Transcript Pediatric Overweight and Obesity Wendy Novoa, M.S. November 14, 2006

Pediatric
Overweight and Obesity
Wendy Novoa, M.S.
November 14, 2006
Overview
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Obesity Trends and Prevalence
Definition of Overweight and Obesity
Causes of Overweight and Obesity
Medical and Psychosocial Complications
Empirically Supported Treatments
Project STORY
Trends and Prevalence
Obesity Trends* Among U.S. Adults
BRFSS, 1985
(*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” person)
No Data
<10%
10%–14%
Obesity Trends* Among U.S. Adults
BRFSS, 1986
(*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” person)
No Data
<10%
10%–14%
Obesity Trends* Among U.S. Adults
BRFSS, 1987
(*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” person)
No Data
<10%
10%–14%
Obesity Trends* Among U.S. Adults
BRFSS, 1988
(*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” person)
No Data
<10%
10%–14%
Obesity Trends* Among U.S. Adults
BRFSS, 1989
(*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” person)
No Data
<10%
10%–14%
Obesity Trends* Among U.S. Adults
BRFSS, 1990
(*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” person)
No Data
<10%
10%–14%
Obesity Trends* Among U.S. Adults
BRFSS, 1991
(*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” person)
No Data
<10%
10%–14%
15%–19%
Obesity Trends* Among U.S. Adults
BRFSS, 1992
(*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” person)
No Data
<10%
10%–14%
15%–19%
Obesity Trends* Among U.S. Adults
BRFSS, 1993
(*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” person)
No Data
<10%
10%–14%
15%–19%
Obesity Trends* Among U.S. Adults
BRFSS, 1994
(*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” person)
No Data
<10%
10%–14%
15%–19%
Obesity Trends* Among U.S. Adults
BRFSS, 1995
(*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” person)
No Data
<10%
10%–14%
15%–19%
Obesity Trends* Among U.S. Adults
BRFSS, 1996
(*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” person)
No Data
<10%
10%–14%
15%–19%
Obesity Trends* Among U.S. Adults
BRFSS, 1997
(*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” person)
No Data
<10%
10%–14%
15%–19%
≥20%
Obesity Trends* Among U.S. Adults
BRFSS, 1998
(*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” person)
No Data
<10%
10%–14%
15%–19%
≥20%
Obesity Trends* Among U.S. Adults
BRFSS, 1999
(*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” person)
No Data
<10%
10%–14%
15%–19%
≥20%
Obesity Trends* Among U.S. Adults
BRFSS, 2000
(*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” person)
No Data
<10%
10%–14%
15%–19%
≥20%
Obesity Trends* Among U.S. Adults
BRFSS, 2001
(*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” person)
No Data
<10%
10%–14%
15%–19%
20%–24%
≥25%
Obesity Trends* Among U.S. Adults
BRFSS, 2002
(*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” person)
No Data
<10%
10%–14%
15%–19%
20%–24%
≥25%
Obesity Trends* Among U.S. Adults
BRFSS, 2003
(*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” person)
No Data
<10%
10%–14%
15%–19%
20%–24%
≥25%
Obesity Trends* Among U.S. Adults
BRFSS, 2004
(*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” person)
No Data
<10%
10%–14%
15%–19%
20%–24%
≥25%
Obesity Trends* Among U.S. Adults
BRFSS, 2005
(*BMI ≥30, or ~ 30 lbs overweight for 5’ 4” person)
No Data
<10%
10%–14%
15%–19%
20%–24%
25%–29%
≥30%
Obesity Trends* Among U.S. Adults
BRFSS, 1990, 1995, 2005
(*BMI 30, or about 30 lbs overweight for 5’4” person)
1995
1990
2005
No Data
<10%
10%–14%
15%–19%
20%–24%
25%–29%
≥30%
Obesity and Overweight in
Children and Adolescents
• Prevalence
– 33% overweight (85th-95th percentile)
– 16% obese (at or above 95th percentile)
– Children in rural areas have a 54.7% increased
risk of obesity
Prevalence
•
Doubled among children 6-11 and tripled among
adolescents 12-17 from 1976-1980 to 1999-2000
(Dietz, 2004)
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1999-2000 data indicate that 31% of children
and adolescents are overweight and 16% are
obese
(Hedley, et al., 2004)
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Black and Mexican American children
disproportionately affected
(Dietz, 2004)
Higher Prevalence in Rural Areas
• Research suggests that children in rural areas have
a 54.7% increased risk of obesity compared to
urban children
• Despite increased risk, many individuals living in
rural areas are medically underserved due to:
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Limited health promotion programs
Higher rates of poverty
Higher percentages of patients without health insurance
Lower numbers of health care providers
In Florida
• 60% of Florida adults are overweight or obese
(CDC BRFSS, 2004)
• 26% of Florida high-school students are
overweight or at risk of becoming overweight
(CDC YRBSS, 2003)
• 21% of non-Hispanic white adults, 33% of nonHispanic black adults, and 26% of Hispanic adults
in Florida are obese
(CDC BRFSS, 2004)
• 28% of low-income children between 2 and 5
years of age in Florida are overweight or at risk of
becoming overweight
(CDC PedNSS, 2003)
Costs
• State specific obesity attributable medical
expenditures: $87 million – $7.7 billion
(Ogden et al., 2006)
• Between 1979-1980, the number of obesity and
obesity-related hospital discharges tripled
(Goran, Ball, & Cruz, 2003)
Definition of Overweight and
Obesity
Definition for Adults
• Definition of Obesity and Overweight in Adults*
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BMI under 18.5: Underweight
BMI 18.6-24.9: Healthy weight
BMI 25-29.9: Overweight
BMI 30 or higher: Obese
*Although BMI correlates with the amount of body
fat, BMI does not directly measure body fat. Some
people, such as athletes, may have a BMI that
identifies them as overweight even though they do
not have excess body fat
What is BMI?
• Body Mass Index (BMI) =
weight (kg)/height (m)2
• BMI is a screening tool, not a diagnostic tool
• In children, BMI is gender and age specific, so
BMI-for-age is used
• No gender or age distinctions are made for adult
BMI calculations
(CDC, 2005)
Advantages of BMI-for-age
• Correlates with clinical risk factors for
cardiovascular disease
• Compares well with measures of body fat
• Recommended by expert committees to
evaluate overweight status in children and
adults
• Tracks well into adulthood
(CDC, 2005)
Link to Adult Obesity
• Overweight in children associated with
more severe obesity among adults
• Some studies suggest up to 80% of
overweight adolescents become obese
adults
• An increased risk exists for girls
(Dietz, 2004)
Tracking BMI-for-Age from Birth to 18 Years with
Percent of Overweight Children who Are Obese at Age 251
100
BMI < 85th
BMI >=85th
BMI >=95th
% obese as adults
83
80
69
60
77
75
67
55
52
36
40
26
20
16 17
15
19
12
11
10
9
10 to 15
15 to 18
0
Birth
Whitaker et al. NEJM:
1997;337:869-873
1 to 3
3 to 6
6 to 10
Age of child (years)
Definition for Children and
Adolescents
• Definition of Obesity and Overweight in
Children and Adolescents:
– Sex and Age-specific BMI
– Obese is at or above 95th percentile, based on
revised CDC growth charts
– Overweight is at or above 85th percentile
(U.S. Department of Health and Human Services, 2001)
CDC Growth Charts
• Percentile curves that illustrate the distribution of
selected body measurements in U.S. children
• The 1977 growth charts were developed by the
National Center for Health Statistics as a clinical
tool for health professionals to determine if the
growth of a child is adequate
• The 1977 charts were adopted by the World
Health Organization for international use
(CDC, 2005)
CDC Growth Charts
• The 2000 CDC growth charts represent the
revised version of the 1977 NCHS growth
charts
• The revised growth charts consist of 16
charts, 8 for boys and 8 for girls
(CDC, 2005)
For Children, BMI Changes with Age
BMI
BMI
Example: 95th
Percentile
Tracking
Boys: 2 to 20 years
BMI
BMI
Age
BMI
2 yrs
4 yrs
9 yrs
13 yrs
19.3
17.8
21.0
25.1
Can you see risk?
• This boy is 3 years, 3 weeks old
• Is his BMI-for-age in the >85th to
<95th percentile?
• Is he at risk for overweight?
Photo from UC Berkeley Longitudinal Study,
1973
Plotted BMI-for-Age
BMI
BMI
Boys: 2 to 20 years
Measurements:
Age=3 y, 3 wks
Height=100.8 cm
(39.7 in)
Weight=18.6 kg
(41 lb)
BMI=18.3
BMI-for-age=
BMI
BMI
>95th percentile
Overweight
Can you see risk?
• This girl is 4 years, 4 weeks old
• Is her BMI-for-age in the >85th to
<95th percentile?
• Is she at risk for overweight?
Photo from UC Berkeley Longitudinal Study,
1974
Plotted BMI-for-Age
BMI
Girls: 2 to 20 years
BMI
Measurements:
Age= 4 y, 4 wks
Height=106.4 cm
(41.9 in)
Weight=15.7 kg
(34.5 lb)
BMI=13.9
BMI
BMI
BMI-for-age=
10th percentile
Normal
Causes
Causes for Overweight
• Overweight and obesity result from an energy
imbalance. This involves eating too many calories
and not getting enough physical activity
• Body weight is the result of genes, metabolism,
behavior, environment and culture
• Behavior and environment are the greatest areas
for prevention and treatment actions
(CDC, 2005)
Causes for Overweight
"Despite obesity having strong genetic
determinants, the genetic composition of the
population does not change rapidly. Therefore, the
large increase in . . . [obesity] must reflect major
changes in non-genetic factors." *
* from Hill, J. O., & Trowbridge, F. L. (1998) Childhood obesity: future
directions and research priorities. Pediatrics. Supplement: 571
Toxic Environment
"We take Joe Camel off the billboard
because it is marketing bad products to our
children, but Ronald McDonald is
considered cute. How different are they in
their impact, in what they're trying to get
kids to do?"
-Kelly Brownell, Yale University
Toxic Environment
• Encourages overeating and inactivity while at the
same time discriminates against overweight or
obese individuals
• Greater access to pre-packaged, calorie dense
foods anytime, anywhere
• Portion sizes have increased over last 20 yrs.
COFFEE
20 Years Ago
Today
Coffee
(with whole milk and sugar)
Mocha Coffee
(with steamed whole milk and
mocha syrup)
45 calories
8 ounces
How many calories
are in today's coffee?
COFFEE
20 Years Ago
Today
Coffee
(with whole milk and sugar)
Mocha Coffee
(with steamed whole milk and
mocha syrup)
45 calories
8 ounces
350 calories
16 ounces
Calorie Difference: 305 calories
BAGEL
20 Years Ago
140 calories
3-inch diameter
Today
How many calories
are in this bagel?
BAGEL
20 Years Ago
140 calories
3-inch diameter
Today
350 calories
6-inch diameter
Calorie Difference: 210 calories
CHEESEBURGER
20 Years Ago
333 calories
Today
How many calories are
in today’s cheeseburger?
CHEESEBURGER
20 Years Ago
Today
333 calories
590 calories
Calorie Difference: 257 calories
SODA
20 Years Ago
85 Calories
6.5 ounces
Today
How many calories are
in today’s portion?
SODA
20 Years Ago
85 Calories
6.5 ounces
Today
250 Calories
20 ounces
Calorie Difference: 165 Calories
CHEESECAKE
20 Years Ago
260 calories
3 ounces
Today
How many calories are in
today’s large portion of
cheesecake?
CHEESECAKE
20 Years Ago
Today
260 calories
3 ounces
640 calories
7 ounces
Calorie Difference: 380 calories
CHICKEN CAESAR SALAD
20 Years Ago
390 calories
1 ½ cups
Today
How many calories are in
today’s chicken Caesar
salad?
CHICKEN CAESAR SALAD
20 Years Ago
390 calories
1 ½ cups
Today
790 calories
3 ½ cups
Calorie Difference: 400 calories
Child and Adolescent
Nutrition
• Less than 40% of children and adolescents in the
United States meet the U.S. dietary guidelines for
saturated fat
(US Dpt. of Agriculture, 1998)
• Almost 80% of young people do not eat the
recommended number of servings of fruits and
vegetables
(Grunbaum et al., 2003)
• Only 39% of children ages 2–17 meet the USDA’s
dietary recommendation for fiber (found primarily
in dried beans and peas, fruits, vegetables, and
whole grains)
(Lin et al., 2001)
Child and Adolescent Nutrition
• 85% of adolescent females do not consume
enough calcium
(NIH, 1997)
• During the last 25 years consumption of milk has
decreased 36% among adolescent females
(Cavadini et al., 2000)
• From 1978 to 1998, average daily soft drink
consumption almost doubled among adolescent
girls, increasing from 6 oz to 11 oz, and almost
tripled among adolescent boys, from 7 oz to 19 oz.
(US Dpt. of Agriculture, 1998)
Physical Activity
• Overweight children average 3,000 less
steps per day than normal weight children
(Tudor-Locke et al., 2004)
• 71% of 9th graders but only 40% of 12th
graders enrolled in a physical education
class in 2003
(Grunbaum et al., 2004)
Physical Activity
• The percentage of high school students who
attended physical education classes daily
decreased from 42% in 1991 to 25% in 1995
• In 2003, 38% of 9th graders but only 18% of 12th
graders attended a daily physical education class
• Among the 56% of students who are enrolled in a
physical education class, 80% exercised or played
sports for 20 minutes or more during an average
class
(Grunbaum et al., 2004)
Secondary Complications
Risks of Obesity and Overweight
• 60% of overweight children have at least one risk
factor for cardiovascular disease, 25% have at
least two risk factors:
–  BP
– Hyperlipidemia
– Hyperinsulinemia
• Increased risk of endocrine and pulmonary
problems, orthopedic, gastroenterological, and
neurological difficulties
(Strauss, 1999)
Risks of Obesity and Overweight
• Type 2 Diabetes account for 8-45% of all new cases of
diabetes
(Dietz, 2004)
• Risk factors of Type 2 Diabetes include:
– increased body fat and abdominal fat
– insulin resistance
– ethnicity (greater risk in African-American, Hispanic, and Native
American children)
– onset of puberty
(Goran, Ball, & Cruz, 2003)
• Prevalence of metabolic syndrome increased with the
severity of obesity
– Reached 50% in severely obese youngsters
– Each half-unit increase in BMI was associated with 1.55 odds ratio
increased risk of metabolic syndrome
(Weiss, et al., 2004)
Obesity and Overweight in
Children and Adolescents
• Medical
Complications:
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Endocrine
Pulmonary
Orthopedic
Gastroenterological
Neurological
Cardiovascular
Metabolic Syndrome
• Psychosocial
Complications:
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Social Stigmatization
Teasing
Depression
Psychosocial
Maladjustment
– Body Image
– Body Dissatisfaction
– Self-Esteem
Self-Esteem
• Women who were overweight as older adolescents
were less likely to be married, had less education,
and lower household income than women who had
not been overweight at 7-year-follow-up
(Gortmaker, Must, Perrin, Sobol, & Deitz, 1993)
• Body dissatisfaction reported in girls as young as
9 years old, and internalization of “thin ideal”
predicted to be a critical influence on development
of body dissatisfaction
(Sands & Wardle, 2003)
Social Stigmatization
• Replicated a 1961 study
• Found rates of stigmatization is getting worse
• 458, 5th and 6th grade children ranked drawings of
students about how much they liked the student in
the picture
• Students were overweight, disabled, and “normal”
(normal weight or no disability)
• Students ranked the overweight child lowest
• Girls ranked the overweight student lower than
boys
(Latner & Stunkard, 2003)
Body Image
• Consistently replicated finding that obese children
have a more negative body image than their peers
(French et al., 1995; Manus & Killeeen, 1995)
• 13601, 9-12 graders compared self-reported
suicidal ideation and attempts to perceived weight
and BMI (calculated from self-reported ht and wt)
• Negative body image was a risk factor for suicidal
ideation even when BMI was controlled for
• In other words, perceptions of weight were more
important than actual weight with regard to mood
and suicide risk
(Eaton et al., 2005)
Self-Esteem
• Mixed results in previous literature
including:
– Lower self-esteem than non-obese peers
– No differences
– Those that find lower self-esteem is not
significantly lower in obese populations when
body image is controlled for
(Gortmaker, 1993; French et al., 1995; Manus & Killeeen, 1995; Strauss, 2000)
Self-Esteem
• Higher body weight related to lower
Physical Appearance subscale scores and
mean self-concept
(O’Dea & Abraham, 1999)
• Decreases in physical and social functioning
for overweight vs. non-overweight children
(Williams, Wake, Hesketh, 2005)
Self-Esteem
• Emphasis of slimness was most strongly linked to:
– Body dissatisfaction
– Disordered eating
– Global self-esteem
• An emphasis on popularity and hours spent
watching television related to body dissatisfaction
• Sport participation seemed to serve as a protective
function
(Tiggemann, 2001)
Self-Esteem
• Current research indicates lower than normal weight peers
– Higher body weight students had lower ratings of global selfconcept
– Overweight 9-10 year old students experienced significant declines
in self-esteem over 4 years
• Why is this important?
– Positive self-esteem associated with positive adjustment and
functioning while negative self-esteem associated with behavior
disorders and negative or depressed mood
Why lower Self-Esteem?
• Developmental Changes:
– Self-esteem gets lower with increasing age
(Strauss, 2000)
• Ethnic differences:
– White females report lower self-esteem than African
American females
(Strauss, 2000)
• Parental concern:
– Obese 10 to 16 year olds more significantly correlated
with self-esteem problems than did BMI
(Stradmeijer et al., 2000)
– Lower body esteem in 5 yr old girls associated with
higer parental concern about weight, independent of
actual weight
(Davison & Birch, 2001)
Why lower Self-Esteem?
• Teasing:
– Predictive of lower self-esteem and poorer body image
for females and males
(Gleason et al., 2000)
• Body image:
– Females at greater risk for self-esteem problems due to
importance of for self-esteem, but risks increasing for
males
(Manus & Killeeen, 1995)
• Locus of Control:
– 9-11 yr old children reported lower self-esteem if they
believed they were responsible for their overweight
compared to those who didn’t believe they were
responsible
(Pierce & Wardle, 1997)
Why lower Self-Esteem?
• Increased discrepancy between media images and
average individual in the U.S.
– 20 yrs. ago the average model was only 8% thinner than
the average American, today is 23% thinner
– If life size, Barbie would be 5’6” tall, 110 lbs. and
measure 39, 18, 33
• Back too weak to hold up chest, waist too narrow to hold more
than ½ a liver and few centimeters of bowels
• Diet industry alone worth estimated $100 billion a
year
– Overwhelmed with messages about weight loss,
negative images of fat and “fat” people
Unsafe (and ineffective)
Potential Consequences
• A large number of high school students use unsafe
methods to lose or maintain weight
• A nationwide survey found that during the 30 days
preceding the survey:
– 13% of students went without eating for one or more
days
– 6% had vomited or taken laxatives
– 9% had taken diet pills, powders, or liquids without the
advice of their physicians
(Grunbaum et al., 2003)
Pediatric Weight Management
Programs
Pediatric Obesity and Weight
Management Programs
• Essential components include:
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Behavioral goals (dietary and physical activity)
Medical goals to reduce secondary complications
Gradual, permanent weight loss
Parent involvement
• Empirically Supported Treatments exist
• Epstein’s Stop Light program
• Golan’s program
Effects of Weight Management
Programs
• Adolescents in weight loss camps showed
significant:
– Decrease in body dissatisfaction
– Increase in global self-worth, athletic competence, and
physical appearance
(Walker, Gately, Bewick, & Hill, 2003)
• Children 10-15 yo in weight management program
with no significant change in average weight or
BMI showed a significant:
– Decrease in self-concept
– Greatest changes in self-concept score
(Cameron, 1999)
Program Recommendations
• Surgeon General Recommendations:
– Recommend Public Health Response settings
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•
•
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Families and Communities
Schools
Health Care
Media and Communication
(U.S. Department of Health and Human Services, 2001)
Program Recommendations
• Expert Committee Recommendations:
– Children w/BMI 85th percentile should undergo tx
– Tx should include assessment of readiness to engage in
program, assessment of diet and physical activity
habits, primary goal should be healthy eating and
activity
– Tx should begin early, involve families, and institute
permanent changes
– Parenting skills are foundation for successful
intervention w/gradual targeted increases in activity and
targeted reductions in high-fat, high-calorie foods
– Ongoing support for families after initial weightmanagement programs
(Barlow & Dietz, 1998)
Empirically Supported
Treatments
• Chambless Criteria for Well Established Txs
– Minimum of 2 well-designed between group studies
demonstrating efficacy of a particular treatment when
compared to psychological placebo or alternative
treatment
– Equivalent to an already established treatment
– Inclusion of treatment manuals
– Clear definition of sample characteristics
– Treatment effects must be demonstrated by at least two
investigators
(Jelalian & Saelens, 1999)
Empirically Supported
Treatments
•
Criteria for inclusion:
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•
Studies with children and adolescents that targeted
weight loss as a primary objective or reported
information through quantitative or illustrative
presentation of weight loss if other outcomes were
primary interest
Criteria for exclusion:
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Conducted primarily in school setting
Conducted with special populations
Used medication trials
Included participants older than 18 years old
(Jelalian & Saelens, 1999)
Studies for Children
• 26 studies
• Comprehensive behavioral treatment targeting eating and
physical activity is superior to wait-list control or nutrition
education alone
• 4 studies by Epstein and colleagues document long-term
maintenance of loss up to 10 years
• Components include:
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Targeted diet combined with lifestyle or aerobic activity
Parental inclusion
Behavior modification
Self-monitoring of diet and activity
Stimulus control
Contingency management
Parent training
(Jelalian & Saelens, 1999)
Studies for Adolescents
• 7 studies
• “Promising interventions” exist:
– 1) At least one well-controlled study and another less
rigorously controlled study by a separate investigator,
– 2) 2 or more well-controlled studies w/small numbers,
or
– 3) 2 or more well-controlled studies by the same
investigator
(Jelalian & Saelens, 1999)
Studies for Adolescents
• Overlap in inclusion of behavioral modification of
diet, but:
– Not as well developed
– No rigorously conducted study documenting that
outpatient obesity treatment is superior to wait-list
control or instruction only
• Mixed Group (Children and Adolescents or nonstated)
– 9 studies
(Jelalian & Saelens, 1999)
Traffic Light Diet
• 13 of 26 Childhood studies were by Epstein
• Empirically supported with multiple studies
demonstrating significant weight loss that is
maintained up to 10 years post treatment
• Tx implementation that includes teaching children
and parents how to label foods as “green, yellow,
and red” foods based on calorie and nutrient
density
• Tx also includes developing healthy eating and
activity environment for children, behavior change
techniques, and maintenance of behavior change
(Epstein et al., 2000; Epstein et al., 2001)
More Epstein……
• Evaluated problem solving in obesity treatment and found
that additional problem solving did not add to effectiveness
beyond standard family-based treatments
(Epstein et al., 2000)
• Compared emphasizing  fruit and vegetable intake vs. 
fat and sugar intake and found significantly greater
decreases in % overweight in  fruit and vegetable intake
group
(Epstein et al., 2001)
• Compared stimulus control to reinforcement to target
sedentary behavior, found to be equivalent methods
(Epstein et al., 2004)
Golan’s Alternative Approach
• “Health-centered” Approach
• 60 children 7-12 years old in a family-based
health-centered approach targeting only parents
vs. children-only control group
• Demonstrated 29% reduction in children’s
overweight vs. 20.2% reduction in children-only
group 7 yr follow-up
• At 7 yr follow-up, 2 children from child-only
condition exhibited eating disordered symptoms,
no children from parent-only condition exhibited
eating disordered symptoms
(Golan & Crow, 2004)
Primary Care Program
• 4-month behavioral weight control program
initiated in a primary care setting and extended
through telephone and mail contact
• Treatment group had better change in BMI and
higher use of behavioral skills than in control
group
• No significant difference between groups for
energy intake, percentage calories from fat,
physical activity, sedentary behavior, and
problematic weight-related or eating behaviors
(Saelens, et al., 2002)
Planet Health
• School-based multidisciplinary intervention for 2
years with session focused on:
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Decreasing television viewing
Decreasing consumption of high-fat foods
Increasing fruit and vegetable intake
Increasing moderate and vigorous physical activity
• Female obesity reduced compared to controls, no
difference among boys
(Gortmaker et al., 1999)
• Also had reduced risk of using self-induced
vomiting/laxatives or diet pills to control weight in
past 30 days
(Austin et al., 2005)
PACE+ for Adolescents
• Patient-Centered Assessment and Counseling for Exercise
• 117 adolescents 11-18 years recruited from pediatric and
adolescent clinics
• Receive interactive computer counseling, provider
counseling, and extended follow-up
• Intervention targets:
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Moderate physical activity
Vigorous physical activity
Fat intake
Fruit and vegetable intake
• All outcomes except physical activity improved over time,
extended interventions (mail or telephone) showed no
greater outcomes
(Patrick et al., 2001)
Cost Effectiveness of Programs
•
•
24 families randomized to group +
individualized tx or group tx only
All groups included:
–
–
–
–
–
•
Traffic Light Diet
Physical Activity
Self-monitoring
Stimulus Control
Reinforcement
Group treatment alone is more cost effective
than mixed group plus individual format
(Goldfield, et al., 2001)
Weight Management Programs
and Self-Esteem
• Epstein and Golan
– No data on self-esteem rates or changes for participants
• Negative Changes
– Cameron, 1999
• No significant weight loss
• Positive Changes
– Savoye et al., 2005
• Increased at post, but back to baseline at follow-up
– Walker et al., 2003 & Gately et al., 2005
• Increased during a camp setting
• Significant weight loss
• No follow-up data
Why the Change in Self-Esteem?
•
Weight loss
–
•
Behavioral goals
–
–
•
Decreasing consumption of high fat and high calorie
foods
Increasing physical activity levels
Locus of Control
–
–
•
Large focus during programs on “losing weight”
Locus of Control: An individual’s belief regarding
their control over personal outcomes
Limited data on pediatric obesity and locus of control
All hypotheses, none yet examined in a pediatric
weight management program
Obesity and Locus of Control in
Children
• Pierce and Wardle (1997) Findings
– Examined the belief systems of 9-11 year old
overweight children
– Children who indicated they felt their overweight was
due to internal causal beliefs (“I eat too much” or “I
don’t exercise enough”) were strongly and negatively
correlated to self-esteem
– Children who indicated that they felt their overweight
was due to external causes (“It runs in my family” or
“A medical cause”) were strongly and positively
correlated to self-esteem
Project STORY
Project STORY
• Project Sensible Treatment of Obesity
Rural Youth (STORY)
• 4 month pediatric weight management
program
• Delivered in 3 “waves” in rural counties in
north central Florida
• Interventions delivered in Cooperative
Extension Office
Participants
• Data from larger study
• Participants
– 90 overweight children and their parent(s)
– 8-13 years old from 4 rural counties
• Inclusion/Exclusion Criteria
– Child at or above 85th percentile
– Participating parent living in home primarily or equally
responsible for food purchasing and meal preparation
– No condition contraindicating participation in a weight
management program such as dietary and exercise
restrictions
– See proposal for additional criteria
Intervention Groups
• Basic Program
–
–
–
–
–
Modified Stop-Light Program
Use of red, yellow, green classification
Physical activity targets and goals
Self-esteem and body image addressed
Behavioral modification techniques to help
parents and children reach these goals
Intervention Groups
• Behavioral Family Intervention (BFI)
– Simultaneous but separate child and parent treatment
groups
• Behavioral Parent Intervention (BPI)
– Parent only treatment group where parents encouraged
to serve as child’s interventionist at home
• Weight List Control Group (WLC)
– Will receive BFI condition after the 6-month follow-up
Project STORY Goals
1) Decrease consumption of high fat and
high calorie foods with modified version
of “Stop Light Program”
2) Increase physical activity with pedometers
and daily physical activity logs
3) Address Self-Esteem and Body Image
with specific interactive lessons
Summary
• Pediatric Obesity is a major Public Health Concern
• Prevalence will only rise in “toxic environment”
• Early intervention and prevention is critical to prevent
medical, psychosocial, and disease-related costs
• Empirically supported treatments for children are
available with long term maintenance
• Self-Esteem should be monitored and targeted in
overweight and obese individuals
• More research is needed with adolescents
• Effective program components, cost effectiveness, and
media messages are among the next directions for the
field of research
Questions?