Chapter 82--Treatments for Childhood Obesity. Denise E. Wilfley, Ph.D. and Dorothy J. Van Buren, Ph.D.

Transcription

1 Chapter 82--Treatments for Childhood Obesity Denise E. Wilfley, Ph.D. and Dorothy J. Van Buren, Ph.D. In Eating Disorders and Obesity: A Comprehensive Handbook, 3 rd edition Edited by Kelly D. Brownell, Ph.D. and B. Timothy Walsh, M.D. 1

2 Childhood is an important time to address the significant public health problem of obesity. Since children are still growing, slowing the rate of weight gain or achieving very modest weight losses can help children normalize their body weights. Although weight loss maintenance is challenging for adults, children have demonstrated good weight loss maintenance in response to treatment. Since obesity in childhood is a risk factor for the development of eating disorder psychopathology and for continued obesity through adolescence and adulthood, helping overweight or obese children achieve a healthier weight status represents a form of indicated or targeted prevention for these conditions in adulthood. Therefore, treating children who are overweight or obese not only results in improvements in the child s mental and physical health status, but also results in improvements in that child s future health. Organizations and agencies such as the United States Preventive Services Task Force (USPSTF) and the American Academy of Pediatrics (AAP) have issued guidelines or recommendations for the prevention and treatment of obesity in children. Additionally, numerous comprehensive reviews and meta-analyses have documented the effectiveness of multi-component weight loss interventions for children that are of sufficient duration (i.e., greater than 25 hours of contact), include a multicomponent focus on diet and physical activity, and use behavioral change techniques. This chapter provides a brief overview of family-based behavioral weight control treatments (FBT) for childhood obesity. Current findings regarding factors impacting the effectiveness of these treatments, and directions for future research are also discussed. FAMILY-BASED BEHAVIORAL WEIGHT CONTROL Family-based behavioral weight control treatments (FBT), developed and expanded upon by Leonard Epstein, Denise Wilfley, and colleagues, are consistent with USPSTF and AAP guidelines for treatment of childhood obesity and have demonstrated efficacy in both the short- and long-term. Modification of energy balance behaviors (i.e. decreasing caloric intake and increasing caloric 2

3 expenditure) is the cornerstone of many weight loss interventions, including FBT. These goals are achieved through the use of behavioral treatment techniques and the active involvement of a parent or caregiver who is often also overweight or obese. The parent in FBT is encouraged to modify his or her own energy balance behaviors, provide support and encouragement for the child involved in treatment, and to engineer a home environment conducive to a healthy lifestyle for the entire family. It is this focus on change across the entire household that is a hallmark of FBT. Evidence suggests that extended treatment contact focusing on both the continued practice of self-regulatory behavioral skills and the use of family and social networks to support weight loss maintenance behaviors such as improved dietary intake and engagement in increased levels of physical activity is important to the long term maintenance of weight lost during FBT. Diet Dietary targets of FBT include decreasing caloric intake, improving the nutritional quality of foods selected, and shifting food preferences. Decreases in caloric intake of approximately 500 calories per day from baseline, for a total of 1000 to 1200 calories per day for children and 1200 to 1400 per day for adults, are achieved by decreasing consumption of high-energy dense, unhealthy foods, and increasing consumption of nutritious, low-energy dense foods. A family-friendly method of categorizing foods according to traffic light colors is used in FBT to help families identify which foods to decrease (Red foods stop and think; Yellow foods proceed with caution by watching portion sizes), and which to increase (Green foods Go!). Red foods are calorically dense and/or have limited nutritional value (e.g., potato chips, candy, sugar-sweetened beverages). Yellow foods are more calorically dense than Green foods but may be more nutritious than Red foods (e.g. whole grain bread), and most vegetables and fruits are considered Green foods. 3

4 An important feature of FBT is that caloric restriction is not the only dietary goal; shifting taste preferences is also extremely important. To this end, foods that are modified to be lower in calories (e.g., foods with sugar substitutes such as diet soft drinks, low-fat cookies) are still considered Red foods despite their lower caloric content. The goal of FBT is for families to make a shift to more nutritious foods and not to switch from one junk food to a lower calorie version of the same food. In FBT, parental weight loss success predicts child weight loss, and this correlation can be explained, at least in part, by parental maintenance of lower Red food intake over time. Another method utilized in FBT for improving the nutritional quality of food and decreasing caloric intake is to encourage families to eat fewer meals away from the home. The average family in the U.S. eats approximately 35% of their meals away from home and children who are overweight or obese eat a higher proportion of their meals away from home than children who are not overweight or obese. FBT s focus on the reduction of the number of meals eaten away from home has a positive impact not only on participants weight status but also on the nutritional quality of the foods they eat. Physical Activity Physical activity targets in FBT include increasing moderate-to-vigorous physical activity while decreasing time spent in sedentary, non-school or work-related pursuits. The colors of the traffic light again provide a family-friendly way of understanding an activity s intensity or metabolic equivalent (MET). For example, Green activities (Go) are 5.0 METs or higher; Yellow activities (Slow) are between 3.0 and 4.9 METS, while Red activities (Stop) are less than 3.0 METs. Watching TV, playing video games, talking/texting on the phone, and playing games or surfing the Internet on the computer are all Red activities. Any time spent on screen-time activities for a purpose, for work or homework, are not counted against Red activity time. Target goals for moderate-to-vigorous physical activity are 60 to 90 minutes per day for adults and children. However, FBT also emphasizes the importance of lifestyle 4

5 physical activities as useful substitutes for sedentary pursuits. For example, walking to the store rather than driving not only involves more physical activity than driving, but it is also more time consuming, thus leaving less time for engaging in computer games or TV watching. Since sedentary activities are often accompanied by eating, decreasing time spent in sedentary pursuits has the added benefit of decreasing caloric intake in addition to increasing caloric output. Behavioral Change Skills FBT is a behavioral treatment and the use of behavioral techniques for facilitating change is integral to its successful implementation. Self-monitoring, goal setting, successive approximation and shaping, modeling, and reward systems the mainstays of good behavioral therapy are utilized in FBT. Self-monitoring has been associated with better weight outcomes in children as well as in adults, and because of this association, it has long been considered one of the most important behavioral change techniques in weight loss interventions. Interestingly, a recent study of behavior change techniques used in a weight loss program for adults with type 2 diabetes concluded that the number of behavior change techniques participants reported utilizing was associated with weight loss success more so than any one technique. Because of these findings, the authors of this study suggest that the more behavioral change tools we can offer to individuals engaging in weight loss interventions the greater the likelihood that they will be successful in losing weight. To this end, recent research advances in the basic cognitive and behavioral sciences that have informed the development or refinement of additional behavioral change methods such as training to enhance episodic future thinking skills to improve impulse control, or strengthening goal setting skills by including implementation intention procedures to enhance prospective thinking or memory show promise for inclusion in FBT s treatment armamentarium. Family Involvement, Peer Support, and the Community 5

6 Parental involvement and parent training (e.g., praise, selective attention, positive reinforcement, modeling, and limit setting) are integral parts of FBT. Caregivers who are overweight or obese are encouraged to actively try to modify their own dietary and physical activity habits while also supporting their child s weight loss efforts. Research into the social transmission of health behaviors suggests that childhood overweight/obesity is particularly sensitive to adult influence highlighting the importance of focusing on parental weight loss in FBT. Peer support for healthy energy-balance behaviors has also been found to enhance weight loss maintenance in children. Peer interactions are naturally reinforcing so families are encouraged to help their children build positive peer networks, while simultaneously uncoupling socializing from unhealthful behaviors (e.g., unhealthy foods, watching television). However, for some children, peers are a source of distress due to weight-related teasing. Social problems do not seem to interfere with initial weight loss, but children with higher social problems tend to have more difficulty maintaining their weight losses highlighting the importance of helping children and their families acquire skills to address social problems (e.g., effective methods for coping with teasing). Not only does peer support help in the maintenance of healthy energy balance behaviors, good peer relationships improve a child s overall quality of life. When children and their parents learn new weight control behaviors in FBT these new behaviors co-exist with the old behaviors associated with weight gain and these old behaviors are easily activated in our obesogenic world. Therefore, current forms of FBT help families address these challenges by encouraging vigilance regarding the impact their community or built environment can have on eating and activity choices. Families are encouraged to identify not only the constraints or barriers to healthy lifestyle behaviors within their homes and communities, but also to identify and take advantage of the opportunities, resources and interpersonal supports available to them within their communities to 6

7 enhance their efforts to engage in and strengthen newly acquired energy balance behaviors. By encouraging families to consider all the environments in which they function (home, peer, school, community), FBT helps families build a culture of health to attenuate the influences of an obesogenic society. TREATMENT MODALITY AND TREATMENT SETTING While reviews and individual empirical studies support the importance of treatment duration for successful weight loss in pediatric populations, less is known about the impact of treatment modality. Efforts to scale-up weight loss treatment for children have often involved the use of groups. Although groups may provide opportunities for enhanced social support, it is difficult to effectively tailor the behavioral aspects of FBT when working strictly with groups. In fact, a recent review of the literature found that mixed format pediatric weight loss interventions (i.e., programs that include both individual family sessions and group treatment sessions) have better treatment effect sizes than treatments delivered to groups only. Delivery of FBT to individual families allows interventionists to select the skills, treatment targets, and pacing most appropriate for each family s unique challenges and strengths. The result is a more efficient and robust treatment than can be achieved through group alone. Most studies of pediatric weight management programs have taken place in specialty research or university settings. When weight management programs are initiated in community settings they are often delivered through the schools and have been more successful at preventing overweight in children who are not yet overweight or obese than they have been in decreasing weight in children who enter the programs already overweight or obese. A community setting where FBT has had some success is in primary care settings. The co-location of behavioral interventionists or mental health specialists within primary care settings are likely to become more common for the treatment of other childhood health and mental health issues such as attention deficit disorder, anxiety, or depression, and FBT is uniquely 7

8 well-suited for implementation within these emerging health care delivery systems (e.g., integrated behavioral health care or patient-centered medical care homes). CONCLUSION With its emphasis on the family, FBT is a potentially very cost effective treatment for both adults and children since the per unit cost of weight loss is lower for parents and children who are overweight or obese when treated together in FBT compared to treating them separately. Although families in FBT are encouraged to engineer the home environment to support healthy weight and lifestyle behaviors, certain individuals are genetically more vulnerable to our increasingly obesogenic environment than are others. Thus continued research into individual, modifiable factors that affect treatment response is needed, particularly into the study of the cognitive and environmental factors that drive, constrain, or compete with an individual s energy balance choices (e.g., behavioral economics, the built environment). Since severe obesity in childhood tracks into adulthood, and treatment is most successful when started at a young age, advocacy efforts must continue to ensure that access to screening, prevention, and reimbursement for quality care is made available to young children and their families. To meet this need for broader availability of affordable and effective care, research is urgently needed into how best to integrate FBT into existing and emerging health care systems. Several multi-site trials have tested FBT, and in the process of conducting these trials effective methods for training individuals to deliver treatment to a high degree of competency have been developed. With proper training, behavioral interventionists working within primary care, mental health centers, or school settings, could add FBT to their skill set. A central system for training or credentialing individuals to provide FBT is needed so that this effective treatment may be made more widely available. 8

9 FURTHER READING Altman M., Holland J.C., Lundeen D., Kolko, R.P., Stein R.I., Saelens B.E., Welch R.R., Perri M.G., Schechtman K.B., Epstein L.H., Wilfley, D.E. (2015). Reduction in food away from home is associated with improved child relative weight and body composition outcomes and this relation is mediated by changes in diet quality. Journal of the Academy of Nutrition and Dietetics, Experimental confirmation of the importance of targeting an increase in meals eaten at home in pediatric weight loss programs. Best J.R., Goldschmidt A.B., Mockus-Valenzuela D.S., Stein R.I., Epstein L.H., Wilfley D.E. (2015, July 20). Shared weight and dietary changes in parent-child dyads following family-based obesity treatment. Health Psychology, Advance online publication This study sheds light on the contributions shared dietary changes make toward the long established association that has been found between parent and child weight loss in FBT. Best J.R., Stein R.I., Welch R. R., Perri M.G., Epstein L.H., Theim K.R., Gredysa D.M., Saelens B.E., Schechtman K.B., Wilfley D.E. (2012). Behavioral economic predictors of overweight children s weight loss. Journal of Consulting and Clinical Psychology, 80 (6): This study provides a good example of the importance of assessing predictors of weight loss success in childhood weight loss programs and how these findings can be used to guide the development and inclusion of additional behavioral treatment components to potentiate weight loss outcomes. Epstein L.H., Paluch R.A., Wrotniak B.H., Daniel T.O., Kilanowski C., Wilfley D., Finkelstein D. (2014). Costeffectiveness of family-based group treatment for child and parent obesity. Childhood Obesity, 10(2): Children who are overweight or obese often have parents who are also overweight or 9

10 obese, and this study demonstrates the cost savings of family-based behavioral treatment which targets weight changes in both the child and parent in one treatment compared to intervening with children and adults separately. Frerichs L.M., Araz O.M., & Huang T.T.K. (2013). Modeling social transmission dynamics of unhealthy behaviors for evaluating prevention and treatment interventions on childhood obesity. PLoS One, 8(12): e A thought-provoking examination of the importance of expanding our focus from the individual to include their social ties, particularly the importance of taking into account the impact of adults in a child s life, when designing and evaluating efforts to prevent and treat childhood obesity. Goldschmidt, A.B., Wilfley, D.E., Paluch, R.A, Roemmich, J.N, & Epstein, L.H. (2013). Indicated prevention of adult obesity: How much weight change is necessary for normalization of weight status in children? Journal of the American Medical Association Pediatrics, 167(1): Excellent discussion of how small weight changes can have big effects on the weight trajectory of young children. Hankonen N., Sutton S., Prevost A.T., Simmons R.K., Griffin S.J., Kinmonth A.L., & Hardeman W. (2015). Which behavior change techniques are associated with changes in physical activity, diet and body mass index in people with recently diagnosed diabetes? Annals of Behavioral Medicine, 49(1): Although this study was conducted with adults, it is unique in its attempt to evaluate the role of behavior change techniques in weight loss outcomes. Hayes J.F., Altman M., Coppock J.H., Wilfley D.E., & Goldschmidt A. B. (2015). Recent updates on the efficacy of group-based treatments for pediatric obesity. Current Cardiovascular Risk Report, 9:16 DOI /s This review provides preliminary evidence for the importance of using a 10

11 mixed format rather than group-only format when designing and delivering family-based behavioral weight loss programs. Whitlock E.P., O Connor E.A., Williams S.B., Beil T.L., Lutz K.W. (2010). Effectiveness of Primary Care Interventions for Weight Management in Children and Adolescents: An Updated, Targeted Systematic Review for the USPSTF. Evidence Synthesis No.76. AHRQ Publication No EF-1. Rockville, Maryland: Agency for Healthcare Research and Quality. --- This review establishes the research basis for assessing and recommending treatment for childhood obesity. Wilfley, D.E., Stein, R.I., Saelens, B.E., Mockus, D.S., Matt, G.E., Hayden-Wade, H.A., Welch, R.R., Schechtman, K.B., Thompson, P.A., & Epstein, L.H. (2007). Efficacy of maintenance treatment approaches for childhood overweight: a randomized controlled trial. Journal of the American Medical Association, 298: This well-constructed study demonstrates that continued contact improves weight loss outcomes in children and that continued use of behavioral and social facilitation skills have a positive impact on these outcomes. 11