Six-month dietary changes in ethnically diverse, obese adolescents participating in a multidisciplinary weight management program

Study design and rationale for TEENS+REACH: Evaluating ripple effects of a family-based lifestyle intervention to untreated family members

Background

Understanding the effects of family-based lifestyle intervention beyond the treated adolescent is important, given that obesity is a familial disease and there are likely bidirectional relations between an adolescent's treatment success and broader household changes. However, it is unknown if recommended household-wide changes are adopted or if untreated family members experience weight-related benefits.

Methods

TEENS + REACH leverages our ongoing randomized clinical trial of TEENS+, a family-based lifestyle intervention for adolescents with obesity, to determine: 1) if household-wide changes to the shared home environment are implemented, 2) if ripple effects to untreated family members are observed, and 3) whether these changes are predictive of adolescents' weight management success. TEENS + REACH will expand trial assessments to include comprehensive assessments of the shared home feeding, weight, and physical activity environment of the target adolescents. Specifically, we will enroll untreated children (8-17yrs) and caregivers living in the same household as the target parent/adolescent dyad (N = 60 families). At 0, 2, 4 (primary endpoint), and 8-months, the target parent/adolescent dyad and other untreated children and caregivers in the home will complete anthropometric assessments.

Discussion

Results will determine the familial reach of TEENS+ and reveal potential mediators of treatment response, which can inform future efforts to optimize family-based lifestyle interventions.

Trial registration

TEENS + REACH was retrospectively registered in Clinicaltrials.gov March 22, 2023 (NCT05780970) as an observational study ancillary to the TEENS + clinical trial, registered February 22, 2019 (NCT03851796).

The role of parents in behavioral treatment for adolescent obesity: design and rationale for the TEENS+ randomized clinical trial

BACKGROUND

There is an urgent need for innovative approaches to adolescent obesity treatment, particularly among individuals from racially and ethnically marginalized backgrounds, who face increased risk of obesity and its associated morbidity and mortality. There is a particular dearth of research on the long-term efficacy of adolescent obesity treatments. Further, research and clinical practice guidelines consistently recommend parents' inclusion in their adolescents' obesity treatment, yet the most effective strategy to engage parents in adolescent obesity treatment remains unclear. Towards that end, this investigation will conduct a fully-powered, randomized clinical trial to examine the efficacy of two distinct approaches to involving parents in their adolescents' obesity treatment.

METHODS

Participants will be 210 12-16 year old adolescents (body mass index [BMI]≥85th percentile) and parents (BMI≥25 kg/m2) with overweight or obesity. Dyads will be randomized to one of two 4-month treatments: 1) TEENS+Parents as Coaches (PAC), engaging parents as helpers in their child's weight management via parent skills training based on authoritative parenting, or 2) TEENS+Parent Weight Loss (PWL), engaging parents in their own behavioral weight management. All adolescents will participate in the TEENS+ protocol, which includes nutrition education with dietary goals, supervised physical activity, and behavioral support, and integrates motivational interviewing to enhance treatment engagement. Assessments of anthropometrics, dietary intake, physical activity, parenting and home environment variables will be completed at 0, 2, 4, 8, and 12 months with the primary endpoint at 12-month follow-up.

DISCUSSION

Results of this investigation have the potential to significantly advance science in this area and ultimately inform clinical practice guidelines related to the role of parents in adolescent obesity treatment.

TRIAL REGISTRATION

Clinicaltrials.gov NCT03851796. Registered: February 22, 2019.

The role of parents in adolescent obesity treatment: Results of the TEENS+ randomized clinical pilot trial

BACKGROUND

The optimal role for involving parents in adolescent obesity treatment is unknown.

OBJECTIVE

To demonstrate that two parent approaches within adolescent obesity treatment are distinct, as evidenced by differential parent outcomes, and determine the preliminary efficacy of each approach on adolescent weight loss.

METHODS

Adolescent/parent dyads (N = 82; mean adolescent age = 13.7 ± 1.2 years) participated in TEENS+, a 4-month behavioural weight loss treatment. Participants were randomized to: (1) TEENS+parents as coaches (PAC; parent skills training), or (2) TEENS+parent weight loss (PWL; adult behavioural weight loss). Assessments occurred at 0, 4 (post-treatment), and 7-months. Within- and between-group repeated measures general linear mixed models examined change in parent weight (∆kg; primary outcome); parenting, feeding, weight control strategies, home environment, and adolescent body mass index (∆BMI; secondary outcomes).

RESULTS

PWL parents had greater 4-month weight losses (∆kg_0-4m  = -5.14 ± 4.87 kg) compared to PAC (-2.07 ± 3.89 kg; between-group p < 0.01). Key constructs differed between groups as expected. Both groups yielded significant within-group adolescent ∆BMI_0-4m (PWL: -0.97 ± 1.38 kg/m² vs. PAC: -0.93 ± 1.42 kg/m² ; ps < 0.01); during maintenance, adolescents in PWL had ∆BMI_4-7m increases (+0.41 ± 1.07 kg/m² ; p = 0.02) while PAC did not (+0.05 ± 1.31 kg/m² ; p = 0.82).

CONCLUSION

Parent treatments were distinct in implementation and both yielded significant 4-month adolescent weight loss. Differential weight patterns were observed during maintenance, favouring PAC, warranting further exploration.

Impact of Lifestyle Intervention Programs for Children and Adolescents with Overweight or Obesity on Body Weight and Selected Cardiometabolic Factors-A Systematic Review

Excessive body mass is a health problem among children and adolescents that contributes to the occurrence of lipid disorders and abnormal blood pressure. Effective treatment of excessive body mass in children is essential for the health of population in the future. The aim of the study was to identify universal components of lifestyle interventions in children and adolescents with overweight or obesity leading to weight loss and improvement of selected cardiometabolic parameters. The review included studies from the PubMed and Google Scholar databases published in 2010–2019, which were analyzed for eligibility criteria including age of the participants, BMI defined as overweight or obese, nutritional intervention and the assessment of BMI and/or BMI z-score and at least one lipid profile parameter. Eighteen studies were included in the review, presenting the results of 23 intervention programs in which a total of 1587 children and adolescents participated. All interventions, except one, were multi-component. Data analysis suggests a relationship between a decrease in BMI and/or BMI z-score with diet and physical activity, the involvement of a dietician/nutrition specialist and physician in the treatment team and a longer duration of intervention. Moreover, it seems that a decrease in BMI is mostly associated with decreases in total cholesterol, triglycerides, low density lipoprotein cholesterol and blood pressure. No change in BMI and/or BMI z-score is associated with no change in blood pressure. Our data can be used by public health authorities to design effective weight loss programs for children and adolescents.

Cardiometabolic efficacy of multidisciplinary weight loss interventions is not altered in adolescents with obesity initially diagnosed or with a persistent metabolic syndrome

The efficacy of weight loss interventions might be affected by the metabolic profile of adolescents with obesity. In this study, we hypothesized that the initial diagnosis of the MS, or its persistence after an intervention, will not reduce the efficacy of a 16-week multidisciplinary weight loss program. Ninety two adolescents (12-15 years; 62 girls) with obesity completed baseline anthropometric and body composition evaluation (DXA). Lipid profile, insulinemia, glycaemia and blood pressure were measured and metabolic syndrome (MS) diagnosed. The adolescents then followed a 4-month inpatient multidisciplinary weight-management program. All measurements were performed before (T0) and after 4 months of intervention (T1). Body weight, body mass index (BMI) and percentage of fat mass (%FM) decreased significantly between T0 and T1 (P< .001), with no difference in fat-free mass (kg). All metabolic variables (except blood pressure) were improved. 47.6% of the whole sample presented with MS at baseline against 35.7% at T1. Body weight (P = 0.006), BMI (P = 0.0261), %FM (P = 0.0211), hip circumference (= 0.0131), BMI percentile (P = 0.0319), and diastolic blood pressure (P = 0.0365) showed a time x group interaction and their deltas (variations between T0 and T1) were significantly different between adolescents with and without MS at baseline. There was no significant difference between adolescents with persistent and nonpersistent MS except for ΔBMI percentile that deceased significantly more in the nonpersistent group (P = 0.0115). According to our results, the efficacy of weight loss interventions is not reduced in adolescents initially diagnosed with MS or different between those who present a persistent or nonpersistent MS after the intervention.

The Study of Relationship between Nutritional Behaviors and Metabolic Indices: A Systematic Review

Metabolic indices are the wide range of characteristic factors, which can be changed during several medical conditions such as metabolic syndrome. Nutrition and related behaviors are one of the main aspects of human lifestyle which recent investigations have recognized their roles in the development of metabolic disorders. According to the spread of risky nutritional habits/behaviors due to the changes in lifestyle, and its importance in the prevalence of metabolic disorders, the authors attempted to summarize these evidences in a systematic review. The present study is a systematic review that encompasses those studies investigating the association between metabolic indices and nutritional/dietary behaviors published in two international databases in recent 11 years. Twenty-nine related articles were considered and their data were extracted. The relation between food choices and metabolic indices is more frequent in studies. While, inhibition and abstinent and eating together were two behavioral sets with the smallest share of research. Anthropometric indices have the highest rate in the evaluations. Finding the links between nutritional behavior and metabolic indices will be the key point in selecting the different types of interventions. These results will guide therapists to the accurate recognition of metabolic effects in targeting behavior for their intervention.

What Change in Body Mass Index Is Required to Improve Cardiovascular Outcomes in Childhood and Adolescent Obesity through Lifestyle Interventions: A Meta-Regression

Background: Using meta-regression, this article aims at establishing the minimum change in BMI-standard deviation score (SDS) needed to improve lipid profiles and blood pressure in children and adolescents with obesity, to aid future trials and guidelines. Methods: Studies with participants involved in lifestyle interventions, aged 4-19 years, with a diagnosis of obesity according to defined BMI thresholds, were considered for inclusion in a large systematic review. Interventions had to report pre- and post-intervention (or mean change in) BMI-SDS, plus either systolic blood pressure (SBP), high-density lipoprotein (HDL) cholesterol, low-density lipoprotein (LDL) cholesterol, and/or triglycerides (TGs). Random-effects meta-regression quantified the relationship between mean change in BMI-SDS and mean change in cardiovascular outcomes. Results: Seventy-one papers reported various cardiovascular measurements and mean change in BMI-SDS. Fifty-four, 59, 46, and 54 studies were analyzed, reporting a change in SBP, HDL, LDL, and TG, respectively. Reduction in mean BMI-SDS was significantly related to improvements in SBP, LDL, TG, and HDL (p < 0.05); BMI-SDS reductions of 1, 1.2, and 0.7 ensured a mean reduction of SBP, LDL, and TG, respectively, although an equivalent value for HDL improvement was indeterminate. Conclusion: Reductions in mean BMI-SDS of >1, >1.2, or >0.7 are likely to reduce SBP, LDL, and TG, respectively. Further studies are needed to clarify the optimal duration, intensity, and setting for interventions. Consistency is required regarding derived BMI values to facilitate future systematic reviews and meta-analyses.

An Examination of Adolescents' Values in a Motivational Interviewing-based Obesity Intervention

Objectives: In this paper, we examine values selected by adolescents as part of a motivational interviewing (MI) weight loss intervention. Methods: During a values clarification activity, adolescents (N = 52; 75.0% girls; 78.4% African-American; mean age = 13.5 ± 1.8 years; mean body mass index (BMI) = 36.8 ± 6.4 kg/m²) selected their top 5 values. Using MI, interventionists explored selected values with adolescents and related them to target behaviors to develop discrepancy and enhance motivation for engagement in behavioral weight loss behaviors. Values were categorized using thematic analysis. Frequencies of value and theme selection were examined. Results: The majority of adolescents selected values in the Health (N = 38; 73.1%), Religion/ Spirituality (N = 36; 69.2%), Personal Achievement (N = 31; 59.6%), Virtuous (N = 28; 53.8%), and Family (N = 27; 51.9%) categories. Conclusions: Values selected by adolescents with obesity can inform intervention development for this difficult to engage population.

What change in body mass index is associated with improvement in percentage body fat in childhood obesity? A meta-regression

OBJECTIVE

Using meta-regression this paper sets out the minimum change in body mass index-SD score (BMI-SDS) required to improve adiposity as percentage body fat for children and adolescents with obesity.

DESIGN

Meta-regression.

SETTING

Studies were identified as part of a large-scale systematic review of the following electronic databases: AMED, Embase, MEDLINE via OVID, Web of Science and CENTRAL via Cochrane library.

PARTICIPANTS

Individuals aged 4-19 years with a diagnosis of obesity according to defined BMI thresholds.

INTERVENTIONS

Studies of lifestyle treatment interventions that included dietary, physical activity and/or behavioural components with the objective of reducing obesity were included. Interventions of <2 weeks duration and those that involved surgical and/or pharmacological components (eg, bariatric surgery, drug therapy) were excluded.

PRIMARY AND SECONDARY OUTCOME MEASURES

To be included in the review, studies had to report baseline and post-intervention BMI-SDS or change measurements (primary outcome measures) plus one or more of the following markers of metabolic health (secondary outcome measures): adiposity measures other than BMI; blood pressure; glucose; inflammation; insulin sensitivity/resistance; lipid profile; liver function. This paper focuses on adiposity measures only. Further papers in this series will report on other outcome measures.

RESULTS

This paper explores the potential impact of BMI-SDS reduction in terms of change in percentage body fat. Thirty-nine studies reporting change in mean percentage body fat were analysed. Meta-regression demonstrated that reduction of at least 0.6 in mean BMI-SDS ensured a mean reduction of percentage body fat mass, in the sense that the associated 95% prediction interval for change in mean percentage body fat was wholly negative.

CONCLUSIONS

Interventions demonstrating reductions of 0.6 BMI-SDS might be termed successful in reducing adiposity, a key purpose of weight management interventions.

TRIAL REGISTRATION NUMBER

CRD42016025317.

Impact of motivational interviewing on outcomes of an adolescent obesity treatment: results from the MI Values randomized controlled pilot trial

The aim of this study is to examine outcomes from MI Values, a motivational interviewing (MI) intervention implemented adjunctive to obesity treatment. Adolescents (n = 99; 73% African American; 74% female; mean body mass index [BMI] percentile = 98.9 ± 1.2) were randomized to receive two MI sessions or education control. All adolescents participated in structured behavioural weight management treatment. Baseline, 3- and 6-month assessments of anthropometrics, dietary intake and physical activity were obtained. Both groups had significant reductions in BMI z-scores and energy intake and increased physical activity at 3 and 6 months (P < 0.05). MI participants reported greater reductions in 3-month energy intake compared with controls. Participation in MI is associated with reduction in energy intake, consistent with better adherence to dietitian visits previously reported from MI Values. MI might be an effective adjunct to adolescent obesity treatment; future research is needed to determine if motivational interviewing can enhance BMI outcomes, via greater adherence to behavioural intervention.

NOURISH-T: Targeting caregivers to improve health behaviors in pediatric cancer survivors with obesity

BACKGROUND

Obesity rates in pediatric cancer survivors (PCS) are alarmingly high. Although healthy lifestyle changes may prevent future health complications, promoting healthy behaviors in PCS is challenging, and few interventions have successfully addressed this issue.

PROCEDURE

This randomized control trial evaluated the feasibility and preliminary effectiveness of a parent-focused six-session intervention, NOURISH-T (Nourishing Our Understanding of Role Modeling to Improve Support and Health for Healthy Transitions), compared with enhanced usual care (EUC) on the outcomes of caregiver and PCS anthropometric measurements, eating behaviors, and physical activity. Behavioral and self-report assessments of caregivers and PCS in both conditions were conducted at baseline, postintervention, and at a 4-month follow-up.

RESULTS

In comparison to no change among EUC caregivers, NOURISH-T caregivers showed small yet significant decreases from baseline through follow-up on BMI, waist-hip ratio, and total daily caloric intake. However, there was no change with regard to daily fat and sugar intake. NOURISH-T caregivers also showed positive changes in their child feeding behaviors, including decreases in pressuring their child to eat and restricting their child's eating and increased eating together as a family. Similarly, decreases in BMI percentile, waist-hip ratio, and sugary beverage consumption were found for NOURISH-T PCS from baseline to postintervention. NOURISH-T PCS also significantly increased their daily steps, whereas EUC PCS decreased their daily steps.

CONCLUSIONS

Results suggest that an intervention targeting parents is feasible and demonstrates preliminary effectiveness. NOURISH-T showed a longer term effect on caregivers, and, although shorter term effect, a positive impact on the PCS themselves. Implications for ways to improve NOURISH-T as an intervention for increasing healthy behaviors of PCS are discussed.

Diet quality index as a predictor of treatment efficacy in overweight and obese adolescents: The EVASYON study

BACKGROUND & AIM

A diet quality index (DQI) is a tool that provides an overall score of an individual's dietary intake when assessing compliance with food-based dietary guidelines. A number of DQIs have emerged, albeit their associations with health-related outcomes are debated. The aim of the present study was to assess whether adherence to dietary intervention, and the overall quality of the diet, can predict body composition changes.

METHODS

To this purpose, overweight/obese adolescents (n = 117, aged: 13-16 years; 51 males, 66 females) were recruited into a multi-component (diet, physical activity and psychological support) family-based group treatment programme. We measured the adolescents' compliance and body composition at baseline and after 2 months (intensive phase) and 13 months (extensive phase) of follow-up. Also, at baseline, after 6 months, and at the end of follow-up we calculated the DQI.

RESULTS

Global compliance with the dietary intervention was 37.4% during the intensive phase, and 14.3% during the extensive phase. Physical activity compliance was 94.1% at 2-months and 34.7% at 13months and psychological support compliance were growing over the intervention period (10.3% intensive phase and 45.3% during extensive phase). Adolescents complying with the meal frequency criteria at the end of the extensive phase had greater reductions in FMI z-scores than those did not complying (Cohen's d = 0.53). A statistically significant association was observed with the diet quality index. DQI-A variation explained 98.1% of BMI z-score changes and 95.1% of FMI changes.

CONCLUSIONS

We conclude that assessment of changes in diet quality could be a useful tool in predicting body composition changes in obese adolescents involved in a diet and physical activity intervention programme backed-up by psychological and family support.

Strategies to Recruit a Diverse Low-Income Population to Child Weight Management Programs From Primary Care Practices

Purpose and Objectives

Primary care practices can be used to engage children and families in weight management programs. The Texas Childhood Obesity Research Demonstration (TX CORD) study targeted patients at 12 primary care practices in diverse and low-income areas of Houston, Texas, and Austin, Texas for recruitment to a trial of weight management programs. This article describes recruitment strategies developed to benefit both families and health care practices and the modification of electronic health records (EHRs) to reflect recruitment outcomes.

Intervention Approach

To facilitate family participation, materials and programs were provided in English and Spanish, and programs were conducted in convenient locations. To support health care practices, EHRs and print materials were provided to facilitate obesity recognition, screening, and study referral. We provided brief training for providers and their office staffs that covered screening patients for obesity, empathetic communication, obesity billing coding, and use of counseling materials.

Evaluation Methods

We collected EHR data from 2012 through 2014, including demographics, weight, and height, for all patients aged 2 to 12 years who were seen in the 12 provider practices during the study’s recruitment phase. The data of patients with a body mass index (BMI) at or above the 85th percentile were compared with the same data for patients who were referred to the study and patients who enrolled in the study. We also examined reasons that patients referred to the study declined to participate.

Results

Overall, 26% of 7,845 patients with a BMI at or above the 85th percentile were referred to the study, and 27% of referred patients enrolled. Enrollment among patients with a BMI at or above the 85th percentile was associated with being Hispanic and with more severe obesity than with patients of other races/ethnicities or less severe obesity, respectively. Among families of children aged 2 to 5 years who were referred, 20% enrolled, compared with 30% of families of older children (>5 y to 12 y). Referral rates varied widely among the 12 primary care practices, and referral rates were not associated with EHR modifications.

Implications for Public Health

Engagement and recruitment strategies for enrolling families in primary care practice in weight management programs should be strengthened. Further study of factors associated with referral and enrollment, better systems for EHR tools, and data on provider and office adherence to study protocols should be examined. EHRs can track referral and enrollment to capture outcomes of recruitment efforts.

Recruitment and retention in obesity prevention and treatment trials targeting minority or low-income children: a review of the clinical trials registration database

Background

Efforts to recruit and retain participants in clinical trials are challenging, especially in studies that include minority or low-income children. To date, no studies have systematically examined recruitment and retention strategies and their effectiveness in working successfully with this population. We examined strategies employed to recruit or retain minority or low-income children in trials that included an obesity-related behavior modification component.

Methods

First, completed home-, community-, and school-based trials involving minority or low-income children aged 2–17 years were identified in a search of the ClinicalTrials.gov registry. Second, a PubMed search of identified trials was conducted to locate publications pertinent to identified trials. Recruitment and retention rates were calculated for studies that included relevant information.

Results

Our final analytic sample included 43 studies. Of these, 25 studies reported recruitment or retention strategies, with the amount of information varying from a single comment to several pages; 4 published no specific information on recruitment or retention; and 14 had no publications listed in PubMed. The vast majority (92 %) of the 25 studies reported retention rates of, on average, 86 %. Retention rates were lower in studies that: targeted solely Hispanics or African Americans (vs. mixed races of African Americans, whites, and others); involved children and parents (vs. children only); focused on overweight or obese children (vs. general children), lasted ≥1 year (vs. <1 year), were home or community-based (vs. school-based), included nutrition and physical activity intervention (vs. either intervention alone), had body mass index or other anthropometrics as primary outcome measures (vs. obesity-related behavior, insulin sensitivity, etc.). Retention rates did not vary based on child age, number of intervention sessions, or sample size.

Conclusions

Variable amounts of information were provided on recruitment and retention strategies in obesity-related trials involving minority or low-income children. Although reported retention rates were fairly high, a lack of reporting limited the available information. More and consistent reporting and systematic cataloging of recruitment and retention methods are needed. In addition, qualitative and quantitative studies to inform evidence-based decisions in the selection of effective recruitment and retention strategies for trials including minority or low-income children are warranted.

Do Overweight Adolescents Adhere to Dietary Intervention Messages? Twelve-Month Detailed Dietary Outcomes from Curtin University's Activity, Food and Attitudes Program

Dietary components of adolescent obesity interventions are rarely evaluated with comprehensive reporting of dietary change. The objective was to assess dietary change in overweight adolescents, including adherence to dietary intervention. The dietary intervention was part of a multi-component intervention (CAFAP) targeting the physical activity, sedentary and healthy eating behaviors of overweight adolescents (n = 69). CAFAP was a staggered entry, within-subject, waitlist controlled clinical trial with 12 months of follow up. Diet was assessed using three-day food records and a brief eating behavior questionnaire. Changes in dietary outcomes were assessed using linear mixed models, adjusted for underreporting. Food record data suggested reduced adherence to dietary intervention messages over time following the intervention, despite conflicting information from the brief eating behavior questionnaire. During the intervention, energy intake was stable but favorable nutrient changes occurred. During the 12 month maintenance period; self-reported eating behaviors improved, energy intake remained stable but dietary fat and saturated fat intake gradually returned to baseline levels. Discrepancies between outcomes from brief dietary assessment methods and three-day food records show differences between perceived and actual intake, highlighting the need for detailed dietary reporting. Further, adherence to dietary intervention principles reduces over time, indicating a need for better maintenance support.

Cardiometabolic and Fitness Improvements in Obese Girls Who Either Gained or Lost Weight during Treatment

OBJECTIVE

To evaluate the quality of weight change (change in fat mass vs fat-free mass [FFM]), changes in cardiorespiratory fitness (CRF), and frequencies of metabolic risk factors in adolescent females with obesity who either lost or gained weight following lifestyle treatment.

STUDY DESIGN

Fifty-eight girls (mean age = 13.0 ± 1.6 years; 77% black; mean body mass index = 36.5 ± 4.5 kg/m(2)) completed a 6-month lifestyle intervention combining dietary and behavioral counseling with aerobic and resistance exercise training. We examined baseline to 6-month differences in weight (kg), body composition, CRF, and frequencies of metabolic risk factors between weight loss and weight gain groups.

RESULTS

In the weight loss group, body weight (-4.50 ± 3.53 kg, P < .001), fat mass (-4.50 ± 2.20 kg, P < .001), and body fat percentage (-2.97% ± 1.45%, P < .001) decreased, and FFM was unchanged at 6 months. In the weight gain group, body weight (4.50 ± 2.20 kg, P < .001), fat mass (1.52 ± 3.16 kg, P < .024), and FFM (2.99 ± 2.45 kg, P < .001) increased, and body fat percentage was unchanged. Both groups improved CRF (P < .05). Frequencies of metabolic risk factors were reduced across all participants after the 6-month treatment.

CONCLUSIONS

Participation in a weight management program might elicit health improvements in obese adolescent females who increase weight and fat mass, provided that FFM gains are sufficient to negate increases in body fat percentage.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT00167830.

Motivational interviewing targeting diet and physical activity improves adherence to paediatric obesity treatment: results from the MI Values randomized controlled trial

BACKGROUND

Adherence is a challenge in obesity treatment. Motivational interviewing (MI) may promote patient adherence. MI Values is a randomized controlled trial of MI implemented as an adjunct to an adolescent obesity treatment [Teaching Encouragement Exercise Nutrition Support (T.E.E.N.S.)].

OBJECTIVE

Assess effects of MI Values on T.E.E.N.S. attrition and adherence.

METHODS

Participants were randomized to MI (n = 58) or control (n = 41). At weeks 1 and 10, MI participants had brief MI sessions; controls viewed health education videos. All participants continued with T.E.E.N.S. (biweekly dietitian and behavioural support visits; 3 times per week supervised physical activity). Assessments were repeated at baseline, 3 and 6 months. T-tests and chi-square analyses examined T.E.E.N.S. attrition and adherence by group.

RESULTS

Adolescents (N = 99) were primarily African-American (73%) females (74%); age = 13.8 ± 1.8 years, body mass index percentile = 98.0 ± 1.2. Compared with controls, MI participants had greater 3-month adherence overall (89.2% vs. 81.0%, P = 0.040), and to dietitian (91.3% vs. 84.0%; P = 0.046) and behavioural support (92.9% vs. 85.2%; P = 0.041) visits, and greater 6-month adherence overall (84.4% vs. 76.2%, P = 0.026) and to behavioural support visits (87.5% vs. 78.8%, P = 0.011).

CONCLUSIONS

MI enhanced adherence to this obesity intervention. MI Values is the first study to examine the impact of MI on treatment adherence among obese, primarily African-American adolescents.

Design and rationale for NOURISH-T: a randomized control trial targeting parents of overweight children off cancer treatment

Approximately 40% of off-treatment pediatric cancer survivors (PCS) are overweight or obese, which increases their risk for negative long-term physical health complications. Consistent with the Institute of Medicine's (IOM) emphasis on patients transitioning from treatment to cancer survivorship and increasing long-term healthy behaviors in these survivors, we plan to conduct a pilot RCT to address the increasing overweight/obesity rates among PCS by targeting their caregivers as agents for PCS behavior change. We plan to focus on parents' behaviors, attitudes and roles in promoting healthier eating and physical activity (PA) in PCS and adapt an evidence-informed, manualized parent intervention - NOURISH - found to be effective for parents of overweight and obese children and adolescents in reducing child and adolescent BMI. We plan to adapt NOURISH for caregivers of 5-12 year old PCS (6 months-4 years off active cancer treatment). Our pilot feasibility RCT - NOURISH-T (Nourishing Our Understanding of Role modeling to Improve Support for Healthy Transitions) evaluates: 1) the preliminary efficacy of NOURISH-T for PCS, compared with an Enhanced Usual Care (EUC) control condition, and 2) factors to consider to improve future adaptations of the intervention. The project will enroll caregivers of PCS at two pediatric oncology clinics into the 6-week intervention (or EUC) with assessments occurring pre- and post-6 weeks of intervention, and at a 4-month follow-up.

The impact of Curtin University's activity, food and attitudes program on physical activity, sedentary time and fruit, vegetable and junk food consumption among overweight and obese adolescents: a waitlist controlled trial

Background

To determine the effects of participation in Curtin University's Activity, Food and Attitudes Program (CAFAP), a community-based, family-centered behavioural intervention, on the physical activity, sedentary time, and healthy eating behaviours of overweight and obese adolescents.

Methods

In this waitlist controlled clinical trial in Western Australia, adolescents (n = 69, 71% female, mean age 14.1 (SD 1.6) years) and parents completed an 8-week intervention followed by 12 months of telephone and text message support. Assessments were completed at baseline, before beginning the intervention, immediately following the intervention, and at 3-, 6-, and 12- months follow-up. The primary outcomes were physical activity and sedentary time assessed by accelerometers and servings of fruit, vegetables and junk food assessed by 3-day food records.

Results

During the intensive 8-week intervention sedentary time decreased by −5.1 min/day/month (95% CI: −11.0, 0.8) which was significantly greater than the rate of change during the waitlist period (p = .014). Moderate physical activity increased by 1.8 min/day/month (95% CI: −0.04, 3.6) during the intervention period, which was significantly greater than the rate of change during the waitlist period (p = .041). Fruit consumption increased during the intervention period (monthly incidence rate ratio (IRR) 1.3, 95% CI: 1.10, 1.56) and junk food consumption decreased (monthly IRR 0.8, 95% CI: 0.74, 0.94) and these changes were different to those seen during the waitlist period (p = .004 and p = .020 respectively).

Conclusions

Participating in CAFAP appeared to have a positive influence on the physical activity, sedentary and healthy eating behaviours of overweight and obese adolescents and many of these changes were maintained for one year following the intensive intervention.

Trial Registration

Australia and New Zealand Clinical Trials Registry ACTRN12611001187932

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.

A school nurse-delivered intervention for overweight and obese adolescents

BACKGROUND

Models are needed for implementing weight management interventions for adolescents through readily accessible venues. This study evaluated the feasibility and efficacy of a school nurse-delivered intervention in improving diet and activity and reducing body mass index (BMI) among overweight and obese adolescents.

METHODS

Six high schools were randomized to either a 6-session school nurse-delivered counseling intervention utilizing cognitive-behavioral techniques or nurse contact with provision of information. Eighty-four overweight or obese adolescents in grades 9 through 11 completed behavioral and physiological assessments at baseline and 2- and 6-month follow-ups.

RESULTS

At 2 months, intervention participants ate breakfast on more days/week (difference = 1.01 days; 95% CI: 0.11, 1.92), and had a lower intake of total sugar (difference = -45.79 g; 95% CI: -88.34, -3.24) and added sugar (difference = -51.35 g; 95% CI: -92.45, -10.26) compared to control participants. At 6 months, they were more likely to drink soda ≤ one time/day (OR 4.10; 95% CI: 1.19, 16.93) and eat at fast food restaurants ≤ one time/week (OR 4.62; 95% CI: 1.10, 23.76) compared to control participants. There were no significant differences in BMI, activity, or caloric intake.

CONCLUSION

A brief school nurse-delivered intervention was feasible, acceptable, and improved selected obesogenic behaviors, but not BMI.

Nourishing Our Understanding of Role Modeling to Improve Support and Health (NOURISH): design and methods

Pediatric overweight is associated with numerous physical and psychological health risks, and overweight children are at significant risk for obesity in adulthood. African-American children are at particularly high risk for obesity and related health complications. However, this racial group has traditionally had limited access to obesity treatment and relatively few studies have included sufficient numbers of lower-SES, African American participants. Further, although parental involvement in treatment for pediatric overweight has been found to be beneficial, few studies have examined the efficacy of offering treatment exclusively to parents, a potentially cost-effective approach which could benefit the entire family. This pilot project will evaluate the efficacy of an intensive parenting intervention, (NOURISH; Nourishing Our Understanding of Role modeling to Improve Support and Health), targeting racially diverse parents of overweight children (ages 6-11). NOURISH addresses several urgent research priorities by targeting the underserved and addressing the significant disparity in obesity treatment services. Parents meeting study criteria (having a child between the ages of 6 and 11 with a BMI ≥ the 85th percentile) will be offered participation in the randomized trial comparing NOURISH with a control group. We hypothesize that children whose parents participate in NOURISH will manifest greater decreases in BMI, and greater improvements in dietary intake, and quality of life compared to children whose parents do not participate. This study is designed explicitly to gather preliminary feasibility, acceptability, and effectiveness data to inform a subsequent larger randomized controlled trial.

A values-based Motivational Interviewing (MI) intervention for pediatric obesity: study design and methods for MI Values

To reduce pediatric obesity in clinical settings, multidisciplinary behaviorally-based treatment programs are recommended. High attrition and poor compliance are two difficulties frequently encountered in such programs. A brief, empathic and directive clinical intervention, Motivational Interviewing (MI), might help address these motivational and behavioral issues, ultimately resulting in more positive health outcomes. The efficacy of MI as an adjunct in the treatment of pediatric obesity remains relatively understudied. MI Values was developed to implement within an existing multidisciplinary treatment program for obese, ethnically diverse adolescents, the T.E.E.N.S. Program (Teaching, Encouragement, Exercise, Nutrition, Support). T.E.E.N.S. participants who consent to MI Values are randomized to either MI or an education control condition. At weeks 1 and 10 of T.E.E.N.S. participation, the subset of participants assigned to the MI condition engages in individual MI sessions and control participants view health education videos. All MI sessions are audiotaped and coded to monitor treatment fidelity, which has been satisfactory thus far. Participants complete comprehensive assessments at baseline, 3- and 6-month follow-ups. We hypothesize that MI participants will demonstrate greater reductions in Body Mass Index (BMI) percentile, improved diet and physical activity behaviors, better compliance with T.E.E.N.S., and lower attrition than participants in the control group. We present study design and methods for MI Values as well as data on feasibility of recruitment methods and treatment integrity. At study completion, findings will contribute to the emerging literature examining the efficacy of MI in the treatment of pediatric obesity.