The Journal of Pediatrics
Volume 157, Issue 3 , Pages 357-359, September 2010

Treatment for Obese Children: A Ray of Hope?

  • Rae-Ellen W. Kavey, MD, MPH

      Affiliations

    • Corresponding Author InformationReprint requests: Rae-Ellen W. Kavey, MD, MPH, Division of Pediatric Cardiology, Department of Pediatrics, University of Rochester School of Medicine, 601 Elmwood Ave, Rochester, NY 14642.

Division of Pediatric Cardiology, Department of Pediatrics, University of Rochester School of Medicine, Rochester, New York

published online 14 June 2010.

Article Outline

BMI, Body mass index, NHANES, National Health and Nutrition Evaluation Survey, USPSTF, US Preventive Services Task Force

 

See related article, p 388

Pediatric obesity is a pressing public health concern in developed countries around the world.1 In the United States, analysis of data from the National Health and Nutrition Examination Survey (NHANES) from 2007 to 20082 reported that 16.9% of children and adolescents had a body mass index (BMI) ≥95th percentile on the basis of Centers for Disease Control and Prevention growth charts and would be termed obese per the expert committee recommendations endorsed by the American Academy of Pediatrics.3 Although overall prevalence estimates were unchanged compared with those from 1999 to 2000, there was a significant increase in the prevalence of boys with BMI ≥97th percentile, the heaviest group, for ages 6 to 19 years. Persistent differences in obesity prevalence by region, racial/ethnic group, and socioeconomic status are exemplified in a recent report from the Bogalusa Heart Study, which began in the 1970s.4 Screening of 5- to 17-year-old school children revealed that the prevalence of obesity has increased more than 5-fold, from 5.6% in 1973 to 1974, to 30.8% in 2008 to 2009. In Australia, the prevalence of childhood obesity tripled between 1985 and 1997 and has since continued to rise.5 Information from longitudinal epidemiologic studies indicates that children with high BMI have a strong chance of becoming obese adults6 and are at risk for a range of serious conditions, including hyperinsulinemia/type 2 diabetes mellitus, hypertension, and dyslipidemia beginning in childhood, and premature cardiovascular disease in adult life.7, 8 Thus, obesity in children and adolescents is prevalent and severe, with important health consequences.

In the past, reports of the effectiveness of obesity treatment programs in children have indicated that sustained benefits are uncommon.9, 10 However, a recent US Preventive Services Task Force (USPSTF) systematic review of weight management interventions published since 2005 for obese children aged ≥6 years concluded that comprehensive moderate- to high-intensity interventions addressing diet, activity, and behavioral management techniques result in modest but significant weight change; limited evidence suggests that these improvements are sustained in the 12 months after completion of active treatment.11 Moderate- to high-intensity interventions were defined as those with >25 hours of contact in a 6-month period. In the context of this report, the results of the HIKCUPS trial published in this issue of The Journal represent important new information.12

The study was a randomized controlled trial of a parent-centered dietary modification program, a child-centered physical activity program, and a combination of these in 5.5- to 9.9-year-old overweight and obese Australian children. Enrolled children were predominantly obese, with proportions ranging from 76% to 80% in the 3 groups, on the basis of growth charts from the United Kingdom, the usual growth reference for Australian children. Subjects were recruited directly with advertisements in multiple media settings, with only 10% referred by pediatric care providers. Each intervention included a weekly 2-hour face-to-face session for 10 weeks, homework activities to be completed between sessions, and a relapse prevention program involving telephone contact once a month for 3 months.

Of 165 children enrolled, results were reported for 69% at 6 months and 64% at 12 months. This dropout rate, comparable with that seen in other obesity trials, is emblematic of the difficulty in conducting obesity treatment interventions. To address this, analysis was by intention-to-treat. All 3 groups significantly reduced BMI z-scores from baseline. Compared with the Activity alone group, participants in the Diet and combined Diet + Activity groups had approximately twice as great a reduction in BMI z-score, sustained at 1-year follow-up. One of the strengths of the trial is the age-group specific design with the focus of the diet intervention on parents alone; several earlier studies have shown that in obese pre-pubertal children, targeting parents exclusively is significantly more effective than parents plus children or children alone.13, 14, 15 The less effective isolated Activity intervention in this study targeted the children alone, and the results may reflect the absence of a direct parental role in this young age group. The results may also be caused by the intervention's focus on movement skills without a direct approach to reducing sedentary behavior, an identified component in other successful programs used to prevent and treat overweight and obesity in children.16, 17, 18 Another strength is the intensity of the intervention, which included 20 hours of face-to-face contact in 10 weeks, with subsequent telephone follow-up for an additional 12 weeks. Compared with other recently published trials, the investigators speculate that the greater reductions in BMI z-score here can be attributed to the greater face-to-face intervention contact hours. This would be in agreement with the USPSTF report, in which interventions involving >25 hours of contact in a 6-month period were associated with significant weight change.11 Finally, although the Activity alone intervention resulted in less BMI change, it was associated with significantly greater systolic blood pressure reduction. This may reflect changes in arterial function seen in exercise interventions with obese children, even in the absence of weight loss.19, 20, 21, 22

This study is not without limitations. Most significantly volunteers being recruited via advertisements who commit to a long-term intervention like this represent a very different group than patients referred by physicians from a clinical care setting. Effectiveness studies are clearly needed to evaluate the response to such interventions in more typical clinical settings. In addition, a longer follow-up period is needed to be certain that changes are sustained. In adults, high levels of regular physical activity have been shown to be associated with successful weight loss maintenance,23 and there is some beginning evidence that a combination of increased regular exercise and decreased sedentary activity is associated with weight maintenance after obesity treatment in adolescents.24 Late results from this trial for the different interventions will provide evidence about the relative importance of diet change and activity in sustaining change in BMI z-score.

Overall, the results of studies like this combined with the USPSTF report suggest that there is now reason for cautious optimism in the treatment approach to overweight and obese children. If effectiveness study results confirm these findings in different settings, the next—and major—challenge will be to make treatment programs like this widely available. This will require appropriate training for health care providers in managing behavior change, increased availability of dietitians with expertise in working with children, and broad access to activity training. Perhaps even more challenging will be the requirement to develop appropriate reimbursement and insurance coverage policies for these important health interventions.

Back to Article Outline

References 

  1. Lobstein T, Baur L, Uauy R. Obesity in children and young people: a crisis in public health. Report of the International Obesity Task Force Childhood Obesity Working Group. Obes Rev. 2004;5:4–104
  2. Ogden CL, Carroll MD, Curtin LR, Lamb MM, Flegal KM. Prevalence of high body mass index in US children and adolescents, 2007-2008. JAMA. 2010;303:242–249
  3. Barlow SE and the Expert Committee. Expert committee recommendations regarding the prevention, assessment and treatment of child and adolescent overweight and obesity. Pediatrics. 2007;120:S164–S192
  4. Broyles S, Katzmarzyk PT, Srinivasan SR, Chen W, Bouchard C, Freedman DS, et al. The pediatric obesity epidemic continues unabated in Bogalusa. Louisiana. Pediatrics. 2010;125:900–905
  5. Booth M, Okely AD, Denny-Wilson E, Yang B, Hardy L, Dobbins T. NSW Schools Physical Activity and Nurtition Survey 2004. Sydney, New South Wales, Australia: NSW Department of Health; 2005;
  6. Serdula MK, Ivery D, Coates RJ, Freedman DS, Williamson DF, Byers T. Do obese children become obese adults? A review of the literature. Prev Med. 1993;22:167–177
  7. Freedman DS, Mei Z, Srinivasan SR, Berenson GS, Dietz WH. Cardiovascular risk factors and excess adiposity among overweight children and adolescents: the Bogalusa Heart Study. J Pediatr. 2007;150:12–17
  8. National Institutes of Health. Clinical Guidelines on the Identification and Treatment of Overweight and Obesity in Adults: The Evidence Report. Obes Res. 1998;6(suppl 2):51–209s
  9. Oude Luttikhuis H, Baur L, Jansen H, Shrewsbury VA, O'Malley C, Stolk RP, et al. Interventions for treating obesity in children. Cochrane Database of Systematic Reviews 2009, Issue 1. Art. No.: CD0011872. doi:10.1002/14651858.CD001872.pub2.
  10. McGovern L, Johnson JN, Paulo R, Hettinger A, Singhal V, Kamath C, et al. Treatment of pediatric obesity: a systematic review and meta-analysis of randomized trials. J Clin Endocrinol Metab. 2008;93:4600–4605
  11. Whitlock EP, O'Connor EA, Williams SB, Beil TL, Lutz KW. Effectiveness of weight management interventions in children: a targeted systematic review for the USPSTF. Pediatrics. 2010;125:e396–e418
  12. Okely AD, Collins CE, Morgan PJ, Jones RA, Warren JM, Cliff DP, et al. Multi-site randomized controlled trial of a child-centered physical activity program, a parent-centered dietary-modification program, or both in overweight children: the HIKCUPS study. J Pediatr. 2010;157:388–394
  13. Golan M, Weizman A, Apter A, Fainaru M. Parents as the exclusive agents of change in the treatment of childhood obesity. Am J Clin Nitr. 1998;67:1130–1135
  14. Golan M, Kaufman V, Shahar DR. Childhood obesity treatment: targeting parents exclusively vs parents and children. Br J Nutr. 2006;95:1008–1015
  15. Golan M, Fainaru M, Weizman A. Role of behavior modification in the treatment of childhood obesity with the parents as the exclusive agents of change. Int J Obes Relat Metab Disord. 1998;22:1217–1224
  16. Epstein LH, Valoski A, Vara LS, McCurley J, Wisniewski L, Kalarchian MA, et al. Effects of decreasing sedentary behavior and increasing activity on weight change in obese children. Health Psychol. 1995;14:109–115
  17. Epstein LH, Paluch RA, Gordy CC, Dorn J. Decreasing sedentary behaviors in treating pediatric obesity. Arch Pediatr Adolesc Med. 2000;154:220–226
  18. Robinson TN. Reducing children's television viewing to prevent obesity: a randomized controlled trial. JAMA. 1999;1561–1567
  19. Watts K, Beye P, Siafarikas A, Davis EA, Jones TW, O'Driscoll G, et al. Exercise training normalizes vascular dysfunction and improves central adiposity in obese adolescents. J Am Coll Cardiol. 2004;43:1823–1827
  20. Watts K, Beye P, Siafarikas A, O'Driscoll G, Jones TW, Davis EA, et al. Effects of exercise training on vascular function in obese children. J Pediatr. 2004;144:620–625
  21. Meyer AA, Kundt G, Lenschow U, Schuff-Werner P, Kienast W. Improvement of early vascular changes and cardiovascular risk factors in obese children after a six-month exercise program. J Am Coll Cardiol. 2006;48:1865–1870
  22. Woo KS, Chook P, Yu CW, Qiao M, Leung SS, Lam CW, et al. Effects of diet and exercise on obesity-related vascular dysfunction in children. Circulation. 2004;109:1981–1986
  23. Wing RR, Hill JO. Successful weight loss maintenance. Annu Rev Nutr. 2001;21:323–341
  24. Peneau S, Thibault H, Meless D, Soulie D, Carbonel P, Roinsol D, et al. Anthropometric and behavioral patterns associated with weight maintenance after an obesity treatment in adolescents. J Pediatr. 2008;152:678–684

PII: S0022-3476(10)00387-2

doi:10.1016/j.jpeds.2010.04.068

Refers to article:

  • Multi-Site Randomized Controlled Trial of a Child-Centered Physical Activity Program, a Parent-Centered Dietary-Modification Program, or Both in Overweight Children: The HIKCUPS Study , 07 May 2010

    Anthony D. Okely, Clare E. Collins, Philip J. Morgan, Rachel A. Jones, Janet M. Warren, Dylan P. Cliff, Tracy L. Burrows, Kim Colyvas, Julie R. Steele, Louise A. Baur
    The Journal of Pediatrics September 2010 (Vol. 157, Issue 3, Pages 388-394.e1)

The Journal of Pediatrics
Volume 157, Issue 3 , Pages 357-359, September 2010

Article Tools