Pediatric Annals

Comprehensive Behavioral Treatment of Overweight and the Pediatric Practice

Deborah De Santis-Moniaci, PhD; Lisa Altshuler, PhD

Abstract

The percentage of children who are currently overweight in the United States has reached staggering proportions. This epidemic calls on us as healthcare professionals to utilize the effective assessment and treatment techniques we have available to address this concern. This article will explore the rates of pediatrie overweight (defined as a body mass index above the 95th percentile)1,2 and its negative medical, psychological, social, and economic consequences. It will review the evidence supporting comprehensive behavioral treatment for children and adolescents and describe its basic principles. Finally, it will discuss the important role that physicians must play in preventing and assessing pediatrie overweight in their patients. It also will explore those aspects of the comprehensive treatment approach that can be utilized effectively in pediatrie practice.

PREVALENCE AND CONSEQUENCES OF OVERWEIGHT

The National Health and Nutrition Examination Survey (NHANES) III demonstrates the magnitude of the problem we are facing today in comparison to just 20 years ago.1'2 In 1976 to 1980, approximately 7% of 6- to 11-year-olds were assessed as having a body mass index (BMI) above the 95th percentile. By 2003 to 2004, that figure had risen to about 19%. Similarly, 5% of 12- to 19year-olds were found to be overweight in 1976 to 1980, in contrast to more than 17% deemed overweight in 2003 to 2004. Although all racial groups have been affected, Mexican-American boys and girls as well as non-Hispanic black girls have shown the greatest increases in their percentile overweight.

Left untreated, childhood overweight has been shown to persist into adulthood.3,4 Children who have a BMI above the 85% percentile by ages 3 to 5 have a 36% chance of being overweight adults.3 By ages 6 to 9, this chance increases to 55%, and by ages 15 to 17, it increases further to 67%.

The negative consequences associated with this increase in pediatrie overweight are far reaching. Overweight children have increased risk of developing significant medical conditions, such as cardiovascular disease, hypertension, and diabetes, in their youth.4 In Greater Cincinnati, the percentage of new cases of non-insulin dependent diabetes mellitus (NIDDM) (type 2) rose among children from birth to age 19.5 Ninety-two percent of these newly diagnosed cases had a BMI above the 90th percentile. Being an overweight adolescent boy (defined as above the 75th percentile) increases the risk of death from all causes and from specific causes like coronary heart disease, stroke, and colon cancer in adulthood, independent of adult weight status.6 Similarly, being an overweight adolescent elevates risk of morbidity for both sexes. Medical costs related to overweight are also on the rise. Between 5% to 7% of national health care spending in the United States is linked to overweight and overweight-related conditions.7

Certain overweight children experience psychological difficulties, although a causal link between weight and psychological problems has not been shown consistently. Psychological problems, including behavior issues, depression, low self-esteem, anxiety, and eating disorders, have been noted in children who are overweight.4 Approximately 57% of children (n=155) referred for nutrition services met criteria for a diagnosis from the Diagnostic and Statistical Manual of Mental Disorders, fourth edition, most commonly an anxiety disorder.8 These overweight children also exhibited significantly poorer social skills and more behavioral difficulties than a diabetic control group. When time spent overweight was taken into account, researchers found that children who were overweight between the ages of 9 to 16 exhibited more psychiatric problems, especially oppositional defiant disorder in both sexes and depressive disorders in boys.9

1. Ogden CL, Regal KM, Carroll MD, Johnson CL. Prevalence and trends in overweight among US children and adolescents, 19992000. IAMA. 2002;288(14): 1728-1732.

2. Ogden CL, Carroll…

The percentage of children who are currently overweight in the United States has reached staggering proportions. This epidemic calls on us as healthcare professionals to utilize the effective assessment and treatment techniques we have available to address this concern. This article will explore the rates of pediatrie overweight (defined as a body mass index above the 95th percentile)1,2 and its negative medical, psychological, social, and economic consequences. It will review the evidence supporting comprehensive behavioral treatment for children and adolescents and describe its basic principles. Finally, it will discuss the important role that physicians must play in preventing and assessing pediatrie overweight in their patients. It also will explore those aspects of the comprehensive treatment approach that can be utilized effectively in pediatrie practice.

PREVALENCE AND CONSEQUENCES OF OVERWEIGHT

The National Health and Nutrition Examination Survey (NHANES) III demonstrates the magnitude of the problem we are facing today in comparison to just 20 years ago.1'2 In 1976 to 1980, approximately 7% of 6- to 11-year-olds were assessed as having a body mass index (BMI) above the 95th percentile. By 2003 to 2004, that figure had risen to about 19%. Similarly, 5% of 12- to 19year-olds were found to be overweight in 1976 to 1980, in contrast to more than 17% deemed overweight in 2003 to 2004. Although all racial groups have been affected, Mexican-American boys and girls as well as non-Hispanic black girls have shown the greatest increases in their percentile overweight.

Left untreated, childhood overweight has been shown to persist into adulthood.3,4 Children who have a BMI above the 85% percentile by ages 3 to 5 have a 36% chance of being overweight adults.3 By ages 6 to 9, this chance increases to 55%, and by ages 15 to 17, it increases further to 67%.

The negative consequences associated with this increase in pediatrie overweight are far reaching. Overweight children have increased risk of developing significant medical conditions, such as cardiovascular disease, hypertension, and diabetes, in their youth.4 In Greater Cincinnati, the percentage of new cases of non-insulin dependent diabetes mellitus (NIDDM) (type 2) rose among children from birth to age 19.5 Ninety-two percent of these newly diagnosed cases had a BMI above the 90th percentile. Being an overweight adolescent boy (defined as above the 75th percentile) increases the risk of death from all causes and from specific causes like coronary heart disease, stroke, and colon cancer in adulthood, independent of adult weight status.6 Similarly, being an overweight adolescent elevates risk of morbidity for both sexes. Medical costs related to overweight are also on the rise. Between 5% to 7% of national health care spending in the United States is linked to overweight and overweight-related conditions.7

Certain overweight children experience psychological difficulties, although a causal link between weight and psychological problems has not been shown consistently. Psychological problems, including behavior issues, depression, low self-esteem, anxiety, and eating disorders, have been noted in children who are overweight.4 Approximately 57% of children (n=155) referred for nutrition services met criteria for a diagnosis from the Diagnostic and Statistical Manual of Mental Disorders, fourth edition, most commonly an anxiety disorder.8 These overweight children also exhibited significantly poorer social skills and more behavioral difficulties than a diabetic control group. When time spent overweight was taken into account, researchers found that children who were overweight between the ages of 9 to 16 exhibited more psychiatric problems, especially oppositional defiant disorder in both sexes and depressive disorders in boys.9

Women who are overweight in late adolescence or between childhood and adulthood10 seem to experience social and economic consequences related to overweight As adults, these women are less likely to be gainfully employed,10 have lower incomes,11 are less likely to be in a relationship or married,10'11 and complete fewer years of schooling.11 This is independent of baseline aptitude and socioeconomic status.11 Men who are overweight in late adolescence are less likely to be married.11 In contrast, individuals facing other conditions, such as asthma, diabetes, and cerebral palsy, demonstrate no such social or economic differences from normal weight samples.11

EVIDENCE SUPPORTING COMPREHENSIVE BEHAVIORAL TREATMENTOF OVERWEIGHT

Increasing evidence has shown that comprehensive behavioral treatment that combines diet, exercise, behavioral change strategies, and family participation is the most effective approach for treating pediatrie overweight12 and its associated medical and psychological issues.13 Comprehensive treatments tend to produce greater short-term weight loss than non-comprehensive treatments (ie, those that do not utilize a combined approach of diet, exercise, and behavioral change strategies).12 Treatments that include behavioral techniques, such as stimulus control and self-monitoring, demonstrate more than a one standard deviation weight loss advantage over those that do not.12

In a review of seven controlled treatment studies, 6- to 16-year-olds (n=356) demonstrated significant reductions in their weight following comprehensive treatment as compared to controls (n=144).14 Children (ages 13 years or younger) demonstrated a 5% to 20% decrement in their percent overweight after treatment.15 Ten years thereafter, 31% of the children were no longer classified as overweight. The short- and long-term efficacy of comprehensive treatment for adolescents, on the other hand, was described as "promising" because of the limited number of controlled studies that focus specifically on this age group.

Following an average of 5 months of comprehensive treatment, even modest changes in BMI (-5% to -27%) were predictive of significant improvements in total cholesterol, triglycérides, LDLcholesterol, HDL-cholesterol, and insulin concentrations, with no effect on growth. A significant number of children with abnormal medical results before treatment had normalized lipid values and insulin concentrations following comprehensive treatment.

One year post-treatment, children demonstrated significant improvements in their psychological well-being, namely in overall behavioral problems and in specific behavioral issues, such as withdrawal, anxiety, and depression.16 These improvements were related to two main factors: the degree of weight loss and improvement in maternal psychopathology. Two years after treatment, parents and children continued to show emotional and behavioral improvements.17

COMPREHENSIVE PROGRAM DESCRIPTION

Children who have a BMI above the 85% percentile or who are rapidly gaining weight are typically eligible for comprehensive behavioral treatment18 A detailed history is obtained assessing an individual 's eating and physical activity patterns, motivation and barriers for treatment, psychological issues, and familial conflicts. Individuals who have eating disorders or acute psychiatric conditions are often screened out and referred for other services. Since families are an integral component of the approach, parents typically must agree to attend treatment sessions. Programs are usually staffed by a multi-disciplinary team, including psychologists, nutritionists, nurses, endocrinologists, and exercise instructors.

For the most part, parents and children are seen weekly in a group setting over 4 to 18 weeks14 and in weekly or monthly maintenance sessions thereafter. The literature shows that longer lengths of treatment and more structured programs result in greater weight loss.14 In sessions, parents and children are taught to utilize basic behavioral techniques, such as self-monitoring, stimulus control, and goal setting.

Self-monitoring is a technique in which individuals gain awareness of the eating and physical activity habits that may be contributing to their weight gain through daily records. 19 On food records, individuals note specific information about what they are eating and drinking, including the times they eat and the portions they consume. At a more advanced level, they may also record information about their level of hunger when eating and feelings that may fuel food intake. Similarly, exercise records provide information on the kind of exercise individuals engage in and the intensity and duration of that exercise. Self-monitoring of weight, food intake and exercise is associated with short and long-term weight loss in children20 and adults.21,22

Stimulus control is also an effective technique23 that involves altering the external environment to enhance the likelihood that an individual will engage in eating and exercise behaviors that support weight loss.24 Techniques can include removing tempting, high-fat foods from sight; serving food on individual plates in the kitchen rather than serving food family style at the table; and restricting television watching to certain times of the day.19

Goal setting is another widely used and successful behavioral technique25 in comprehensive programs. Specific, measurable and realistic goals are typically set with an individual on a weekly basis - goals such as eating two fruits a day or walking three times per week for about 30 minutes. When goals are achieved, the individual can feel a sense of success. Rewards, such as privileges, can also be attached to successful completion of a goal. When goals are not achieved, there is an opportunity to reassess the difficulty of the goal, to assess if the individual possesses the skills necessary to accomplish it, or to identify personal or other impediments to successfully completing the goal.

Role-playing and problem solving are also integral parts of the treatment session where families can practice new behaviors and work on difficulties that arise throughout the week. 18 Parents are considered role models and are taught to praise their children for specific behavioral changes. Children are also taught to praise their parents for changes they successfully make.

The exercise component of the program typically involves increasing aerobic, calisthenics, or lifestyle exercise (ie, increasing daily movement by using the stairs instead of the elevator or parking a few blocks away from home and walking) or a combination of these. 12 Exercise goals are structured so that individuals engage in more exercise over time, ideally 30 minutes per day, 6 days a week.18 Programs have also targeted decreasing the amount of time an individual spends seated, with good results.26

A common nutritional approach is the Traffic Light Diet,18 along with the U.S. Department of Agriculture Food Guide Pyramid.27 The Traffic Light Diet separates foods into green ("go") foods, yellow ("caution") foods, or red ("stop") foods based on their fat and sugar content.18 The goal is to eat more green and yellow foods and limit intake of red food.

COMPREHENSIVE TECHNIQUES IN THE PEDIATRIC PRACTICE

Although pediatricians may not have the resources to create a comprehensive treatment program for overweight children, there is much that they can do in terms of preventing, assessing, and possibly treating this problem using some of the principles inherent in this approach. Physicians have played an important role in other national issues, such as smoking cessation and promotion of breastfeeding.28 In one report, 75% of women whose providers encouraged them to breastfeed did so. In another, patients whose doctor spoke with them about weight loss were more likely to take steps towards change.29 A 3- to 5-minute discussion about increasing physical activity during a well-care visit produced significant increases in minutes spent walking per week among sedentary adults.30

As recommended by the American Academy of Pediatrics in 2003,31 prevention and early detection of overweight is of utmost importance to help curb this epidemic. Therefore, BMI should be calculated and plotted in all children and adolescents seen once a year as part of routine care, and risk for overweight-related medical conditions, such as sleep apnea and high cholesterol, should be monitored. BMI charts are available at the Center for Disease Control and Prevention Web site (http://www.cdc. gov/nccdphp/dnpa/bmi/childrens_BMI/ about_childrens_BMI.htm). Those considered at risk for overweight, due to such factors as family history and birth weight, should be closely monitored. Healthy food and exercise messages should be given during routine visits for all children and adolescents. Messages can include promoting breastfeeding and encouraging all family members to develop good health habits by having healthy foods and snacks available, such as fruits and vegetables. Promoting physical activity for everyone in the home is important, as is discouraging sedentary behaviors like television watching and playing video games. Significant changes in BMI should be discussed with families, as well as the factors contributing to the weight gain, in a nonjudgmental, blame-free manner. Optimally, BMI changes would be discussed with families before the child becomes severely overweight.

Once identified as overweight, assessing the causes and comorbidities of the overweight is vital.32 This evaluation includes assessing the medical and psychological causes and comorbidities of overweight, as well as the health patterns contributing to the overweight. A pediatrician who is not able to conduct any of these evaluations should refer the patient to another health care professional, such as a behavioral psychologist, endocrinologist, or nutritionist. Setting up collaborations in advance with a variety of trusted health care professionals in the community will promote the ease of such referrals.

A medical evaluation should be conducted on those children and adolescents who have a BMI above the 95th percentile, have a BMI between the 85th to 95th percentile with complications, or who have shown large increases in BMI over time. This evaluation should assess medical causes of overweight, including genetic or endocrinologie causes, as well as comorbidities of overweight, such as high blood pressure and diabetes. Previous reports published in Pediatrie Annals in January 2004 have presented detailed guidelines for comorbidity screening.33 Screening for the psychological causes or consequences of overweight, including binge eating and depression, is also necessary, as is assessing food and exercise habits.32 Understanding what a child eats in a 24hour period or on a typical day provides important information about frequency of meals and snacks, frequency of takeout meals, the kinds of foods and beverages a child consumes, whether a parent is present during meals, or if the family has already made changes to promote healthier habits in their child. Similarly, an understanding of the vigorous as well as everyday physical activity in which the child engages is vital, as is assessing the time spent being sedentary each day.

With this information, the pediatrician is in a position to provide a family with feedback about the array of assessments conducted and can work on creating a treatment plan with them. Based on the results, a child may need to be referred for psychological/psychiatric services or for further medical work-up or treatment. Pediatricians should refer a family for comprehensive behavioral treatment or to see a behavioral psychologist and nutritionist if these services are available in their community. It is important for the pediatrician to explain his/her concerns and to educate families about the risks associated with overweight in a supportive way. This can help motivate families to change32 and follow through with the recommendations made. For those families not yet ready to change, a pediatrician has the opportunity to assess BMI changes over time and to revisit the issue of change with the family during future appointments. Using strategies such as motivational interviewing may be appropriate to help move families toward making a decision to change.

If referring to a program is not an option, the pediatrician can utilize many of the components of the comprehensive approach discussed above to initiate changes in the family. Families require more frequent appointments while working toward stabilizing, reducing, and maintaining their weight and changes thereafter. Engaging other staff, such as nurses or nutritionists, is of value due to the time commitments involved in this work.

Treatment goals should be discussed with families at length. These goals vary depending on a child's age, BMI and medical status.32 Weight maintenance is recommended for children ages 7 or younger who are experiencing no medical complications and for children older than age 7 whose BMI is between the 85th to 95th percentile. Weight loss is recommended for children ages 7 or younger who have a BMI greater than the 95th percentile who are experiencing medical comorbidities, for children older than age 7 who have a BMI between the 85th to 95th percentile who have medical Comorbidities, and for children who are age > 7 who have a BMI greater than the 95th percentile. Once weight maintenance is achieved, gradual weight loss is recommended until the child is below the 85th percentile. The benefit that even modest weight reduction can have in improving health should be discussed with families.13'34 As the adult literature illustrates, a sustained 10% weight loss in overweight adult men and women can decrease the number of years people have hypertension, type 2 diabetes, high cholesterol, and increase Ufe expectancy.34

The integral role of parents in this process should be clarified at the outset. Parents should be role models of healthy eating and exercise habits in the home. Furthermore, the whole family should change their health habits rather than singling out the overweight child. Children will be more likely to engage in healthy practices if their parents and family are doing so as well. Parents should create a supportive environment in the home and utilize reinforcement instead of criticism to promote change.

Small, specific and measurable goals that they can work on between visits should be set up with families. Pediatricians should discuss what families are willing to work on and then set goals that are possible for them to achieve within that time frame. For instance, a nutrition goal may be to eat breakfast each morning, and an exercise goal may be walking 20 minutes to school each day. Families can then write down these goals and chart their progress at home. At their next visit, these goals can be reviewed and problems that arose can be worked on together. Attaching a reward or privilege for accomplishing goals can motivate children and adolescents to work toward them. Instead of food, rewards such as going to the movies are appropriate to reinforce goal achievement.

Pediatricians can encourage families to record food and exercise behaviors as well as track their weight between visits. Again, this information can be reviewed with families at each appointment to assess progress and guide future goals. Parents should be educated about changing their home environment (ie, stimulus control) to support weight maintenance and loss. Concrete suggestions, such as having consistent meal and snack times, turning off the television during meals, eating at the dinner table, and serving foods in the kitchen away from sight, are important steps to creating such an environment.33

Drawing from the Traffic Light Diet18 and the U.S. Department of Agriculture's Food Guide Pyramid,27 the nutrition focus should be on promoting more nutritious, low-caloric food intake in the family from such sources as whole grains, fruits, and vegetables.35 At the same time, decreasing highfat/high-sugar foods such as soda and cookies should be encouraged rather than eliminating these foods completely. Important nutritional changes can include the following: replacing sugarrich beverages with water, low-fat milk and/or diet drinks; substituting healthy snacks, such as low-fat yogurt and fruits, for less healthy choices; having vegetables as part of dinner each night; baking or broiling rather than frying foods; and offering vegetables or fruits instead of second portions.33,35

In terms of physical activity, children and adolescents should aim to have 30 to 60 minutes of movement almost every day35 and to restrict sedentary activities like television watching to 2 hours per day.31 Families benefit from problem solving and guidance about how to accomplish these two tasks when issues such as time constraints, money, and environmental dangers hamper daily exercise and often force children to stay indoors. Determining activities that children can do at home as alternatives to television watching, such as playing games and drawing, may be helpful as will setting up specific times each day that children and adolescents are allowed to watch television. Pediatricians providing families with information on community resources and after-school programs is also of great benefit to families who may not know about the opportunities in their area.

FUTURE RESEARCH

Although there are numerous controlled studies supporting the short-term efficacy of comprehensive behavioral treatments for children, more data is necessary to support its long-term impact on weight loss and its associated medical and psychological conditions. Research focusing specifically on adolescents is also required. Identifying specific dietary, exercise, and behavioral strategies that are most efficacious for individuals based on age, cultural background, and severity of obesity is needed so that services can be tailored to patients' needs. Research on the effect that pediatricians' prevention and management efforts can have on this epidemic is of utmost importance. Furthermore, data supporting the most effective strategies pediatricians can use during patient visits is necessary as larger numbers of children and adolescents require assistance in managing their weight.

SUMMARY

Pediatrie overweight challenges us as health care providers to utilize the best strategies we have available to help prevent and treat this nationwide epidemic. Comprehensive behavioral treatment is an effective approach for promoting weight loss and health benefits in children and is a promising approach for adolescents. Pediatricians can play an important role in curbing the rise of overweight through early detection and monitoring, and by using a variety of comprehensive behavioral treatment strategies to help manage overweight in their patients.

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