Effective Weight Loss for Children: A Meta-analysis of Intervention Studies 2002-2015

Clinical and metabolic effect of a multidisciplinary intervention through a comprehensive care program for children and adolescents with obesity

Introducción.

La obesidad infantil requiere una atención con programas multidisciplinarios que integren todas sus dimensiones.

Objetivo.

Describir los cambios clínicos y metabólicos en pacientes con obesidad después de su participación en un programa de atención integral en obesidad infantil.

Materiales y métodos.

Se hizo un estudio observacional y analítico retrospectivo de una cohorte de pacientes de 6 a 17 años de edad atendidos en el programa de obesidad del Hospital Universitario de San Vicente Fundación (2012-2015), el cual incluyó la atención multidisciplinaria y una intervención educativa. Se evaluaron variables antropométricas y de laboratorio en el momento del ingreso al programa y en la última evaluación. Se exploraron las diferencias según el tiempo de seguimiento.

Resultados.

Se evaluaron 53 pacientes con una edad promedio de 11 ± 2 años, 52,8 % de los cuales eran hombres. El seguimiento de los pacientes fue de 18 ± 6 meses, aunque en el 30 % de ellos fue de 31 a 36 meses. Se encontró una disminución del índice de masa corporal (IMC; puntaje Z) entre el ingreso (2,75 ± 0,58) y el último control (2,32 ± 0,63) con un valor de p de 0,000 (IC₉₅% 0,27-0,58). El 79,25 % de los pacientes redujo el puntaje Z del IMC. Esta disminución fue significativa independientemente del tiempo de seguimiento. La proporción de pacientes con un puntaje Z del IMC mayor de 3 pasó del 33,4 al 14,6 %. El número de criterios positivos para el síndrome metabólico disminuyó en el seguimiento. Los niveles de triglicéridos y de hemoglobina A1c (HbA1c) mejoraron significativamente.

Conclusiones.

El manejo de la obesidad infantil con una intervención multidisciplinaria asociada a apoyo educativo grupal continuo puede influir significativamente en los cambios clínicos y metabólicos. Es necesario prolongar el tiempo de seguimiento para prevenir las recaídas.

The feasibility and acceptability of a primary school-based programme targeting diet and physical activity: the PhunkyFoods Programme

Background

This study aims to evaluate the feasibility and acceptability of the PhunkyFoods Programme, a primary school-based intervention to promote healthy nutrition and physical activity knowledge and behaviours to assess outcomes to inform a phase 3 trial.

Methods

The cluster randomised feasibility trial recruited eight primary schools from the North of England. Elibility criteria included all primary schools in one town, excluding independent and special schools and schools that comprised of only key stage 2 pupils (years 3–6). Eight schools agreed to participate. Randomisation to intervention or control arms was in a 1:1 ratio. Intervention schools received PhunkyFoods over 17 months. Control schools continued with usual curriculum. Assessors were blinded to group assignment. Measures comprised of a Healthy Lifestyle Knowledge Questionnaire and Synchronised Nutrition and Activity Program to assess diet and physical activity, height, weight, and psychological wellbeing. Feasibility outcomes were recruitment, attrition rates, interviews with teaching staff, focus groups with pupils to explore the acceptability of outcome measures, implementation, intervention content, and programme fidelity.

Results

Three hundred fifty-eight pupils, aged 6–9 years from eight schools were recruited at baseline (control n = 170, intervention n = 188); 337 (94.1%) at 6 months (control n = 163, intervention n = 181); and 331 (92.5%) at 18 months (control n = 152, intervention n = 179), and 6 pupils opted out. Trends in increased knowledge of healthy lifestyle behaviours, healthier eating, and liking of fruit and vegetables were reported in the intervention compared to the control group. Year 4 intervention pupils had significantly higher healthy balanced diet knowledge scores compared to control pupils, mean difference 5.1 (95% CI 0.1 to 10.1, p=0.05). At 18 months, the mean percentage of vegetables liked was higher (intervention 53.9% vs. 43.0% control). Similarly, percentage of fruits liked was also higher (intervention 76.9% vs. 67.2% control). Qualitative data showed that delivery of the intervention was feasible and acceptable to teachers and pupils. Lessons were learned to inform the phase 3 trial around the dietary assessment measure and timing of recruitment.

Conclusions

Whilst the study was not powered to detect a definitive effect, results suggest a potential to increase knowledge of healthy lifestyle behaviours and dietary behaviours, suggesting that with minor changes, a phase 3 trial is likely to be deliverable.

Trial registration

ISRCTN, ISRCTN15641330. Registered 8 May 2015—retrospectively registered, 10.1186/ISRCTN15641330

Feasibility, acceptability, and effectiveness of a multidisciplinary intervention in childhood obesity from primary care: Nutrition, physical activity, emotional regulation, and family

Childhood obesity is a growing problem with a complex aetiology, for which multidisciplinary interventions are required. Our programme describes a novel structured psychosocial family-based intervention targeting the emotional regulation in childhood obesity, using a train trip metaphor aimed at improving healthy lifestyles for the family. The aims were (a) to describe the feasibility and acceptability of this psychosocial family-based intervention among children with overweight or obesity in primary care and (b) to examine the effectiveness of the "ENTREN-F" programme (with family intervention) compared with the "ENTREN" programme (without family intervention) among Spanish children regarding anthropometric variables, physical activity, emotional well-being, and family functioning. Children were randomly allocated to either ENTREN-F programme (n = 30) or psychological intervention for children (ENTREN, n = 40), and assessments were carried out over time (T₀ baseline vs. T₁ post/6-month vs. T₂ 6-month follow-up). Both parent groups expressed high levels of satisfaction with the interventions. ENTREN-F resulted in higher adherence to treatment and was more effective in improving z-body mass index, reducing children's anxiety, and increasing family adaptability than the ENTREN programme. There were no significant changes in parents' emotional well-being and expressed emotion. Both groups improved in the children's emotional well-being and light physical activity. In summary, this multidisciplinary psychosocial family-based intervention was succesful.

The impact of abnormal BMI on surgical complications after pediatric colorectal surgery

BACKGROUND/PURPOSE

While childhood obesity is a growing problem, the implications of BMI on elective pediatric surgery remains poorly described. This study evaluates the impact of obesity on surgical outcomes after elective colorectal procedures.

METHODS

Children ages 2-18 years undergoing elective colorectal surgery for IBD were identified from the NSQIP-Pediatric database. Patients were classified as underweight (UW), normal weight (NW), overweight (OW) and obese (OB) based on their age- and sex-adjusted BMI. Postoperative complications were compared between cohorts.

RESULTS

858 patients (14.8% UW, 64.3% NW, 13.1% OW, 7.8% OB) were identified, with overall complications occurring in 15.3% and SSI in 10.1%. Obese/overweight patients had higher rates of deep incisional SSI (4.5%OB, 4.5%OW, 0%NW, p=0.002) and superficial wound disruption (5.4%OB, 5.8%OW, 1.6%NW, p=0.04). Incremental increase in BMI by 1.0kg/m² was associated with 4.3% increased likelihood of developing deep incisional SSI and 2.3% increase of superficial wound disruption. Obese/overweight children also had increased incidence of septic shock and UTI, as well as longer operative times, days of mechanical ventilation and LOS.

CONCLUSIONS

Increasing BMI was associated with increased wound complications in IBD patients undergoing elective intestinal surgery. Preoperative optimization and weight loss strategies may potentially reduce SSI and other infectious complications.

LEVEL OF EVIDENCE

III.

Effective implementation of primary school-based healthy lifestyle programmes: a qualitative study of views of school staff

Background

Primary schools are valuable settings to implement healthy lifestyle (healthy eating and physical activity) interventions, aimed at targeting childhood obesity. This study explored school staff perceptions of factors that hinder and enable successful implementation and sustainability of healthy lifestyle interventions in primary schools. Qualitative data was pooled and analysed from two evaluations carried out in primary schools in North England: a feasibility study of a nutrition and physical activity educational programme (PhunkyFoods Feasibility Study), and an evaluation of a healthy eating programme (The Food Dudes Evaluation).

Methods

Sixty-five qualitative semi-structured interviews were conducted with head teachers, teachers, catering managers, designated school-based programme coordinators and programme staff supporting schools with programme delivery, at 14 schools involved in both evaluations. Thematic analysis was undertaken and emergent themes categorised using a framework for successful implementation by Durlak and Dupre (2008).

Results

Overall, all schools were delivering a range of healthy lifestyle programmes, often with overlapping content. Perceived challenges to implementation of individual programmes included: limited time, timing of implementation, limited training and support, insufficient resources, capacity and facilities, staff perceptions of intervention and perceived skill-proficiency (for cooking and physical activities). Short-term funding, lack of external and internal support were perceived to hinder sustainability. Staff recommendations for successful implementation of future programmes included: extended training and planning time, sufficient capacity, external support for delivery, good resources (interactive, practical and adaptable), and facilities for cooking, healthy eating, gardening and physical activities. Head teachers need to prioritise delivery of a few key healthy lifestyle programmes, in an overcrowded curriculum. Schools need to employ strategies to engage participation of staff, pupils and parents long term.

Conclusions

Effective implementation of school-based healthy lifestyle programmes was thought to be aided by flexible and adaptable programmes, enabling good contextual fit, well-resourced programmes and effective leadership at multiple levels, pupil (pupils support delivery) and parent involvement. To facilitate sustainability, it was perceived that programmes need to be integrated within the curriculum and school policies long term, with sustained support from head teachers and staff. These findings are relevant to programme developers, policy makers and those involved in delivering interventions.

Electronic supplementary material

The online version of this article (10.1186/s12889-019-7550-2) contains supplementary material, which is available to authorized users.

Nurse-Led Telephone Follow-Up to Improve Parent Promotion of Healthy Behaviors in Young Children With Motivational Interviewing Techniques

INTRODUCTION

The American Academy of Pediatrics (AAP) recommends primary care-based health promotion for obesity prevention at all visits, focusing on nutrition and activity.

METHODS

In this quality improvement project, a primary care innovation was developed to support parents in promoting healthy habits in their children ages 2 to 5 years old. Nurse-led telephone support using motivational interviewing was implemented during two follow-up phone calls aimed at helping parent-child dyads reach self-created activity or nutrition goals.

RESULTS

Parent-rated confidence and motivation related to meeting these goals showed significant increases. During the second call, 80% self-reported goal completion and high satisfaction with the visits. Registered nurses reported a significant increase in their self-efficacy of communication with parents.

DISCUSSION

This project showed the feasibility of using nurse telephone visits in an urban low-income primary care setting to improve parental recognition and understanding of healthy habits that align with American Academy of Pediatrics recommendations for obesity prevention.

The effect of a multidisciplinary intervention program for overweight and obese children on cardiorespiratory fitness and blood pressure

BACKGROUND

Multidisciplinary intervention programs for overweight and obese children mainly focus on reducing bodyweight and body mass index (BMI), but they may also positively impact blood pressure (BP), and cardiorespiratory fitness (CRF), which is a stronger predictor for all-cause mortality than BMI.

OBJECTIVE

To evaluate whether Kids4Fit, a multidisciplinary weight reduction program, has a positive effect on CRF and BP in overweight and obese children in socially deprived areas.

METHODS

A quasi-experimental study design with a waiting list control period including children who participated in a multidisciplinary intervention program of 12 weeks was set-up. Blood pressure measurements and shuttle-run test (SRT) were performed at baseline, at the start of the intervention, at the end of intervention and after 52 weeks. The effect of Kids4Fit on BP and on SRT scores were analyzed using mixed models.

RESULTS

A total of 154 children were included [mean age 8.5 years (SD 1.8)]. No significant change was seen in systolic BP percentiles at 52 weeks after start of the Kids4Fit intervention (β 0.08, (95%CI -0.06, 0.22)). Diastolic BP percentiles increased significantly over time (β 0.20 (0.08, 0.31)). Effect plots showed an initial significant increase of the SRT scores but this effect diluted after the intervention.

CONCLUSION

A local multidisciplinary intervention program in deprived areas had a significant positive effect on CRF, but this effect diluted after the intervention. Diastolic BP percentiles significantly increased over time. However, systolic BP did not change over time.

Interventions aimed at preventing and reducing overweight/obesity among children and adolescents: a meta-synthesis

The prevalence of child and adolescent obesity has been a major worldwide problem for decades. To stop the number of youth with overweight/obesity from increasing, numerous interventions focusing on improving children's weight status have been implemented. The growing body of research on weight-related interventions for youth has been summarized by several meta-analyses aiming to provide an overview of the effectiveness of interventions. Yet, the number of meta-analyses is expanding so quickly and overall results differ, making a comprehensive synopsis of the literature difficult. To tackle this problem, a meta-synthesis was conducted to draw informed conclusions about the state of the effectiveness of interventions targeting child and adolescent overweight. The results of the quantitative synthesis of 26 meta-analyses resulted in a standardized mean difference (SMD) of -0.12 (95%CI: -0.16, -0.08). Several moderator analyses showed that participant and intervention characteristics had little impact on the overall effect size. However, a moderator analysis distinguishing between obesity treatment and obesity prevention studies showed that obesity treatment interventions (SMD: -0.048, 95%CI: -0.60, -0.36) were significantly more effective in reducing body mass index than obesity prevention interventions (SMD: -0.08, 95%CI: -0.11, -0.06). Overall, the results of this meta-synthesis suggest that interventions result in statistically significant effects albeit of relatively little clinical relevance.

Overweight and Obesity in Schoolchildren: Hierarchical Analysis of Associated Demographic, Behavioral, and Biological Factors

Studies focused on the mechanisms involved in the development of obesity in children and adolescents have reported associations between this condition and birth weight, sedentary lifestyle, and hereditary conditions. However, few studies have simultaneously evaluated these factors. This cross-sectional study aims to identify demographic, behavioral, and biological factors associated with overweight/obesity in children and adolescents. 381 schoolchildren aged seven to 17 years were included in the study to evaluate the associations between overweight/obesity and biological factors (including family history of obesity, birth weight, and the fat mass and obesity-associated (FTO) rs9939609 polymorphism), demographic variables (including gender and age), and behavioral variables (including physical activity and/or sports participation). The results of this study showed that there was a lower prevalence of obesity in schoolchildren aged 11-17 years (PR: 0.89; p=0.004). Obesity was more prevalent in children whose father (PR: 1.24; p < 0.001) and maternal grandmother (PR: 1.16; p=0.019) were obese. Higher prevalence rates of obesity were also identified in schoolchildren who were overweight at birth (PR: 1.18; p=0.002) and carriers of the obesity risk genotype (PR: 1.13; p=0.016). Biological factors, such as family history of obesity, overweight at birth, and the presence of the fat mass and obesity-associated rs9939609 polymorphism were associated with the prevalence of obesity in children and adolescents.

How family interactions about lifestyle changes affect adolescents' possibilities for maintaining weight loss after a weight-loss intervention: a longitudinal qualitative interview study

AIM

This study aims to examine how family interactions related to lifestyle changes influence adolescents' potential for maintaining weight loss after participating in a weight-loss treatment programme.

BACKGROUND

Obesity among adolescents is a large and complex health problem worldwide. Family support is crucial if adolescents are to benefit from weight-loss intervention.

DESIGN

Qualitative research interviews with families who participated in a weight-loss programme.

METHODS

The sample consisted of 10 families selected among participants in a 1-year multidisciplinary family-based weight-loss programme. Three rounds of semi-structured interviews stretching over 5 years (2010-2015) were transcribed verbatim, then analyzed using Kvale and Brinkmann's framework for working with qualitative research interviews.

FINDINGS

Five years after the intervention ended, we found that a family's interactions were a key factor in how the family handled challenges involved in changing its diet and increasing physical activity and that daily activities in modern families influenced their interaction, as activities demanded so much of the family that it was difficult to sustain the lifestyle changes necessary for the adolescent to maintain achieved weight loss. Supporting the adolescent was far more difficult than families expected; more time-consuming and also a cause of family conflicts. Siblings who did not need to lose weight played a major, but overlooked, role.

CONCLUSION

The family's interactions and its handling of lifestyle changes were important to the adolescent's maintained weight loss. It is fundamental that the entire family is supportive, regardless of family structure and these issues ought to be addressed in future interventions.

A Community-Based Nutrition and Physical Activity Intervention for Children Who Are Overweight or Obese and Their Caregivers

There is a need for efficacious interventions to reduce the prevalence of childhood obesity, and a limited body of research suggests that collaborative community-based programs designed for children and their caregivers may be effective in reducing obesity rates. This paper reports the results of a community-based obesity intervention, South County Food, Fitness and Fun (SCFFF), designed for preadolescent children who are overweight or obese and their caregivers. SCFFF was developed in response to community concerns. Families were referred to the program by their physician and participated in the program at no cost. The 16-week intervention includes weekly group nutrition and physical activity sessions. Analyses determined that 65 out of the 97 children who completed SCFFF provided 2-year follow-up data and had reduced BMI z-scores over 2 years following the intervention. These participants decreased their energy, fat, carbohydrate, saturated fat, and sodium intake and increased core body strength and endurance from baseline to the end of the intervention. SCFFF was effective in reducing relative weight and improving diet and core muscle strength and endurance in children who are overweight or obese.

Multicomponent Lifestyle Interventions for Treating Overweight and Obesity in Children and Adolescents: A Systematic Review and Meta-Analyses

BACKGROUND

Treatment of childhood obesity is important in preventing development of obesity-related diseases later in life. This systematic review evaluates the effect of multicomponent lifestyle interventions for children and adolescents from 2 to 18 years.

METHODS AND RESULTS

We performed systematic searches in nine databases. Thirty-nine studies met the criteria for meta-analyses. We found a significant difference in body mass index (BMI) after 6 months (MD -0.99 (95% CI -1.36 to -0.61)), 12 months (MD -0.67 (95% CI -1.01 to -0.32)), and 24 months (MD -0.96 (95% CI -1.63 to -0.29)) in favour of multicomponent lifestyle interventions compared to standard, minimal, and no treatment. We also found a significant difference in BMI Z scores after 6 months (MD -0.12 (95% CI -0.17 to -0.06)), 12 months (MD -0.16 (95% CI -0.21 to -0.11)), and 24 months (MD -0.16 (95% CI -0.21 to -0.10)) in favour of multicomponent lifestyle interventions. Subgroup analyses suggested an increased effect in specialist health care with a group treatment component included in the intervention.

CONCLUSION

Multicomponent lifestyle interventions have a moderate effect on change in BMI and BMI Z score after 6, 12, and 24 months compared with standard, minimal, and no treatment.

Study Protocol: A randomized controlled trial evaluating the effect of family-based behavioral treatment of childhood and adolescent obesity-The FABO-study

Background

The purpose of the FABO-study is to evaluate the effect of family-based behavioral social facilitation treatment (FBSFT), designed to target children’s family and social support networks to enhance weight loss outcomes, compared to the standard treatment (treatment as usual, TAU) given to children and adolescents with obesity in a routine clinical practice.

Methods

Randomized controlled trial (RCT), in which families (n = 120) are recruited from the children and adolescents (ages 6–18 years) referred to the Obesity Outpatient Clinic (OOC), Haukeland University Hospital, Norway. Criteria for admission to the OOC are BMI above the International Obesity Task Force (IOTF) cut-off ≥ 35, or IOTF ≥ 30 with obesity related co-morbidity. Families are randomized to receive FBSFT immediately or following one year of TAU. All participants receive a multidisciplinary assessment. For TAU this assessment results in a plan and a contract for chancing specific lifestyle behaviors. Thereafter each family participates in monthly counselling sessions with their primary health care nurse to work on implementing these goals, including measuring their weight change, and also meet every third month for sessions at the OOC. In FBSFT, following assessment, families participate in 17 weekly sessions at the OOC, in which each family works on changing lifestyle behaviors using a structured cognitive-behavioral, socio-ecological approach targeting both parents and children with strategies for behavioral maintenance and sustainable weight change.

Outcome variables include body mass index (BMI; kg/m²), BMI standard deviation score (SDS) and percentage above the IOTF definition of overweight, waist-circumference, body composition (bioelectric impedance (BIA) and dual-X-ray-absorptiometry (DXA)), blood tests, blood pressure, activity/inactivity and sleep pattern (measured by accelerometer), as well as questionnaires measuring depression, general psychological symptomatology, self-esteem, disturbed eating and eating disorder symptoms. Finally, barriers to treatment and parenting styles are measured via questionnaires.

Discussion

This is the first systematic application of FBSFT in the treatment of obesity among youth in Norway. The study gives an opportunity to evaluate the effect of FBSFT implemented in routine clinical practice across a range of youth with severe obesity.

Trial registration

ClinicalTrails.gov NCT02687516. Registered 16th of February, 2016

Electronic supplementary material

The online version of this article (doi:10.1186/s12889-016-3755-9) contains supplementary material, which is available to authorized users.