Behavioral Treatment of Obesity in Children and Adults: Objectives

Transcription

1 Behavioral Treatment of Obesity in Children and Adults: Evidence-based Interventions entions Hollie Raynor, Ph.D., R.D., L.D.N. Associate Professor Department of Nutrition Obesity Research Center Objectives Define evidence-based treatment Describe the components of evidence- based childhood obesity interventions Describe the components of evidence- based adult obesity interventions Identify effective dietary interventions ti used in adult behavioral weight control interventions 1

2 What is Evidence-based? The focus on using evidence-based interventions ti comes from concerns that t patients/clients receive treatment that is grounded in tradition and/or outdated training, rather than scientific evidence Research community encouraged to scrutinize and evaluate interventions in order to ascertain their efficacy What is Evidence-based? How are interventions evaluated? Accumulation of research Quality of research Experimental vs. Observational designs Methods Measures (self-report vs. objective) Randomized Controlled Trials Meta-analysesanalyses 2

3 What is Evidence-based? Evidence-based medicine Current best evidence for making clinical decisions about the care of patients/clients Incorporates best research evidence, clinical expertise, and patient values Currently used to improve the quality of care, and can provide objective criteria for decisions regarding the allocation of health care resources What is Evidence-based? Limitations Understanding efficacy (emphasis on internal validity) vs. effectiveness (emphasis on external validity) Type of population studied Geographic settings Health care setting Will change over time 3

4 Overweight/Obese - definition Definitions of overweight and obese are based upon body mass index (BMI): weight (kg)/height (m 2 ) In children, BMI percentile for age and gender is the preferred measure for detecting overweight in children and adolescents Overweight (at risk for overweight): 85 th to 94 th percentile BMI Obese (overweight): >95 th percentile BMI 4

5 Overweight/Obese - definition In adults, overweight and obese are classified by BMI BMI > 25 = overweight BMI > 30 = obese BMI > 40 = extreme obesity Inches Body Mass Index Table BMI = 25 BMI = 30 Body weight (lbs)

6 Goals of Behavioral Lifestyle Interventions Behavioral lifestyle interventions focus on changing eating and leisure-time activity it behaviors Goal is to: Improve weight status Weight loss in adults Reductions in zbmi (or percent overweight) in children Maintain weight status Long term weight loss maintenance Weight gain prevention Behavioral Lifestyle Interventions Dietary goals Leisure-time activity goals Behavioral modification techniques 6

7 ) Behavioral Theory Evidence-based childhood and adult obesity interventions are based on behavioral theory Antecedents Behaviors Consequences The interventions use behavior modification strategies for changing behaviors Weight loss (kg) -4 Advice/Education Diet (behavioral intervention) Diet + exercise (behavioral intervention) mo 12-mo 24-mo Months Franz MJ et al. Weight-loss outcomes: a systematic review and meta-analysis of weight loss clinical trials with a minimum 1-year follow-up. JADA 2007;107:

8 ADA-Evidence Analysis Library Pediatric weight management Using behavioral counseling as part of a multi-component pediatric weight management (PWM) program to treat overweight results in significant reductions in weight status and adiposity in children and adolescents. Rating: Grade I (good) ADA-Evidence Analysis Library PWM family participation in treating pediatric obesity in children and adolescent obesity treatment Family participation Children (6-12 yrs) Rating: Strong (Imperative) Family participation Adolescents Rating: Fair (conditional) 8

9 ADA-Evidence Analysis Library What about younger children? No ratings as very little research has been conducted in this age group Given the evidence for children aged 6 to 12 yrs, most likely intervention should be family-based Effectiveness aside, weight loss (in contrast to weight management) in this population may be appropriate only under certain circumstances. However, these circumstances have not been identified in the research. ADA-Evidence Analysis Library Using a low-calorie diet (900 to 1,200 kcal per day) as part of a clinically supervised, multi-component weight- loss program is associated with both short-term term and longer-term reduction in adiposity among six- to 12-year-old od children. Rating: Grade I (good) 9

10 ADA-Evidence Analysis Library The Traffic Light Diet is an effective component of a clinically supervised, multi-component childhood weight- management intervention program. Rating: Grade I (good) Childhood Obesity Interventions Children aged 8 to 12 years of age > 85 th percentile BMI, but not greater than 100% overweight Conducted in research settings Treatment provided over 6 months 10

11 Behavioral Targets Evidence-based interventions target behaviors that reduce energy intake and increase energy expenditure Low-calorie diet ( kcals/day) Most widely studied is the Traffic Light Diet (Epstein and colleagues) Categorizes food into Green, Yellow, Red (based upon energy-density and nutrient quality) Reduce intake of fast-food, food, soda, sweet and salty snack foods Generally does not cause an increase in F&V and dairy products unless specifically targeted in treatment Behavioral Targets Leisure-time activities Increase in physical activity (60 minutes/day), with focus on play and family activities Reduction in TV watching (< 15 hours/week) Increases physical activity May help with decreasing intake 11

12 Riley et al., 2008 Family-based is not just including parents/caregivers in the treatment of their children's obesity it is: Changing the context of the family (home) environment to help support the change a child is making: Parenting Communication Support Environment 12

13 Behavioral Parenting Program Strategies for Antecedents: - Parental modeling Parent makes all of the same changes in behaviors as child - Change the home environment (stimulus control) Eating Eating - Overt and covert restriction Leisure-time behaviors - Problem-solving and pre-planning planning Behavioral Parenting Program Strategies for behaviors: Self-monitoring Goals of program Kcals, Red Foods, F&V Physical Activity TV Watching Weight Parent-child meetings Tie weight change to behavior change to demonstrate relationship between behaviors and weight Feedback on self-monitoring is important 13

14 Behavioral Parenting Program Strategies for consequences: Positive reinforcement Praise Contingency contracting Point system Reduction of negative reinforcement Increase use of extinction for problematic behaviors Family-based: Treatment Structure Group process Cognitive-behavioral i i Social learning (Interventionist serves as model of parenting behaviors) Sessions: Review of assigned homework (group process and social learning) Presentation and discussion of new topic (cognitive behavioral parenting behaviors/practices) Assignment of new homework 14

15 Treatment Structure 6-months of treatment (Parent + child) Weekly sessions for 12 to 16 weeks Group session for parents Group session for children 15 minute individual parent-child meeting with an interventionist For remaining 2 to 3 months of treatment, frequency of sessions drops to either one or two meetings/month Assessments at 0, 6, 12 months (DV = percent overweight or zbmi) Childhood Obesity Treatment These evidence-based interventions targeting children aged 8 to 12 years produces significant reductions in percent overweight (-15 to -20%), with 10-year follow-up showing almost 1/3 of treated children no longer overweight and a mean reduction in percent overweight of -10% in treated children (Epstein, Paluch, & Raynor, 2002; Epstein, Paluch, Kilanowski, Raynor, 2004; Raynor, Kilanowski, Esterlis, & Epstein, 2002 ) 15

16 Maternal and Child Health Bureau Recommendations for Treatment in a Primary Care Setting 1. Start treatment in children as young as 3 years of age 2. Apply a family-based model in treatment 3. Use behavior modification techniques 4. Help families make small changes 5. Target changing 2 or 3 eating and activity behaviors at a time Childhood Interventions Behaviors recommended to target in primary care settings Fast-food intake (limit) Sweetened drink intake (limit) Sweet and salty snack foods (limit) Low-fat dairy (2 servings per day) Fruits & vegetables (1.5 c fruits & 2.5 c vegetables/day) Physical activity (60 minutes per day) TV watching (< 2 hrs/day) 16

17 Childhood Interventions Will these recommendations be effective at treating young children who are overweight? AND What are the best behaviors to target? Pediatric Obesity Treatment Child HELP and Kids CAN Two research programs funded by the American Diabetes Association and the National Institutes of Health For children between the ages of 4 to 9 years, > 85 th percentile BMI, with at least one problematic eating or activity behavior 17

18 Pediatric Obesity Treatment Both programs randomly assign families to one of three, 6 month interventions ti Behavioral parenting program (2 different parenting programs in each study) Newsletter Anthropometric assessments conducted every 3 months (to 12 month follow-up) with feedback to families and pediatrician Child HELP Increase Fruits and Vegetables (2 servings fruit and 3 servings vegetables/day) Low-fat dairy (2 servings/day) Decrease Sweet/salty snack foods (< 3 servings/week) Sweetened drinks (< 3 servings/week) Low-energy-dense foods Decrease intake of foods increase feelings of fullness that are low in nutrient- and may displace density and high in energy- consumption of low- nutrient- density dense foods 102 families randomized 18

19 zbmi Months Newsletter Increase Decrease Kids CAN Traditional Physical Activity (60 min/day) Sweetened drinks (<3 servings/week) Substitution TV watching (<2 hours/day) Low-fat milk (2 servings/day) Focusing on substitute Traditional behaviors that behaviors for targeted target increasing energy behaviors may expenditure and decreasing enhance feelings of energy intake choice for engaging in targeted behavior 81 families randomized 19

20 zbmi Months Newsletter Traditional Substitute Important Components of Treatment Measures of weight status Provides regulatory feedback Parenting focus Children that do better have parents that are doing better Self-monitoring Modeling Stimulus control Pre-planning, problem-solving Programs that target parents only also show good outcomes Caloric prescription appears to be needed to produce clinically relevant weight status improvements 20

21 ADA-Evidence Analysis Library Adult weight management Weight loss and weight maintenance therapy should be based on a comprehensive weight management program including diet, physical activity, and behavior therapy. The combination therapy is more successful than using any one intervention alone. Rating: Strong ADA-Evidence Analysis Library A comprehensive adult weight management program should make maximum use of multiple strategies for behavior therapy (e.g. self monitoring, stress management, stimulus control, problem solving, contingency management, cognitive restructuring, and social support). Behavior therapy in addition to diet and physical activity leads to additional weight loss. Continued behavioral interventions may be necessary to prevent a return to baseline weight. Rating: Strong 21

22 Adult Obesity Treatment Since 1996, most adult behavioral obesity treatments achieve a mean weight loss of 10 kg over 6 months of treatment, but have a weight-loss regain of 38% over a mean f/u of 18 months (Wing, 2002) How can weight loss maintenance be improved? Adult Obesity Interventions Behavioral Targets Low-calorie diet ( kcals/day) Low-fat diet (20% to 30% kcals/fat) Strong focus on increasing structure of the diet Physical activity 200 minutes of moderate-intense activity/week 10,000 steps/day 22

23 Behavior Modification Strategies for Antecedents: - Change the home environment (stimulus control) Eating Leisure-time behaviors - Problem-solving and pre-planningplanning - Goal setting - Cognitive restructuring - Relaxation 23

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26 Behavior Modification Strategies for behaviors: Self-monitoring Goals of program Kcals, fat Physical Activity Weight Tie weight change to behavior change to demonstrate t relationship between behaviors and weight Feedback on self-monitoring is important 26

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28 Behavior Modification Strategies for consequences: Positive reinforcement Weight loss vs. maintenance Reinforcing value of food Structure of Treatment As longer duration of contact improves outcomes, standard length of intervention is 18 months Weight loss interventions Weekly for 6 months 60 minute group sessions 2 times/month for months minute group sessions Assessments at 0, 6, 12, 18 months (DV = wt) 28

29 Important Components of Treatment Measures of weight status Provides regulatory feedback Regular and long-term follow-up Accountability Habit change Self-monitoring Dietary structure Meal plans, meal replacements, portion controlled foods Variety? Lots of physical activity! Materials from DPP p_part.html 29

30 Macronutrient Content of the Diet 30

31 Macronutrient Composition and Weight Loss Maintenance 800 participants p Randomly assigned to 1 of 4 diets: the targeted percentages of energy derived from fat, protein, and carbohydrates in the four diets were 20, 15, and 65%; 20, 25, and 55%; 40, 15, and 45%; and 40, 25, and 35% - diets consisted of similar foods and met guidelines for cardiovascular health F/U over 2 years Received behavior modification, and had a physical activity goal of 90 min/week 31

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33 Dietary Structure 33

34 Do meal replacements help with weight loss? Meal Replacements: Foods of fixed calorie and nutrient content that are designed to take the place of a meal or snack Portion-controlled and nutritionally balanced Shakes, soups, meal/snack bars, and prepared meals Typical recommendation is to replace 2 meals with a meal replacement Do meal replacements help with weight loss? Let s look at the research Purpose: To examine whether using meal replacements improves weight loss in adults enrolled in a weight loss program. Participants: 100 overweight and obese men and women randomly assigned to 2 different diet groups. Length of weight loss program: 27 months 34

35 Do meal replacements help with weight loss? First 3 months: Diet A: calories/day, with participants eating regular foods Diet B: calories/day, with participants using meal replacements for 2 meals and 2 snacks each day Last 24 months: Both groups followed the same kcals/day diet and used meal replacements for 1 meal and 1 snack per day Weight Loss Maintenance Using Meal Replacements 0 Percentage e reduction in initial we eight Standard then Meal Replacement Meal Replacement Ditschuneit et al., AJCN; 1999; 69: Time (months) 35

36 Why are meal replacements effective for weight loss? Advantages of using meal replacements: Convenient Portion-controlled Removes work of estimating portion size and calories Encourages structured eating Widely available Easy to self-monitor Dietary Variety Increased dietary variety is associated with increased intake, weight, and body fat in animals (for a review Raynor & Epstein, 2001, Psychological Bulletin) Increased variety within a meal is associated with increased consumption in humans 36

37 HFF FOS LFM 70 Before intervention Percent variety After intervention Registry Percent variety Percent variety Percent variety LFB Percent variety LFV Mean percent variety in 5 food groups for recent successful weight losers before and after a standard weight loss intervention (n= 96), and registry participants (n = 2237) (M + SEM). Raynor, H. A., Jeffery, R. W., Phelan, S., Hill, J. O., & Wing, R.R. (2005). Amount of food group variety consumed in the diet and long-term weight loss maintenance. Obesity Research, 13, Food Group Variety and Obesity Treatment Studies suggest that limiting the number of different foods, particularly energy-dense foods, in the diet may help with successful weight loss and long-term weight loss maintenance Limiting variety may be especially helpful during maintenance, when self-monitoring of intake is less consistent 37

38 Dietary Variety Prescription 18 month trial testing the effect of limiting snack food variety (R01 - NIDDK) 2 groups: Standard vs. Standard + variety prescription Can this prescription be adhered to over the long-term? Will a greater length of time of limiting variety effect weight loss? What is the mechanism (hedonics and/or stimulus control)? 200 participants Research Team Providence, RI Rena Wing, Ph.D. Chantelle Hart, Ph.D. Elissa Jelalian, Ph.D. Patrick Vivier, M.D. Kathrin Osterholt, M.S. Amanda Fine Allison Martir Patty Tellier Holly Manigan Knoxville, TN Betsy Anderson, M.S., R.D. L.D.N. Ashlee Schoch Lusi Martin Shannon Looney, M.P.H. Christen Mullane, M.A. Jess Bachman, M.S., R.D., L.D.N. Emily Van Walleghen, Ph.D. Andrew Carberry Adriana Coletta 38