and enjoyable for adolescents, involving the family, having an on-line component, recruiting good staff and making it easy for parents to attend. For maintenance, identified barriers included: the high degree of difficulty in sustaining change and limited services to support change. Enablers for maintenance included: on-going follow up, focusing on positive change, utilisation of electronic media and transition back to community services.

CONCLUSIONS

This study highlights significant barriers for adolescents and parents to overcome to engage meaningfully with weight-management or healthy lifestyle programs. A number of enablers were identified to promote ongoing involvement with an intervention. This insight into specific contextual opinions from the local community can be used to inform the delivery of healthy lifestyle programs for overweight adolescents, with a focus on maximising acceptability and feasibility.

Rationale, design and methods for a staggered-entry, waitlist controlled clinical trial of the impact of a community-based, family-centred, multidisciplinary program focussed on activity, food and attitude habits (Curtin University's Activity, Food and Attitudes Program--CAFAP) among overweight adolescents

Background

Current estimates place just under one quarter of adolescents in Australia as overweight or obese. Adolescence has been identified as a critical period for the development of obesity, yet despite this recognition, there is limited systematic research into or evaluation of interventions for overweight adolescents. Reviews have concluded that there is a substantive evidence gap for effective intervention, but physical activity, lifestyle change and family involvement have been identified as promising foci for treatment.

Methods

This paper reports on the development of a staggered-entry, waitlist controlled clinical trial to assess the impact of a multidisciplinary intervention aiming to change the poor health trajectory of overweight adolescents and help them avoid morbid obesity in adulthood—Curtin University’s Activity, Food and Attitudes Program (CAFAP). 96 adolescents, aged 11–16 years, and parents, will attend twice weekly during an 8 week intensive multidisciplinary program with maintenance follow-up focussed on improving activity, food and attitude habits. Follow-up assessments will be conducted immediately after completing the intensive program, and at 3, 6 and 12 months post intensive program. Main outcomes will be objectively-measured physical activity, sedentary behaviour and activity behaviours; food intake (measured by 3 day diary) and food behaviours; body composition, fitness and physical function; mental and social well-being (quality of life, mood and attitudes), and family functioning.

Discussion

This trial will provide important information to understand whether a community based multidisciplinary intervention can have short and medium term effects on activity and food habits, attitudes, and physical and mental health status of overweight adolescents.

Trial registration

Australian New Zealand Clinical Trials Registry ACTRN12611001187932.

A Cognitive Behavioural Intervention for Overweight and Obese Adolescents Illustrated by Four Case Studies

This article reports four case studies illustrating the implementation of the ChooseHealthProgram, a cognitive behavioural lifestyle intervention for overweight and obese adolescents. Participants were an overweight (12 years) and obese (15 years) female, and an overweight (14 years) and obese (12 years) male. The program was delivered by provisional psychologists with program specific training and supervision. All participants demonstrated improvements in body composition, and maintained or improved dietary quality and psychosocial wellbeing. The program had variable effects on physical activity and minimal effect on cardiovascular fitness for three of the four participants. While parents and adolescents required considerable assistance to develop and monitor long term program goals, these goals were a useful clinical tool to support the adolescent and parent to recognise the improvements they had made. Identification and monitoring of specific, measurable, and realistic behaviour change strategies was particularly important in assisting adolescents and their parents to translate session information into improved health behaviours. Results indicate that an adolescent overweight and obesity treatment program that promotes adolescent responsibility and autonomy, and emphasises the importance of parent support and family change is both effective and highly acceptable to both adolescents and parents.

[Paediatric obesities: from childhood to adolescence]

Obesity, as in every western country, is currently the most prevalent chronic disease in childhood in Spain. This has led to obesity being one of the most common consultations in general paediatrics and, particularly, in paediatric endocrinology. Furthermore, obesity associated comorbidities are increasing in prevalence in children and adolescents. It is widely accepted that this increase in the prevalence of obesity is derived from an imbalance between energy intake and expenditure, associated to the lifestyle in western countries. However, there is increasing evidence of the role of individual and familial genetic background in the risk of developing obesity. The pathophysiological basis of the mechanisms responsible for the control of appetite and energy expenditure are being discovered on the basis of the increasing known cases of human monogenic, syndromic and endocrine obesity. Thus it is no longer appropriate to talk about obesity but rather about «obesities», as their pathophysiological bases differ and they require different diagnostic and management approaches. In 2011, the paediatrician must be aware of this issue and focus the clinical history and physical examination towards these specific clinical sign and symptoms, to better manage the available diagnostic and therapeutic resources when faced with a child with obesity.

Parental factors affecting the weights of the placenta and the offspring

AIM

To determine parental, especially paternal factors associated with the weight of the placenta and offspring.

METHODS

This population-based birth-cohort study includes 2947 singleton children born from April 2006 to 2007 and living in Drenthe, The Netherlands. Placental weight and birth weight were measured and questionnaires were filled out for this cohort. Associations between parental factors, and the weight of the placenta and the offspring were evaluated using univariate and multivariate linear regression models.

RESULTS

Univariate regression revealed that the paternal birth weight and body mass index (BMI) of the father were predictors for placental and birth weight of the offspring. However, they were not independent predictors. Independent predictors for placental weight were the maternal factors of pre-pregnancy BMI, birth weight, and diabetes. The maternal factors of weight gain during pregnancy, birth weight, smoking during pregnancy, and diabetes were independent predictors for birth weight of the offspring.

CONCLUSION

Paternal as well as maternal factors influence the weight of the placenta and the offspring.

Counseling to prevent obesity among preschool children: acceptability of a pilot urban primary care intervention

PURPOSE

To help design effective primary care-based interventions, we explored urban parents' reactions to a pilot and feasibility study designed to address risk behaviors for obesity among preschool children.

METHODS

We conducted 3 focus groups (2 in English, 1 in Spanish) to evaluate the pilot intervention. Focus group participants explored the acceptability of the pilot intervention components (completion of a new screening tool for risk assessment, discussion of risk behaviors and behavior change goal setting by physicians, and follow-up contacts with a lifestyle counselor) and the fidelity of the pilot intervention delivery.

RESULTS

Parents expressed a desire to change behaviors to achieve healthier families. They believed that doctors should increase their focus on healthy habits during visits. Parents were more accepting of nutrition discussions than increasing activity (citing a lack of safe outdoor space) or decreasing sedentary behaviors (citing many benefits of television viewing). Contacts with the lifestyle counselor were described as empowering, with parents noting her focus on strategies to achieve change for the whole family while recognizing that many food behaviors relate to cultural heritage. Parents expressed frustration with physicians for offering advice about changing behavior but not how to achieve it, for dismissing concerns about picky eating or undereating, and in some cases for labels of overweight that they believed were inappropriately applied.

CONCLUSIONS

Parents welcomed efforts to address family lifestyle change in pediatric visits. The model of physician goal setting with referral for behavior change counseling is highly acceptable to families. Future interventions should acknowledge parental concerns about undereating and perceived benefits of television viewing.

Dietary determinants of subclinical inflammation, dyslipidemia and components of the metabolic syndrome in overweight children: a review

OBJECTIVE

To review and summarize the dietary determinants of the metabolic syndrome, subclinical inflammation and dyslipidemia in overweight children.

DESIGN

Review of the current literature, focusing on pediatric studies.

PARTICIPANTS

Normal weight, overweight, or obese children and adolescents.

RESULTS

There is a growing literature on the metabolic effects of excess body fat during childhood. However, few pediatric studies have examined the dietary determinants of obesity-related metabolic disturbances. From the available data, it appears that dietary factors are not only important environmental determinants of adiposity, but also may affect components of the metabolic syndrome and modulate the actions of adipokines. Dietary total fat and saturated fat are associated with insulin resistance and high blood pressure, as well as obesity-related inflammation. In contrast to studies in adults, resistin and adiponectin do not appear to be closely linked to insulin resistance or dyslipidemia in childhood. However, circulating leptin and retinol-binding protein (RBP) 4 correlate well with obesity, central obesity and the metabolic syndrome in children. Intakes of antioxidant vitamins tend to be low in obese children and may be predictors of subclinical inflammation. Higher fructose intake from sweets and sweetened drinks in overweight children has been linked to decreased low-density lipoprotein (LDL) particle size.

CONCLUSIONS

Dietary interventions aimed at reducing intakes of total fat, saturated fat and free fructose, whereas increasing antioxidant vitamin intake may be beneficial in overweight children. More research on the relationships between dietary factors and the metabolic changes of pediatric obesity may help to identify the dietary changes to reduce health risks.

Television viewing and food habits in toddlers and preschoolers in Greece: the GENESIS study

The aim of the current study was to evaluate the association between television (TV) viewing time and dietary habits of preschoolers. A representative sample of 2,374 Greek children aged 1-5 years was examined (GENESIS study). The majority of participants (74.0%) spent less than 2 h/day watching TV. Children spending > or =2 h/day watching TV seem to have higher energy intake compared to children watching TV less than 2 h/day, even after adjustment for potential confounders (p < 0.001). Furthermore, it was detected that the former were more likely to consume more than 5, 2, and 1.5 exchanges of fat, meat, and other carbohydrates per day, respectively, compared to the latter. In conclusion, the current findings indicate that prolonged TV viewing time may be associated with increased consumption of high-fat and high-sugar foods resulting in increased daily energy intake. Therefore, interventions aiming to modify children's TV viewing behaviour might need to be implemented.

Weight loss and the effect on stature in children during a residential intervention program

Weight loss is generally high in residential weight-loss programs but the effect of a large weight loss on linear growth is not known. We report the weight loss and the influence on linear growth in a large group of children during a residential weight-loss program focusing on nutrition and physical activity. In a longitudinal noncontrolled intervention study of 990 overweight children (540 girls) attending the weight reduction program from 1990 to 2001 for about 11 weeks (age: 10-14 years, mean BMI-standard deviation score (SDS) at enrollment: 2.83) weight and height were measured initially and after end of treatment. Weekly measurements of height and weight were performed on 138 children. The children lost on average 9.4 kg, reduced their BMI by 4.5 kg/m(2) and BMI-SDS by 0.98. In a multiple regression analysis (P < or = 0.001) weight loss was higher in boys than girls (1.7 kg), higher if the weight was higher at admission (-0.192 kg/kg at baseline) and was positively associated with duration of stay (-80 g/day). Initially the boys' BMI-SDS was higher than the girls' BMI-SDS (P < or = 0.05) but after 8 weeks of treatment the boys had lower BMI-SDS than the girls. There was no negative effect on linear growth during the treatment; on the contrary, linear growth accelerated during the stay as the average increase in height was 2.38 cm corresponding to 11.4 cm/year. In conclusion the children lost close to 1 kg/week during the stay without any negative effect on linear growth. The cause of the linear growth acceleration needs further investigation.

Gendered dimensions of obesity in childhood and adolescence

Background

The literature on childhood and adolescent obesity is vast. In addition to producing a general overview, this paper aims to highlight gender differences or similarities, an area which has tended not to be the principal focus of this literature.

Methods

Databases were searched using the terms 'obesity' and 'child', 'adolescent', 'teenager', 'youth', 'young people', 'sex', 'gender', 'masculine', 'feminine', 'male', 'female', 'boy' and 'girl' (or variations on these terms). In order to limit the potential literature, the main focus is on other reviews, both general and relating to specific aspects of obesity.

Results

The findings of genetic studies are similar for males and females, and differences in obesity rates as defined by body mass index are generally small and inconsistent. However, differences between males and females due to biology are evident in the patterning of body fat, the fat levels at which health risks become apparent, levels of resting energy expenditure and energy requirements, ability to engage in certain physical activities and the consequences of obesity for the female reproductive system. Differences due to society or culture include food choices and dietary concerns, overall physical activity levels, body satisfaction and the long-term psychosocial consequences of childhood and adolescent obesity.

Conclusion

This review suggests differences between males and females in exposure and vulnerability to obesogenic environments, the consequences of child and adolescent obesity, and responses to interventions for the condition. A clearer focus on gender differences is required among both researchers and policy makers within this field.

An overview of pediatric obesity

Pediatric obesity is increasing worldwide and disproportionately affects the economically and socially disadvantaged. Obese children are at risk of developing the (dys)metabolic syndrome, insulin resistance, early-onset type 2 diabetes mellitus, polycystic ovarian syndrome, hypertension, hyperlipidemia, and obstructive sleep apnoea. Those with diabetes may have mixed features of type 1 and type 2 diabetes mellitus. Pediatric obesity is the result of persistent adverse changes in food intake, lifestyle, and energy expenditure. It may be because of underlying a genetic syndrome or a conduct disorder. Children living in urban settings often lack safe, affordable, and accessible recreational facilities. Tight educational schedules mean less free time, while computer games and television have become preferred recreational activities. More families are eating out or eating take-out meals and processed foods at home because of pressures of work and time constraints. Consumer advertising targeted at children and the ready availability of vending machines encourage unwise food choices. Some children eat excessively because they are depressed, anxious, sad, or lonely. Often families and obese children are aware of the need for healthy eating and exercise but are unable to translate knowledge into weight loss. Population-based measures such as public education, school meal reforms, child-safe exercise friendly environments, and school-based and community-based exercise programs have been shown to be successful to varying degrees, but there remain individuals who will need special help to overcome obesity. Overeating (e.g. binge eating) may be a manifestation of disordered coping behavior but may also be because of defects in the neural and hormonal control of appetite and satiety. New pharmacological approaches are targeting these areas. We need a coordinated approach involving government, communities, and healthcare providers to provide a continuum of population-based interventions, focused screening, and personalized multidisciplinary interventions for the obese child and family.

Design of the Dutch Obesity Intervention in Teenagers (NRG-DOiT): systematic development, implementation and evaluation of a school-based intervention aimed at the prevention of excessive weight gain in adolescents

Background

Only limited data are available on the development, implementation, and evaluation processes of weight gain prevention programs in adolescents. To be able to learn from successes and failures of such interventions, integral written and published reports are needed.

Methods

Applying the Intervention Mapping (IM) protocol, this paper describes the development, implementation, and evaluation of the Dutch Obesity Intervention in Teenagers (DOiT), a school-based intervention program aimed at the prevention of excessive weight gain.

The intervention focussed on the following health behaviours: (1) reduction of the consumption of sugar-sweetened beverages, (2) reduction of energy intake derived from snacks, (3) decrease of levels of sedentary behaviour, and (4) increase of levels of physical activity (i.e. active transport behaviour and sports participation).

The intervention program consisted of an individual classroom-based component (i.e. an educational program, covering 11 lessons of both biology and physical education classes), and an environmental component (i.e. encouraging and supporting changes at the school canteens, as well as offering additional physical education classes).

We evaluated the effectiveness of the intervention program using a randomised controlled trial design. We assessed the effects of the intervention on body composition (primary outcome measure), as well as on behaviour, behavioural determinants, and aerobic fitness (secondary outcome measures). Furthermore, we conducted a process evaluation.

Discussion

The development of the DOiT-intervention resulted in a comprehensive school-based weight gain prevention program, tailored to the needs of Dutch adolescents from low socio-economic background.

Dietary intakes of fat and antioxidant vitamins are predictors of subclinical inflammation in overweight Swiss children

BACKGROUND

In obese children, subclinical inflammation is often present and is correlated with the metabolic syndrome. Dietary factors, such as fatty acids and antioxidants, potentially modulate the association between adiposity and subclinical inflammation, but few data are available in children.

OBJECTIVE

The aim of the study was to determine whether dietary fat or antioxidant intakes influence circulating tumor necrosis factor alpha (TNF-alpha), interleukin 6 (IL-6), C-reactive protein (CRP), and leptin concentrations in overweight children.

DESIGN

In a cross-sectional study of 6-14-y-old normal-weight (n = 33), overweight (n = 19), and obese (n = 27) Swiss children, nutritional intakes were assessed from two 24-h dietary recalls and a 1-d dietary record. Percentage body fat from skinfold thicknesses, waist-hip ratio, and blood pressure were measured. Fasting blood samples were collected for the measurement of insulin, glucose, HDL-cholesterol, triacylglycerol, CRP, IL-6, TNF-alpha, and leptin concentrations.

RESULTS

CRP, IL-6, and leptin increased significantly (P < 0.02) with increasing adiposity, independent of age; TNF-alpha did not increase. Total dietary fat and the percentage of energy from fat were significant predictors of CRP concentration, independent of body mass index (P < 0.05). Meat intake was a significant predictor of IL-6 and leptin, independent of body mass index (P < 0.05). Intakes of antioxidant vitamins (vitamins E and C and beta-carotene) were significant predictors of leptin (P < 0.05) but not of CRP, IL-6, or TNF-alpha.

CONCLUSIONS

Overweight Swiss children as young as 6 y have elevated concentrations of inflammatory markers. Intakes of total fat and antioxidant vitamins are determinants of subclinical inflammation in this age group.