Public health interventions for the prevention and treatment of obesity

Role of Behavioral Interventions in the Management of Obesity

Overweight and obesity are the leading lifestyle-related causes of clinical and public health concerns. Health behavior change is central in obesity management. This review provides the various behavioral interventions in the management of obesity. Behavior modification is a structured method for improving lifestyle habits such as exercise, diet, and other practices that might influence behavior. This review article was based on current and older literature on behavioral approaches to target overweight/obesity. Articles about the various interventions to reduce obesity, particularly behavior interventions, were searched and explored. All the articles found to reveal behavior modification techniques, including goal-setting, self-monitoring, stimulus control, cognitive restructuring, stress management, problem-solving, and social support and information were obtained by reading the full text of the articles. The articles which did not provide any information regarding behavior interventions to reduce obesity were excluded from the review. This review discussed practical ways to incorporate behavior interventions in the management of obesity. The benefits and effectiveness of behavioral interventions on achieving and maintaining weight loss are also discussed. Patients using behavioral modification strategies to make these changes are more likely to succeed in long-term weight maintenance.

The influence of temperament on stress-induced emotional eating in children

Background

Stress‐induced emotional eating is a risk factor for overweight and obesity. Previous research proposes both the human serotonin transporter gene (5‐HTTLPR) and child's reactive temperament are promising candidates to help explain individual differences in stress‐induced emotional eating and weight. Understanding the association between specific genotypes, reactive temperament factors, and stress‐induced emotional eating may inform the development of personalized and effective treatment for children who may be at risk for overweight and obesity.

Objective

The current study explored the conditional indirect effect of genetic and environmental susceptibility (i.e., the interaction between 5‐HTTLPR and reactive temperament) on weight (as measured by percent body fat) mediated by stress‐induced emotional eating.

Method

One hundred and forty‐seven children (4 to 6 years old; 50.3% female; 22.4% Hispanic), along with their primary caregiver, completed laboratory tasks and questionnaires that assessed the child's reactive temperament, stress‐induced emotional eating, and percent body fat.

Results

The interaction between 5‐HTTLPR and impulsivity as well as with negative affectivity significantly predicted percent body fat. The interaction between 5‐HTTLPR and impulsivity as well as with negative affectivity significantly predicted both total calorie consumption and rate of total calorie consumption. However, the mediation aspect of this statistical model was not supported.

Conclusions

Child reactive temperament is an important indicator of how children approach eating when stressed. Mental health providers may consider prescribing strategies to reduce emotional eating among children with the SL variant and moderate to high impulsivity as well as children with the LL variant and high negative affectivity.

The rising prevalence of obesity: part B-public health policy solutions

Obesity is likely to supersede tobacco as the biggest cause of premature death. England has some of the worst figures and trends in obesity compared with the rest of the Europe. Rising obesity prevalence is an international crisis that has the potential to overwhelm health care resources as well as creating enormous human suffering and social cost. This article outlines potential public health policy solutions to this crisis.

Which worksite supports for healthy weight do employees use?

This paper explores factors associated with employee use of available supports for improving nutrition and activity behaviors. A cross-sectional telephone-survey assessed presence and use of available program, facility, and policy supports. Logistic regression was used to explore associations between job characteristics (e.g., supervising others) and use of available supports, adjusting for demographic characteristics. After adjustment, most supports were associated with at least one job-related factor. Participants supervising others were more likely to utilize eight supports including personal services for fitness, indoor exercise and shower facilities, and flextime for physical activity. The programs and facilities associated with the most factors were health fairs (e.g., increased likelihood with increased hours worked/week) and indoor exercise and shower facilities (e.g., increased likelihood with increased flexibility at work), respectively. Policies were associated with fewer factors. Since use of many programs and facilities differed based on job-related factors, employers might target supports based on job-related factors.

Workplace social and organizational environments and healthy-weight behaviors

BACKGROUND

The workplace is an important setting for health promotion including nutrition and physical activity behaviors to prevent obesity. This paper explores the relationship between workplace social environment and cultural factors and diet and physical activity (PA) behaviors and obesity among employees.

METHODS

Between 2012 and 2013, telephone interviews were conducted with participants residing in four Missouri metropolitan areas. Questions included demographic characteristics, workplace socio/organizational factors related to activity and diet, and individual diet and PA behaviors, and obesity. Multivariate logistic regression was used to examine associations between the workplace socio/organizational environment and nutrition, PA, and obesity.

RESULTS

There were differences in reported health behaviors and socio/organizational environment by gender, race, age, income, and worksite size. For example, agreement with the statement the 'company values my health' was highest among Whites, older employees, and higher income workers. As worksite size increased, the frequency of reporting seeing co-workers doing several types of healthy behaviors (eat fruits and vegetables, doing PA, and doing PA on breaks at work) increased. In adjusted analyses, employees agreeing the company values my health were more likely to engage in higher PA levels (aOR=1.54, 95% CI: 1.09-2.16) and less likely to be obese (aOR=0.73, 95% CI: 0.54-0.98). Seeing co-workers eating fruits and vegetables was associated with increased reporting of eating at least one vegetable per day (aOR=1.43, 95% CI: 1.06-1.91) and seeing co-workers being active was associated with higher PA levels (aOR 1.56, 95% CI: 1.19-2.05).

CONCLUSIONS

This research suggests that social/organizational characteristics of the workplace environment, particularly feeling the company values the workers' health and to seeing co-workers engaging in healthy behaviors, may be related to nutrition and PA behaviors and obesity. These findings point to the potential for intervention targets including environment and policy changes.

Racial differences in obesity risk knowledge among low-income reproductive-age women

OBJECTIVE

To examine the level of obesity risk knowledge (ORK) among reproductive-age women and racial differences associated with it.

METHODS

We conducted this study based on cross-sectional data gathered from 1153 (310 whites, 491 blacks, 335 Hispanics, and 17 others) low-income women (16-40 years old) attending publicly funded reproductive health clinics in Texas during 2010-2011. Data were collected through self-administered questionnaires that assessed sociodemographics and ORK based on ORK-10 scale.

RESULTS

The mean score was 5.9, 5.3, and 5.3 (possible score 0-10) for whites, blacks, and Hispanics, respectively. Acculturated Hispanic women had mean ORK scores (mean score 5.8) similar to scores of whites. Multiple linear regression analysis after adjusting for confounders showed that ORK score was lower among black (β coefficient = -0.6; p < 0.001) and Hispanic (β coefficient = -0.4; p = 0.002) women than among white women. Age, high school diploma or college level education, and Internet use, but not obesity status, were associated with higher ORK scores.

CONCLUSION

In general, obesity risk knowledge was low among low-income reproductive-age women, and knowledge scores were even lower among minority women. Strategies to incorporate ORK into obesity awareness and prevention programs should be formulated.

Behavioral treatment for weight gain prevention among black women in primary care practice: a randomized clinical trial

IMPORTANCE

Few weight loss treatments produce clinically meaningful weight loss outcomes among black women, particularly in the primary care setting. New weight management strategies are necessary for this population. Weight gain prevention might be an effective treatment option, with particular benefits for overweight and class 1 obese black women.

OBJECTIVE

To compare changes in weight and cardiometabolic risk during a 12-month period among black women randomized to a primary care-based behavioral weight gain prevention intervention, relative to usual care.

DESIGN, SETTING, AND PARTICIPANTS

Two-arm randomized clinical trial (the Shape Program). We recruited patients from a 6-site community health center system. We randomized 194 overweight and class 1 obese (body mass index [calculated as weight in kilograms divided by height in meters squared], 25-34.9) premenopausal black women aged 25 to 44 years. Enrollment began on December 7, 2009; 12- and 18-month assessments were completed in February and October 2, 2012.

INTERVENTIONS

The medium-intensity intervention included tailored behavior change goals, weekly self-monitoring via interactive voice response, monthly counseling calls, tailored skills training materials, and a gym membership.

MAIN OUTCOMES AND MEASURES

Twelve-month change in weight and body mass index and maintenance of change at 18 months.

RESULTS

Participants had a mean age of 35.4 years, a mean weight of 81.1 kg, and a mean body mass index of 30.2 at baseline. Most were socioeconomically disadvantaged (79.7% with educational level less than a college degree; 74.3% reporting annual income <$30,000). The 12-month weight change was larger among intervention participants (mean [SD], -1.0 [0.5] kg), relative to usual care (0.5 [0.5] kg; mean difference, -1.4 kg [95% CI, -2.8 to -0.1 kg]; P = .04). At month 12, 62% of intervention participants were at or below their baseline weights compared with 45% of usual-care participants (P = .03). By 18 months, intervention participants maintained significantly larger changes in weight (mean difference, -1.7 kg; 95% CI, -3.3 to -0.2 kg).

CONCLUSIONS AND RELEVANCE

A medium-intensity primary care-based behavioral intervention demonstrated efficacy for weight gain prevention among socioeconomically disadvantaged black women. A "maintain, don't gain" approach might be a useful alternative treatment for reducing obesity-associated disease risk among some premenopausal black women.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00938535.

Trading health for a healthy weight: the uncharted side of healthy weights initiatives

Healthy eating and weight initiatives have been incorporated into many schools to combat the growing obesity problem. There is little research, however, on the effectiveness of these programs or any inadvertent harmful effects on children's mental health. Our aims were to report on how school-based healthy weights initiatives can trigger the adoption of unhealthy behaviours for some children. This is a case series of four children seen at specialized eating disorder clinics. Each child attributed eating pattern changes to information garnered from school-based healthy eating curricula. Unanticipated consequences of these initiatives are described and alternative approaches are discussed.

The Changing Environment and Population Obesity in the United States

The recent unexpected increases in the prevalence of obesity in the United States are widely agreed to be the result of changes in environmental conditions. This paper reviews the available data from diverse sources on environmental factors and obesity. Coverage includes descriptive data on temporal trends in the environment, cross-sectional and longitudinal studies of the association between environmental exposures and body weight, and experimental trials that have related environmental factors thought to be potentially important in influencing energy intake and expenditure and body weight. Over the period covered by the "obesity epidemic," a variety of environmental factors have changed dramatically. Some would seem to favor increased body weight (e.g., increased availability of convenience foods and increased use of automobiles and televised entertainment), and others would seem to favor decreased body weight (e.g., a lower-fat food supply and the increased availability of some forms of physical activity). Definitive conclusions about the relative contributions of energy intake and expenditure to increasing body weight or about the contribution of specific environmental exposures to increasing body weight are far from clear. Increased sophistication in methods for making valid inferences from existing environmental data would be helpful. Even more important, given the urgency of the problem, is experimental research on the question of what environmental changes would be necessary to reverse the obesity epidemic.

Pathways to Obesity Prevention: Report of a National Institutes of Health Workshop1

There is an extensive research base on obesity treatment and on the health benefits of weight loss, but relatively little research has focused on obesity prevention. This article summarizes results of a workshop conducted by investigators funded under a National Institutes of Health initiative designed to stimulate novel research for obesity prevention. The 20 pilot studies funded under this initiative involved study populations that were diverse with respect to life stage and ethnicity, were conducted in a variety of natural and research settings, and involved a mix of interventions, including face-to-face group and individual counseling, as well as mail, telephone, and internet-based approaches. The workshop, which occurred approximately halfway through the 3-year funding period, emphasized concepts and experiences related to initiating and conducting obesity prevention studies. Investigators discussed theoretical perspectives as well as various challenges encountered, for example, in study implementation in different clinical and community settings, in working with children and families, and in studying pregnant and postpartum women. Other topics discussed included the difficulty of motivating individuals for prevention of weight gain, relevant cultural and racial/ethnic considerations, and the particular need for valid and practical measures of energy balance, body composition, and physical fitness in obesity prevention research. A key conclusion was that using obesity treatment as the primary paradigm may be a limiting perspective for considering obesity prevention issues. Further insights derived from the workshop deliberations are reflected in a detailed list of recommendations for future obesity prevention research.

Energy-Dense Snack Food Intake in Adolescence: Longitudinal Relationship to Weight and Fatness

OBJECTIVE

The longitudinal relationship between the consumption of energy-dense snack (EDS) foods and relative weight change during adolescence is uncertain. Using data from the Massachusetts Institute of Technology Growth and Development Study, the current analysis was undertaken to examine the longitudinal relationship of EDS food intake with relative weight status and percentage body fat and to examine how EDS food consumption is related to television viewing.

RESEARCH METHODS AND PROCEDURES

One hundred ninety-six nonobese premenarcheal girls 8 to 12 years old were enrolled between 1990 and 1993 and followed until 4 years after menarche. At each annual follow-up visit, data were collected on percentage body fat (%BF), BMI z score, and dietary intake. Categories of EDS foods considered were baked goods, ice cream, chips, sugar-sweetened soda, and candy.

RESULTS

At study entry, girls had a mean +/- SD BMI z score of -0.27 +/- 0.89, consumed 2.3 +/- 1.7 servings of EDS foods per day, and consumed 15.7 +/- 8.1% of daily calories from EDS foods. Linear mixed effects modeling indicated no relationship between BMI z score or %BF and total EDS food consumption. Soda was the only EDS food that was significantly related to BMI z score over the 10-year study period, but it was not related to %BF. In addition, a significant, positive relationship was observed between EDS food consumption and television viewing.

DISCUSSION

In this cohort of initially nonobese girls, overall EDS food consumption does not seem to influence weight status or fatness change over the adolescent period.

Weight change in control group participants in behavioural weight loss interventions: a systematic review and meta-regression study

Background

Unanticipated control group improvements have been observed in intervention trials targeting various health behaviours. This phenomenon has not been studied in the context of behavioural weight loss intervention trials. The purpose of this study is to conduct a systematic review and meta-regression of behavioural weight loss interventions to quantify control group weight change, and relate the size of this effect to specific trial and sample characteristics.

Methods

Database searches identified reports of intervention trials meeting the inclusion criteria. Data on control group weight change and possible explanatory factors were abstracted and analysed descriptively and quantitatively.

Results

85 trials were reviewed and 72 were included in the meta-regression. While there was no change in control group weight, control groups receiving usual care lost 1 kg more than control groups that received no intervention, beyond measurement.

Conclusions

There are several possible explanations why control group changes occur in intervention trials targeting other behaviours, but not for weight loss. Control group participation may prevent weight gain, although more research is needed to confirm this hypothesis.

Active generations: an intergenerational approach to preventing childhood obesity

BACKGROUND

Over the last 3 decades, US obesity rates have increased dramatically as more children and more adults become obese. This study explores an innovative program, Active Generations, an intergenerational nutrition education and activity program implemented in out-of-school environments (after school and summer camps). It utilizes older adult volunteers to implement a version of the evidence-based childhood obesity prevention program, Coordinated Approach to Child Health, in 8 US cities.

METHODS

Approximately 760 children in third- to fifth-grade participated in Active Generations, a 10-lesson, intergenerational, childhood obesity prevention program. Children completed an age-appropriate survey instrument, the Active Generations survey (AGS). The AGS is a valid and reliable, self-administered, self-report, paper-and-pencil survey designed to assess knowledge, attitudes, and behaviors. It was administered by trained volunteers on the first day and last day of the program. Constructs assessed included physical activity, nutrition, and media use.

RESULTS

Students significantly increased their reported fruit and vegetable consumption post-program. For example, the percentage of students reporting eating 3 or more servings of vegetables per day was 16% greater post-program. Students were more likely to report reading food labels and greater confidence that they could participate in physical activity. They also significantly decreased their daily screen time.

CONCLUSIONS

Active Generations is a promising childhood obesity prevention program.

HealthWorks: results of a multi-component group-randomized worksite environmental intervention trial for weight gain prevention

Background

U.S. adults are at unprecedented risk of becoming overweight or obese, and most scientists believe the primary cause is an obesogenic environment. Worksites provide an opportunity to shape the environments of adults to reduce obesity risk. The goal of this group-randomized trial was to implement a four-component environmental intervention at the worksite level to positively influence weight gain among employees over a two-year period. Environmental components focused on food availability and price, physical activity promotion, scale access, and media enhancements.

Methods

Six worksites in a U.S. metropolitan area were recruited and randomized in pairs at the worksite level to either a two-year intervention or a no-contact control. Evaluations at baseline and two years included: 1) measured height and weight; 2) online surveys of individual dietary intake and physical activity behaviors; and 3) detailed worksite environment assessment.

Results

Mean participant age was 42.9 years (range 18-75), 62.6% were women, 68.5% were married or cohabiting, 88.6% were white, 2.1% Hispanic. Mean baseline BMI was 28.5 kg/m² (range 16.9-61.2 kg/m²). A majority of intervention components were successfully implemented. However, there were no differences between sites in the key outcome of weight change over the two-year study period (p = .36).

Conclusions

Body mass was not significantly affected by environmental changes implemented for the trial. Results raise questions about whether environmental change at worksites is sufficient for population weight gain prevention.

Trial Registration

ClinicalTrials.gov: NCT00708461

External validity reporting in behavioral treatment of childhood obesity: a systematic review

CONTEXT

To aid translation of childhood obesity interventions evidence into practice, research studies must report results in a way that better supports pragmatic decision making. The current review evaluated the extent to which information on key external validity dimensions, participants, settings, interventions, outcomes, and maintenance of effects, was included in research studies on behavioral treatments for childhood obesity.

EVIDENCE ACQUISITION

Peer-reviewed studies of behavioral childhood obesity treatments published between 1980 and 2008 were identified from (1) electronic searches of social science and medical databases; (2) research reviews of childhood obesity interventions; and (3) reference lists cited in these reviews. Included studies reported on a controlled obesity intervention trial, targeted overweight or obese children aged 2-18 years, included a primary or secondary anthropometric outcome, and targeted change in dietary intake or physical activity behaviors.

EVIDENCE SYNTHESIS

1071 publications were identified and 77 met selection criteria. Studies were coded on established review criteria for external validity elements. All studies lacked full reporting of generalizability elements. Across criteria, the average reporting was 23.9% (range=0%-100%). Infrequently reported were setting-level selection criteria and representativeness, characteristics regarding intervention staff, implementation of the intervention content, costs, and program sustainability.

CONCLUSIONS

Enhanced reporting of relevant and pragmatic information in behavioral investigations of childhood obesity interventions is needed to improve the ability to evaluate the applicability of results to practice implementation. Such evidence would improve translation of research to practice, provide additional explanation for variability in intervention outcomes, and provide insights into successful adaptations of interventions to local conditions.

The effect of parental feeding behaviours and participation of children in organized sports/activities on child body mass index

PURPOSE

In this cross-sectional descriptive study, we explored the relationship of parental feeding practices and child physical activity levels with measured body mass index (BMI) in a sample of 97 Ontario preschoolers.

METHODS

Child weight and height were measured; physical activity and sedentary behaviours were assessed by questionnaire. Preschoolers' parents used the Child Feeding Questionnaire to report their attitudes, concerns, and practices in relation to child feeding. Hierarchical multiple linear regression was used to determine relationships among variables.

RESULTS

Up to 25% of the preschoolers were overweight and/or obese. The regression model accounted for 53% of the variance in child BMI. Child BMI was predicted to be higher when parents had concerns about and perceived their children to be overweight, and when they felt responsible for what their children ate. Children's BMIs were predicted to be lower for those whose parents pressured them to eat and also for those who engaged in organized sports or activities.

CONCLUSIONS

This study suggests an association between BMI and parental perceptions, concerns, and practices related to child feeding and organized sports or activities. Public health initiatives related to healthy eating and/or obesity prevention should include a focus on parents of preschool-aged children with the home environment as a potential setting.

Step ahead a worksite obesity prevention trial among hospital employees

BACKGROUND

The worksite represents a promising venue in which to address the issue of obesity.

DESIGN

Pair-matched, cluster-RCT. Data were collected from 2005 to 2008 and analyzed in 2008.

SETTING/PARTICIPANTS

A random sample of 806 employees was selected to represent the workforce of six hospitals in central Massachusetts.

INTERVENTION

The 2-year ecologic intervention sought to prevent weight gain through changes in worksite weight-related norms using strategies targeted at the organization, interpersonal environment, and employees.

MAIN OUTCOME MEASURES

The primary outcome was change in BMI at the 12- and 24-month follow-ups. Change in perceptions of organizational commitment to employee health and normative coworker behaviors were secondary outcomes.

RESULTS

There was no impact of the intervention on change in BMI from baseline to 12 (beta=0.272; 95% CI=-0.271, 0.782) or 24 months (beta=0.276; 95% CI=-0.338, 0.890) in intention-to-treat analysis. When intervention exposure (scale=0 to 100) was used as the independent variable, there was a decrease of 0.012 BMI units (95% CI=-0.025, 0.001) for each unit increase in intervention participation at the 24-month follow-up. Employees in intervention sites reported significantly greater improvements in perceptions of organizational commitment to employee health at 12 and 24 months compared to control sites, but there was no impact on perceptions of normative coworker behaviors.

CONCLUSIONS

The intervention had a dose-response relationship with BMI, with positive effects proportional to extent of participation. Although the intervention was able to change organizational perceptions, successfully improving changes in actual and perceived social norms may be needed to achieve population-level impact in complex worksite organizations.

Relationship of parental characteristics and feeding practices to overweight in infants and young children in Beijing, China

Background

Childhood obesity has become a major public health problem in many countries. To explore the risk factors of overweight in infants and young children might be helpful in developing an early overweight intervention strategy.

Objective

To assess the prevalence of overweight and the relationship of parental characteristics and feeding practices to overweight in infants and young children in Beijing, China.

Design

Data on weight and length/height were collected on 4654 children aged 1–35 months in twelve communities in Beijing from a cross-sectional study. Overweight was defined as weight-for-length/height ≥2sd above the median of the WHO reference. Two hundred and fifteen families with overweight children and 215 families with normal-weight children were interviewed using a questionnaire to obtain feeding practices.

Results

The overall prevalence of overweight was 4·7 %. Both parental overweight and low parental education were significantly higher among overweight than normal-weight children. The total energy intake was significantly higher in overweight than in normal-weight children at 12–35 months of age. Compared with normal-weight children, significantly fewer overweight children were breast-fed for at least 4 months. Overweight children were also more likely to have been introduced to infant formula and semi-solid foods during the first 4 months.

Conclusion

Early prevention strategies should include feeding practices identified as putting children at risk of obesity. These include early cessation of breast-feeding and premature introduction of other foods.

A systematic review of the evidence regarding efficacy of obesity prevention interventions among adults

In the past, interventions aimed at reducing obesity have mainly targeted at weight loss treatment in obese adults, with limited long-term effects. With the increasing number of people being obese and being at risk for obesity, there has been a shift in focus towards prevention of obesity. We conducted a systematic review of the peer-reviewed literature on the efficacy of obesity prevention interventions in adults in order to identify effective interventions and intervention elements. Pubmed, OVID, and Web of Science databases were searched from January 1996 to June 2006. Interventions aimed at primary prevention of weight gain among adults achieved by focusing on dietary intake, physical activity or the combination of both were included. The outcome measure had to be difference in change in body mass index or body weight between the intervention and the control groups. Nine studies were included, five long-term studies (at least 1 year) and four short-term (3 months to 1 year). Seven studies evaluated an intervention that focused on a combination of diet and physical activity to prevent weight gain, one on diet only and one on physical activity only. One dietary intervention (long-term), and three combined dietary and physical activity interventions (one long-term and two short-term) produced significantly positive results at end of follow-up. The two long-term, effective interventions consisted of intensive and long-term intervention implementation, including groups sessions designed to promote behavioural changes. The current evidence of efficacy of obesity prevention interventions is based on a very small number of studies. Some studies showed a positive impact on body mass index or weight status, but there was too much heterogeneity in terms of study design, theoretical underpinning and target population to draw firm conclusions about which intervention approaches are more effective than others. More research is urgently needed to extend the body of evidence.

Scaling up interventions for chronic disease prevention: the evidence

Interventions to prevent morbidity and mortality from chronic diseases need to be cost effective and financially feasible in countries of low or middle income before recommendations for their scale-up can be made. We review the cost-effectiveness estimates on policy interventions (both population-based and personal) that are likely to lead to substantial reductions in chronic diseases--in particular, cardiovascular disease, diabetes, cancer, and chronic respiratory disease. We reviewed data from regions of low, middle, and high income, where available, as well as the evidence for making policy interventions where available effectiveness or cost-effectiveness data are lacking. The results confirm that the cost-effectiveness evidence for tobacco control measures, salt reduction, and the use of multidrug regimens for patients with high-risk cardiovascular disease strongly supports the feasibility of the scale-up of these interventions. Further assessment to determine the best national policies to achieve reductions in consumption of saturated and trans fat--chemically hydrogenated plant oils--could eventually lead to substantial reductions in cardiovascular disease. Finally, we review evidence for policy implementation in areas of strong causality or highly probable benefit--eg, changes in personal interventions for diabetes reduction, restructuring of health systems, and wider policy decisions.

Behavioural interventions for preventing and treating obesity in adults

The purpose of this study was to review existing behavioural interventions for preventing and treating obesity in adult population that were published between 2000 and September 2006. A total of 23 interventions were found. Most of these interventions targeted both physical activity and nutrition behaviours. Majority of the interventions were not based on any explicit behavioural theory. In terms of duration, the interventions ranged from 3 weeks to 9 years. Approximately half of the interventions were less than 6 months in duration. Most of the interventions were implemented by the researchers themselves. However, some interventions were implemented by nurse educators, nutritionists, trained public health nurses, dietitians, healthcare providers, fitness workers and certified diabetic educators. Most of the interventions used group sessions as the predominant method to deliver the programme. Three of the interventions used media. Majority of the interventions were implemented in patient care settings with some in community settings. The most common determinant for measuring impact of the interventions has been body mass index. Fifteen interventions showed positive change in adiposity indices while six showed no change in adiposity indices. Recommendations for enhancing the effectiveness of behavioural interventions for prevention of obesity are presented.

Obesity, metabolic syndrome, and cardiovascular disease

Early childhood overweight and obesity have alarmingly increased over the years. Adulthood obesity is a well demonstrated significant independent predictor of cardiovascular risk (CVR) and/or mortality, which predisposes to the major components of metabolic syndrome (MS). Evidence of MS in obese children has been also reported associated with biochemical and inflammatory factors that affect vascular physiologic function. Assessment of vascular function can be measured noninvasively in children allowing early detection of endothelial dysfunction and severe increase of arterial stiffness before clinical manifestations of atherosclerosis. Impairment of endothelial function related to the severity of obesity and to the degree of insulin resistance is considered as a condition that confers a premature atherogenicity status and is linked to adult conventional cardiovascular risk factors. Adipose tissue factors that interfere with insulin action and endothelial cell function have also been identified as major precursors of CVR factors. The metabolic and cardiovascular consequences of childhood obesity are well demonstrated and have a major impact on the development of atherosclerosis and lifetime CVR. The development of programs involving both diet and exercise for children with overt overweight/obesity appears to be essential to improve vascular function and metabolic disorders. Such interventions should be complemented by a primary prevention against childhood obesity.

A meta-analytic review of obesity prevention programs for children and adolescents: the skinny on interventions that work

This meta-analytic review summarizes obesity prevention programs and their effects and investigates participant, intervention, delivery, and design features associated with larger effects. A literature search identified 64 prevention programs seeking to produce weight gain prevention effects, of which 21% produced significant prevention effects that were typically pre- to post effects. Larger effects emerged for programs that targeted children and adolescents (vs. preadolescents) and females, programs that were relatively brief, programs that solely targeted weight control versus other health behaviors (e.g., smoking), programs evaluated in pilot trials, and programs wherein participants must have self-selected into the intervention. Other factors, including mandated improvements in diet and exercise, sedentary behavior reduction, delivery by trained interventionists, and parental involvement, were not associated with significantly larger effects.

Preventing paediatric obesity; recommendations from a community-based qualitative investigation

Childhood obesity is on the rise, and interventions targeted at pre-school-aged children are essential for the primary prevention of this disease. Physical activity programming and decreasing screen viewing may be advantageous ways to reduce the early onset of obesity. Parents' perceptions regarding effective tools and programmes to target obesity are needed to develop an efficacious programme. Ten semi-structured focus groups were conducted for this qualitative study. Two experienced moderators facilitated all focus groups which were conducted in local day cares, workplaces and play groups, frequented by parents. All focus groups were audio-recorded and transcribed verbatim. Strategies to ensure trustworthiness of the data were employed. A heterogeneous sample of 71 parents were asked about their pre-schoolers' physical activity levels and screen viewing behaviours, in addition to their suggestions for programmes to facilitate the development of healthy habits. Parents agreed that physical activity programming was an ideal way to combat obesity in pre-schoolers. Programming suggestions included involving parents in the programme planning and operation, increasing accessibility to programmes, providing more facilities, better promotional strategies such as the use of a television commercial, and resources/ideas to engage children in the home. Parents' programming suggestions lacked discussion around addressing screen viewing as a viable way to attend to the current obesity epidemic. Parents must be made aware of programmes and resources currently available. Modifying current programmes' scheduling to include morning and afternoon sessions, and arranging for physicians to hand out resources with physical activity ideas, particularly during the winter months, is essential.

Cognitive determinants of energy balance-related behaviours: measurement issues

The burden of disease as a result of overweight and obesity calls for in-depth examination of the main causes of behavioural actions responsible for weight gain. Since weight gain is the result of a positive energy balance, these behavioural actions are referred to as 'energy balance-related behaviours' (EBRBs). In the broadest sense, there are only two EBRBs: food intake and physical activity. However, both diet and physical activity are complex behavioural categories that involve a variety of actions. This article discusses the potential problems and opportunities related to the assessment of cognitive determinants of energy intake and energy expenditure behaviours. We argue for the necessity of studying determinants of EBRBs within an energy balance approach, i.e. focusing on energy input as well as output, instead of only studying dietary change or physical activity behaviour. As a result, however, theoretically sound questionnaires assessing determinants of EBRBs are likely to annoy respondents. It is especially the measurement of the behaviours and the use of belief-based constructs that cause questionnaires to be long, which may lead to low response rates and invalid data. In this article, we propose a careful and systematic consideration of the inclusion or exclusion of measures of cognitive determinants. First, if studies show that an EBRB is strongly influenced by environmental factors and is not or only to a minor extent under intentional control, measurement of cognitions is of little use. Second, only when we have proof that attitudes, norms and perceived behavioural control predict intentions, should we aim to assess the underlying beliefs. Third, since assessment of beliefs results in similar or better prediction than using belief-valuation combinations, we should not 'annoy' respondents with valuation items. Finally, we argue that the traditional paper-and-pencil survey is still the most reliable and practical data collection method. However, pilot studies applying computerised adaptive methods to determinants of EBRBs are encouraged.

Validation of a brief, reliable scale to measure knowledge about the health risks associated with obesity

BACKGROUND

Obesity represents a serious threat to health through its association with conditions such as type 2 diabetes mellitus, coronary heart disease and certain types of cancer. Knowledge regarding risk to health is an important determinant of behaviour and is the focus of many health education strategies. To the authors' knowledge, there is no valid and reliable measure of knowledge regarding the health risks associated with obesity.

AIM

To validate a short, reliable psychometric scale measuring knowledge regarding the effects of obesity on health, the Obesity Risk Knowledge (ORK-10) scale.

METHODS

The ORK-10 scale was administered to a sample of individuals with no specific obesity-related expertise (n=230) and a sample of experts (n=200). Univariate and multivariate statistical analyses were used to investigate the scale's criterion validity.

RESULTS

The ORK-10 scale has good internal consistency (Cronbach's alpha coefficient>0.7) and is acceptable for use in a UK adult population with an estimated reading age of 12-13 years. The scale demonstrated strong criterion validity, as those with educational or vocational expertise in the field of obesity achieved significantly higher scores than nonexperts (median 9.0 vs 4.0, Z=-17.364; P<0.001). This relationship was maintained after controlling for the potentially confounding factors of age and level of education. Nonexperts demonstrated low levels of knowledge regarding the health risks associated with obesity.

CONCLUSIONS

The ORK-10 scale meets standard psychometric criteria for reliability and validity. This scale could be used to assess the effectiveness of health education interventions, to target the provision of health information and to investigate the interaction between knowledge and obesity-related behaviour.

Screen-viewing behaviors among preschoolers parents' perceptions

BACKGROUND

Childhood obesity has emerged as a public health concern in Canada. It has been suggested that excessive screen viewing (i.e., television, computer, video) is a major factor contributing to the increased risk of obesity in children. Exploring young children's experiences with this modifiable behavior may be beneficial to the creation of a multifaceted program aimed at the primary prevention of obesity.

OBJECTIVES

To seek parents' perceptions and insights pertaining to their preschoolers' screen-viewing behaviors.

METHODS

This qualitative study targeted a heterogeneous sample of parents with children aged 2.5 to 5 years. Two experienced moderators using a semistructured interview guide conducted the ten focus groups between September and November 2003. All focus groups were audio-recorded and transcribed verbatim. In fall 2003 to spring 2004, inductive content analysis was conducted independently by a minimum of two qualitative researchers.

RESULTS

Many parents were not concerned with the amount of screen viewing their children engaged in, although the content of what was on the screen was of particular interest to them. Very few parents seemed to appreciate the linkage between preschoolers' screen-viewing habits and their potential risk for obesity.

CONCLUSIONS

Public health interventions are needed to increase parents' awareness with respect to the harmful effects of excessive screen viewing in preschoolers.

Factors associated with parental readiness to make changes for overweight children

OBJECTIVE

The prevalence of childhood obesity is increasing in the United States. However, it has been difficult to help children successfully lose weight and maintain weight loss. Parental involvement in this effort is important. Currently, little is known about parents' readiness to make behavior changes to help their children lose weight. The objective of this study was to describe demographic factors and parental perceptions associated with parents' readiness to make weight-reducing lifestyle changes for their overweight and at-risk-for-overweight children.

METHODS

A total of 151 parents of children who were aged 2 to 12 years and had BMIs >or=85th percentile for age and gender completed a 43-item self-administered questionnaire. Parental stage of change, defined as precontemplation stage, contemplation stage, and preparation/action stage, was determined using an algorithm involving current parental practices and future intentions. Parents in the preparation/action stage were considered to be ready to make behavior changes to help their child lose weight. Maximum-likelihood multinomial logistic regression was used to identify demographics and perceptions associated with parental stage of change.

RESULTS

Sixty-two percent of the children had a BMI >or=95th percentile. Their mean age was 7.5 years, and 53% were male. Of the 151 parents, 58 (38%) were in the preparation/action stage of change, 26 (17%) were in the contemplation stage, and 67 (44%) were in the precontemplation stage. Factors associated with being in the preparation/action stage of change were having overweight or older (>or=8 years) children, believing that their own weight or child's weight was above average, and perceiving that their child's weight was a health problem. After controlling for multiple factors, having an older child (odds ratio [OR]: 2.99; 95% confidence interval [CI]: 1.18-7.60), believing that they themselves were overweight (OR: 3.45; 95% CI: 1.36-8.75), and perceiving that their child's weight was a health problem (OR: 9.75; 95% CI: 3.43-27.67) remained significantly associated with being in the preparation/action stage of change.

CONCLUSIONS

Several demographic factors and personal perceptions are associated with a parent's readiness to help his or her child lose weight. Knowledge of these factors may be beneficial to providers and program developers when addressing pediatric overweight with parents and initiating new interventions.

Netherlands Research programme weight Gain prevention (NHF-NRG): rationale, objectives and strategies

OBJECTIVE

To outline the rationale, objectives and strategies used in a systematically designed research programmme to study specific weight gain-inducing behaviours, their social-psychological as well as environmental determinants, and the effects of interventions aimed at the prevention of weight gain.

DESIGN

The evidence for potential behavioural determinants and strategies to prevent weight gain was reviewed, and the methods applied within the Netherlands Research programme weight gain prevention (NHF-NRG) project were described. The project is designed according to the Intervention Mapping protocol.

SETTING

The Netherlands.

SUBJECTS

The main target groups are (a) adolescents (12-16 y) in secondary school, (b) young adults (20-40 y) at the workplace and (c) recently retired people (55-65 y) at home.

INTERVENTIONS

Each intervention includes an individual component, in which computer-tailored information is provided. Additionally, interventions are aimed at changing environmental components.

RESULTS

The short-term results of this project can be expected by the beginning of 2005. Guidelines for nationwide weight gain prevention, based on this research programme, will become available in 2007.

CONCLUSIONS

Based on the few interventions that were evaluated to date, no robust conclusions can be drawn regarding the effectiveness of obesity prevention. The systematic and multidisciplinary design of the NHF-NRG programme enables the identification of potentially effective methods and strategies for the prevention of weight gain.

Effects of promotional materials on vending sales of low-fat items in teachers' lounges

This study examined the impact of an environmental intervention in the form of promotional materials and increased availability of low-fat items on vending machine sales. Ten vending machines were selected and randomly assigned to one of three conditions: control, or one of two experimental conditions. Vending machines in the two intervention conditions received three additional low-fat selections. Low-fat items were promoted at two levels: labels (intervention I), and labels plus signs (intervention II). The number of individual items sold and the total revenue generated was recorded weekly for each machine for 4 weeks. Use of promotional materials resulted in a small, but not significant, increase in the number of low-fat items sold, although machine sales were not significantly impacted by the change in product selection. Results of this study, although not statistically significant, suggest that environmental change may be a realistic means of positively influencing consumer behavior.

Public perceptions of the causes and prevention of obesity among primary school children

OBJECTIVE

To investigate lay perceptions of the causes and prevention of obesity among primary school children.

DESIGN

A cross-sectional survey of randomly selected sample of adults in a shopping centre.

SUBJECTS

315 adults in Melbourne, Australia.

MEASUREMENTS

Subjects completed a self-completion questionnaire, in which they rated the importance of 25 possible causes of obesity and the importance of 13 preventive measures on four-point scales: not important; quite important; very important; extremely important. Demographic information about the respondents' age, sex, marital status, education level and parental status was also collected.

RESULTS

The most important reported causes of childhood obesity were related to overconsumption of unhealthy food, parental responsibility, modern technology and the mass media. The most popular prevention activities were associated with specific actions aimed at children. Principal components analysis of the causes data revealed eight factors, provisionally named: parental responsibility, modern technology and media, overconsumption of unhealthy food, children's lack of knowledge and motivation, physical activity environment, lack of healthy food, lack of physical activity and genes. Two prevention factors were also derived, named government action and children's health promotion. Parents saw modern technology and media, and government activities as more important causes, and government policy as a more important means of prevention than nonparents and men. Women's responses tended to be similar to those of parents. There were few educational differences, although nontertiary educated respondents reported that modern technology and media were more important causes of obesity than did the tertiary educated.

CONCLUSION

The findings suggest that the public appears to hold quite sophisticated views of the causes and prevention of children's obesity. They suggest that a number of prevention strategies would be widely supported by the public, especially by parents.

Obesity and hunger among Mexican-Indian migrant children on the US-Mexico border

BACKGROUND

Although Mexican-Indian migrant workers live under precarious conditions in both Mexico and the USA, they have more access to food than they did in their original communities. The nutritional status and food security among the children of these workers have not been reported.

OBJECTIVE

The purpose of this study was to assess the prevalence of overweight, obesity, undernutrition and hunger among migrant children in a city on the US-Mexico border.

DESIGN

During 2001-2002, a total of 1767 children from six schools from the Tijuana Indian school system was measured to assess anthropometric status. Third and fifth grade children were also interviewed for their perception of hunger experience and dietary intake by 24-h recall method.

RESULTS

The overall prevalence of overweight and obesity was 38%. Abdominal obesity was found in 26% of subjects, while 43% had both obesity and abdominal obesity. The prevalence of undernutrition according to weight-for-age was 1.2%, and by height-for-age it was 4.8%. The prevalence of hunger was 2.5%, and at risk of hunger was 44%. Daily intake of food groups in servings was: 8.7 grains, 1.2 fruit, 1.0 vegetable, 2.1 milk and 2.6 meat. Only one child (0.07%) consumed The Apple of Health recommended portions.

CONCLUSIONS

This study confirmed the coexistence of obesity, hunger, undernutrition and limited food group consumption among Indian children living in a prosperous and the largest US-Mexico border city.

Strength training for obesity prevention in midlife women

OBJECTIVE

The primary goal of this study was to assess whether increases in fat-free mass (FFM) and decreases in total and percentage fat mass from 15 weeks of twice weekly supervised strength training would be maintained over 6 months of unsupervised exercise in a randomized controlled trial.

DESIGN

In all, 60 women aged 30-50 y, body mass index between 20 and 35 kg/m(2), were randomized to control or treatment groups. The treatment group performed twice-weekly supervised strength training followed by 6 months of unsupervised training. Measurements at baseline, 15, and 39 weeks included body weight and body composition by dual-energy X-ray absorptiometry. Repeated measures regression was used to assess between-group differences for changes over time.

RESULTS

Almost 90% of prescribed exercise sessions were completed. The body composition treatment effects over 15 weeks were largely maintained over 6 months of unsupervised exercise. Over the total 39 weeks of strength training, the treatment group gained +0.89 kg more in FFM, lost -0.98 kg more in fat mass, and lost -1.63% more in percent body fat when compared to the control group. P-values for these between-group differences in 39-week changes were 0.009, 0.06, and 0.006, respectively. Strength training did not result in any significant weight loss or waist circumference attenuation. Adjustment for changes in energy intake and physical activity did not alter these results.

CONCLUSIONS

Twice-weekly strength training is behaviorally feasible for busy midlife women and the favorable body composition changes resulting from supervised strength training can be maintained over time. These findings lay the groundwork for determining the long-term health benefits of this behaviorally feasible exercise prescription, potentially including prevention of age-associated fat gains.

How well do children aged 5-7 years recall food eaten at school lunch?

OBJECTIVE

This study aimed to determine the accuracy with which children aged 5 to 7 years were able to report the food eaten at a school lunch.

SUBJECTS/SETTING

Two hundred and three children (103 boys, 100 girls) aged 5-7 years were recruited from three primary schools in Oxford.

DESIGN

Trained investigators made observational records of the school dinner and packed lunch intakes of four or five children per session. Children were interviewed within two hours of finishing the lunchtime meal and asked to provide a free recall of their meal. When the child had completed the recall, non-directive prompts were used to assess if the child was able to remember anything else. Foods recalled were classified as matches (recalled food agreed with observation), omissions (failed to report a food observed) or phantoms (recalled food was not observed).

RESULTS

The percentage of accurate recall was significantly higher (P<0.01) in children eating packed lunch (mean 70 +/- 29%) than in children consuming school dinners (mean 58 +/- 27% ). This difference may have been due to increased familiarity of foods in packed lunches. Leftovers were not readily reported in this age group. Prompts and cues enhanced recall by all children.

CONCLUSIONS

This study indicated that there was a wide range in the ability of children aged 5-7 years to recall intake from a packed lunch and/or school dinner. This dietary assessment method is unlikely to be suitable at an individual level. Investigators using dietary recall to estimate food intake in children aged 5-7 years need to be aware of the limitations of this method.

Obesity: responding to the global epidemic

Obesity has reached epidemic proportions in the United States and other developed nations. In the United States, 27% of adults are obese and an additional 34% are overweight. Research in the past decade has shown that genetic influences clearly predispose some individuals to obesity. The marked increase in prevalence, however, appears to be attributable to a toxic environment that implicitly discourages physical activity while explicitly encouraging the consumption of supersized portions of high-fat, high-sugar foods. Management of the obesity epidemic will require a two-pronged approach. First, better treatments, including behavioral, pharmacologic, and surgical interventions, are needed for individuals who are already obese. The second and potentially more promising approach is to prevent the development of obesity by tackling the toxic environment. This will require bold public policy initiatives such as regulating food advertising directed at children. The authors call not for the adoption of a specific policy initiative, but instead propose that policy research, based on viewing obesity as a public health problem, become a central focus of research.