Practitioner review: bridging the gap between research and clinical practice in pediatric obesity

Family-based pediatric weight management interventions in US primary care settings targeting children ages 6-12 years old: A systematic review guided by the RE-AIM framework

Obesity is a pandemic that disproportionately affects children from vulnerable populations in the USA. Current treatment approaches in primary care settings in the USA have been reported to be insufficient at managing pediatric obesity, primarily due to implementation challenges for healthcare systems and barriers for families. While the literature has examined the efficacy of pediatric obesity interventions focused on internal validity, it lacks sufficient reporting and analysis of external validity necessary for successful translation to primary care settings. We conducted a systematic review of the primary-care-setting literature from January 2007 to March 2020 on family-based pediatric weight management interventions in both English and/or Spanish for children ages 6-12 years in the USA using the Reach, Efficacy/Effectiveness, Adoption, Implementation, Maintenance (RE-AIM) framework. A literature search, using PRISMA guidelines, was conducted in January 2022 using the following electronic databases: Medline Ovid, Embase, and Cochrane Library. 22 270 records were screened, and 376 articles were reviewed in full. 184 studies were included. The most commonly reported dimensions of the RE-AIM framework were Reach (65%), Efficacy/Effectiveness (64%), and Adoption (64%), while Implementation (47%) and Maintenance (42%) were less often reported. The prevalence of reporting RE-AIM construct indicators ranged greatly, from 1% to 100%. This systematic review underscores the need for more focus on external validity to guide the development, implementation, and dissemination of future pediatric obesity interventions based in primary care settings. It also suggests conducting additional research on sustainable financing for pediatric obesity interventions.

Predictors of attendance in a practical clinical trial of two pediatric weight management interventions

The objective of this study was to evaluate demographic and psychosocial predictors of attendance in a family-based behavioral weight management clinical trial. Ninety-three children and adolescents aged 7-17 (Mean age = 11.59, s.d. = 2.6) who were either overweight or obese (Mean BMI percentile = 98.2) and their parents received either a 10-session behavioral treatment or a three-session brief family intervention in the context of a randomized clinical trial (10). Psychosocial and anthropometric measures were obtained before enrollment and at the end of 10 weeks for both treatment groups. Univariate linear regression and hierarchical multiple regression analyses were used to identify predictors of attendance to treatment from an a priori set of hypothesized predictors. Three variables demonstrated significant associations with the dependent variable, percent of treatment sessions attended. Specifically, distance from participant's home to treatment site, lower gross family income, and youth self-report of depressive symptoms were each associated with lower percent attendance (all Ps < 0.05). These results corroborate (i.e., income, depressive symptoms) and expand (i.e., distance from treatment site) previous reports in the literature of potential barriers to effective treatment for pediatric obesity, and suggest the need for research on treatment delivery methods that could increase participation among low-income families (e.g., eHealth, mHealth options). Depressive symptoms could represent an additional barrier to treatment attendance, suggesting that assessment and treatment for these symptoms may be appropriate before commencing weight management treatment.

Reliability and validity of the SE-HEPA: examining physical activity--and healthy eating-specific self-efficacy among a sample of preadolescents

OBJECTIVE

The purpose of this study was to examine the psychometric properties of the self-efficacy for healthy eating and physical activity measure (SE-HEPA) for preadolescents.

METHOD

The reliability of the measure was examined to determine if the internal consistency of the measure was adequate (i.e., αs > .70). Next, in an effort to determine if a two-factor model was a better fit than a one-factor model, as hypothesized, an exploratory factor analysis in a confirmatory factor analysis framework was used to determine model fit. Additionally, the criterion-related validity of the measure was evaluated by conducting correlational analyses to determine if SE-HEPA scores were associated with preadolescent body mass index.

RESULTS

Consistent with the hypotheses, Cronbach's alphas indicated good reliability for the measure (i.e., αs > .70) and factor analyses indicated the two-factor model provided a better fit than the one-factor model. Additionally, correlations revealed a significant relationship between the two factors (i.e., healthy eating, physical activity) and preadolescent body mass index.

CONCLUSIONS

The SE-HEPA will allow researchers and clinicians to better understand self-efficacy for behaviors important to weight loss among preadolescents. This could, in turn, inform future efforts aimed at increasing behaviors that promote healthy weight status among this population within the context of family-based weight loss programs.

Childhood obesity and co-morbid problems: effects of Epstein's family-based behavioural treatment in an Icelandic sample

OBJECTIVE

This study assessed the effects of Epstein's family-based behavioural treatment in a clinical sample of obese children in Iceland. Also, it explored whether co-morbid concerns affect treatment outcome.

METHODS

Eighty-four obese children [mean body-mass-index standard-deviation-scores (BMI-SDS) = 3.11, aged 7.5-13.6 years] and a participating parent initiated treatment in response to a school-based screening. Sixty-one families completed treatment and were followed for 1 year post treatment. Measurements included height, weight, reports of psychological well-being (Strengths and Difficulties Questionnaire, Multidimensional Anxiety Scale for Children, Children's Depression Inventory, Piers-Harris Self Concept Scale, Social Skills Rating System) and academic competencies.

RESULTS

Among treatment completers a large effect size was obtained for change in BMI-SDS during treatment (mean difference = -0.40, SD = 0.29). Psychological well-being improved and treatment effects were maintained at 1-year follow-up. At baseline, 69% of the children presented with one or more co-morbid concerns. Children who scored above cut-off for concern on parent-reported hyperactivity (Strengths and Difficulties Questionnaire subscale T-score ≥ 65) reduced their BMI-SDS less during treatment than children with lower hyperactivity scores whereas children who scored in the clinical range for social anxiety (Multidimensional Anxiety Scale for Children subscale T-score ≥ 65) reduced their BMI-SDS significantly more than children with lower social anxiety scores. The social anxiety effect was still present at 1-year follow-up, but not the hyperactivity effect (P > 0.05). No differential response was shown for children with higher depression scores, lower self-concept or low academic competencies.

CONCLUSIONS

Epstein's family-based behavioural treatment produced promising effects in both the short and the longer term in a clinical sample of Icelandic children with substantial rates of co-morbid concerns. Co-morbid problems affect outcome and tailoring treatment to address co-morbid concerns might improve outcomes for certain subgroups.

A primary care healthy choices intervention program for overweight and obese school-age children and their parents

INTRODUCTION

The escalating crisis of childhood overweight and obesity creates an urgent demand for evidence-based interventions that can be used by primary care providers. Therefore, the purpose of this study was to test the feasibility, acceptability, and preliminary efficacy of a theory-based Healthy Choices Intervention (HCI) Program with fifteen 9-12 year old overweight and obese children and their parents in a primary care setting.

METHODS

A 1-group, 7-week pre-/posttest study design was used. Outcome measures included: body mass index (BMI) percentile, physical activity and nutrition knowledge, beliefs, choices and behaviors, anxiety, depression, self-concept, and social competence.

RESULTS

Children and parents found the HCI to be useful and informative. Positive effects of the HCI for the children included decreased BMI percentile, increased knowledge, beliefs, choices and behaviors, and self-control. Positive effects of the intervention for the parents included increased knowledge, beliefs, behaviors, and decreased anxiety.

DISCUSSION

This study provides evidence to support the feasibility, acceptability, and preliminary effects of the HCI with overweight and obese school-age children and their parents within a primary care setting.

Immersion treatment of childhood and adolescent obesity: the first review of a promising intervention

Obese children have attended weight loss camps and residential programmes for more than 40 years. This paper provides the first systematic review of the effects of those programmes. Twenty-two studies met inclusion criteria (targeted and assessed change in weight status, minimal stay of 10 days and nights). Similar components across programmes included controlled diet, activities, nutrition education, and therapy and/or education regarding behaviour change. Participants lost substantial amounts of weight in all 22 studies, as measured by reductions in per cent-overweight during intervention. Eleven programmes included long-term follow-up evaluations. Compared with results highlighted in a recent meta-analysis of out-patient treatments, these immersion programmes produced an average of 191% greater reductions in per cent-overweight at post-treatment and 130% greater reduction at follow-up. Furthermore, mean attrition rates were much lower when compared with standard out-patient treatment. Inclusion of a cognitive-behavioural therapy (CBT) component seemed especially promising; follow-up evaluations showed decreased per cent-overweight at follow-up by an average of 30% for CBT immersion programmes vs. 9% for programmes without CBT. Explanations for the potentially greater impact of immersion relative to out-patient treatments are presented, including possibly differential effects on self-efficacy for both children and their parents.

New psycho-pedagogic approach to obesity treatment: a 5-year follow-up

OBJECTIVE

The aim of the present study was to evaluate the body weight evolution in obese patients admitted for a 2-week residential program and followed-up on ambulatory basis, as well as to evaluate factors having impact on weight evolution after 5 years.

METHODS

Thirty-nine obese patients participated in a 2-week structured interdisciplinary weight loss program, involving individual and group therapies, and including physical activity, nutritional education and standard cognitive-behavioral techniques. Patients were then followed-up regularly by their general practitioners for 5 years.

RESULTS

After 5 years, 33 subjects completed the study. Seventy percent of the patients lost weight or maintained their weight loss. Total score for dietary structure, eating behavior disorders, dietary surveillance and weight management strategies, as evaluated by a validated questionnaire, was significantly lower in the weight loss group (22.4+/-4.3) as compared to maintenance group (24.4+/-6.1, p<0.05) and regain group (29.7+/-4.0, p<0.01). Patients who lost weight presented a more important follow-up on long-term weight management (p<0.05), a better dietary results (p<0.01) as well as more physical activity (p<0.05) that the regain group.

CONCLUSION

The present study demonstrated that an initial multidimensional and multidisciplinary in-hospital program with a consecutive long-term ambulatory follow-up may lead to a significant weight loss (55%) and/or weight maintenance (15%).

PRACTICE IMPLICATIONS

A multidisciplinary and well-designed initial treatment and long-term follow-up program is mandatory for obesity management.

Child mental health problems and obesity in early adulthood

OBJECTIVE

To examine whether mental health problems in childhood increase the likelihood of overweight or obesity during early adulthood among male subjects.

STUDY DESIGN

In a national prospective population-based study conducted in Finland, child mental health, including depression, emotional problems, conduct problems, and hyperactivity (determined on the basis of child, parent, and teacher information), was assessed at age 8 years. Body mass index (BMI) was obtained from military examination records (n = 2209) conducted in early adulthood (age range, 18-23 years).

RESULTS

Both moderate (50th-90th percentile) and high (>90th percentile) levels of conduct problems at age 8 years were prospectively associated with a young adult being obese (BMI > or = 30; odds ratio [OR], 2.0; 95% CI, 1.2-3.2; and OR, 2.9; 95% Confidence interval [CI], 1.5-5.9; respectively). Conduct problems were also prospectively associated with a young adult being overweight (25 < or = BMI < 30; OR, 1.5; 95% CI, 1.1-1.9 for moderate levels of conduct problems, and OR, 1.9; 95% CI, 1.2-2.8 for high levels), after controlling for hyperactive problems and sociodemographic factors.

CONCLUSIONS

Conduct problems in childhood are prospectively associated with overweight and obese in young adulthood. Future studies should address the potential for interventions to reduce obesity risk in young adulthood for boys who manifest conduct problems early in life.

New perspectives on health disparities and obesity interventions in youth

OBJECTIVE

This article reviews intervention studies that address health disparities and the increasing rate of obesity in minority youth. The review focuses on interventions that target obesity-related behaviors (diet, physical activity, sedentary behaviors) and adiposity outcomes (body mass index) in minority children and adolescents.

METHODS

A conceptual framework is presented that integrates ecological, cultural, social, and cognitive approaches to reducing obesity in ethnically diverse youth. The review highlights effective interventions in minority youth and distinguishes between culturally targeted and culturally tailored components.

RESULTS

A limited number of studies have been conducted that target obesity-related behaviors and adiposity outcomes in minority youth. The most successful interventions for minority youth have incorporated culturally targeted and culturally tailored intervention components using multi-systemic approaches.

CONCLUSIONS

Further research is needed that focuses on testing the efficacy of theoretically based approaches that integrate culturally appropriate program elements for improving obesity-related behaviors and adiposity outcomes in minority youth.

Social implications of overweight and obesity in children

PURPOSE

To elucidate some of the social impacts that overweight and obesity in children has on families. Healthcare practitioners may be unaware of these impacts if not similarly affected.

DESIGN

Qualitative semistructured, interview-based study.

METHODS

A purposive sample of parents (n = 58) with overweight and obese children (n = 48) from three areas in the United Kingdom was used. Analysis was thematic and iterative, underpinned by Grounded Theory.

RESULTS

There are many social situations that have an impact on the child directly (stigmatization), on parents (blame), and on the family in general (being ostracized).

PRACTICE IMPLICATIONS

Seeing the child and his/her family in a broader context with improved understanding of the complexity of raising an overweight child.

Care of the overweight adolescent including polycystic ovarian syndrome

Obstetrician-gynecologists are responsible for promoting healthy eating and physical activity in adolescents during annual screening examinations. Adolescents with a body mass index for age greater than or equal to the 95th percentile should undergo an in-depth health assessment to determine psychosocial morbidity and risk of cardiovascular disease. Further research is needed to determine the most efficacious approach to the prevention and treatment of obesity in adolescents. For now, it is best to extrapolate an approach from data pertaining to children and adults, while being cognizant of the special psychosocial and physical needs of adolescents.