Behavioral Treatment of Obesity in Children and Adults: E idence based Interventions Evidence-based Inter entions

Hollie Raynor, Ph.D., R.D., L.D.N. Associate Professor Department of Nutrition Obesity Research Center

Objectives
Define evidenceevidence-based treatment Describe the components of evidence evidencebased childhood obesity interventions Describe the components of evidenceevidencebased adult obesity interventions Id tif effective Identify ff ti dietary di t interventions i t ti used in adult behavioral weight control interventions

What is Evidence-based?
The focus on using evidence evidence-based i t interventions ti comes from f concerns that th t patients/clients receive treatment that is grounded in tradition and/or outdated training, rather than scientific evidence Research R h community it encouraged dt to scrutinize and evaluate interventions in order to ascertain their efficacy

What is Evidence-based?
How are interventions evaluated?
Accumulation of research
Quality of research
Experimental vs. Observational designs Methods Measures (self(self-report vs. objective) Randomized Controlled Trials

Meta Meta-analyses

What is Evidence-based?
Evidence Evidence-based medicine
Current best evidence for making clinical decisions about the care of patients/clients Incorporates best research evidence, clinical expertise, and patient values Currently y used to improve p the q quality y of care, and can provide objective criteria for decisions regarding the allocation of health care resources

What is Evidence-based?
Limitations
Understanding efficacy (emphasis on internal validity) vs. effectiveness (emphasis on external validity)
Type of population studied Geographic settings Health care setting

Will change over time

Overweight/Obese - definition
Definitions of overweight and obese are based upon body mass index (BMI): weight (kg)/height (m2) In children, BMI percentile for age and gender is the preferred measure for detecting overweight in children and adolescents Overweight (at risk for overweight): 85th to 94th percentile BMI Obese (overweight): >95th percentile BMI

Overweight/Obese - definition
In adults adults, overweight and obese are classified by BMI BMI > 25 = overweight BMI > 30 = obese BMI > 40 = extreme obesity

Body Mass Index Table

BMI = 25 Inches 60 61 62 63 64 65 66 67 68 69 70 71 129 133 137 142 146 151 155 160 165 170 175 180

BMI = 30 153 158 164 169 174 180 186 191 197 203 209 215

Body weight (lbs)

Goals of Behavioral Lifestyle Interventions

Behavioral lifestyle interventions focus on changing h i eating ti and d leisure l i leisure-time ti activity ti it behaviors Goal is to:
Improve weight status
Weight loss in adults Reductions in zBMI (or percent overweight) in children

Maintain weight status

Long term weight loss maintenance Weight gain prevention

Behavioral Lifestyle Interventions

Dietary goals Leisure Leisure-time activity goals Behavioral modification techniques

Behavioral Theory
Evidence-based childhood and adult obesity Evidenceinterventions are based on behavioral theory
Antecedents Behaviors Consequences

The interventions use behavior modification strategies for changing behaviors

-2

W eight loss (kg) )

Ad i /Ed Advice/Education ti Diet (behavioral intervention)

-4

Diet + exercise (behavioral intervention)

-6

-8

-10 0 6-mo 12-mo 24-mo

Months

Franz MJ et al. Weight-loss outcomes: a systematic review and meta-analysis of weight loss clinical trials with a minimum 1-year follow-up. JADA 2007;107:1755-67.

ADA-Evidence Analysis Library

Pediatric weight management
Using behavioral counseling as part of a multimulti -component pediatric weight management (PWM) program to treat overweight results in significant reductions in weight status and adiposity in children and d adolescents. d l t
Rating: Grade I (good)

ADA-Evidence Analysis Library

PWM family participation in treating pediatric obesity in children and adolescent obesity treatment
Family participation Children (6(6-12 yrs)
Rating: Strong (Imperative)

Family participation Adolescents

Rating: Fair (conditional)

ADA-Evidence Analysis Library

What about younger children?
No ratings as very little research has been conducted in this age group Given the evidence for children aged 6 to 12 yrs, most likely intervention should be familyfamily-based Effectiveness aside, weight loss (in contrast to weight management) in this population may be appropriate i t only l under d certain t i circumstances. i t However, these circumstances have not been identified in the research.

ADA-Evidence Analysis Library

Using a lowlow-calorie diet (900 to 1 1,200 200 kcal per day) as part of a clinically supervised, multimulti-component weight weightloss program is associated with both shortshort -term and longer longer-term reduction in adiposity ad pos y a among o gs six- to sixo 1212-yea yearyear -o old d children.
Rating: Grade I (good)

ADA-Evidence Analysis Library

The Traffic Light Diet is an effective component of a clinically supervised, multimulti -component childhood weight weightmanagement intervention program.
Rating: Grade I (good)

Childhood Obesity Interventions

Children aged 8 to 12 years of age > 85th percentile BMI, but not greater than 100% overweight Conducted in research settings Treatment provided over 6 months

10

Behavioral Targets
Evidence Evidence-based interventions target behaviors that reduce energy intake and increase energy expenditure
Low Low-calorie diet (900(900-1200 kcals/day)
Most widely studied is the Traffic Light Diet (Epstein and colleagues) Categorizes food into Green, Yellow, Red (based upon energyenergy -density and nutrient quality) Reduce R d i intake t k of f fastfast f t-food, f d soda, d sweet t and d salty lt snack k foods Generally does not cause an increase in F&V and dairy products unless specifically targeted in treatment

Behavioral Targets
Leisure Leisure-time activities
Increase in physical activity (60 minutes/day), with focus on play and family activities Reduction in TV watching ( (< < 15 hours/week)
Increases physical activity May help with decreasing intake

11

Riley et al., 2008

Family Family-based is not just including parents/caregivers in the treatment of their children's children s obesity it is:
Changing the context of the family (home) environment to help support the change a child is making:
Parenting Communication Support Environment

12

Behavioral Parenting Program

Strategies for Antecedents: - Parental P t l modeling d li
Parent makes all of the same changes in behaviors as child

- Change the home environment (stimulus control)

Eating
- Overt and covert restriction

Leisure Leisure-time behaviors

- Problem Problem-solving and prepre-planning

Behavioral Parenting Program

Strategies for behaviors:
Self Self-monitoring
Goals of program
Kcals, Red Foods, F&V Physical Activity TV Watching Weight

Parent Parent-child meetings

Tie weight change to behavior change to demonstrate relationship between behaviors and weight Feedback on self self-monitoring is important

13

Behavioral Parenting Program

Strategies for consequences:

Positive reinforcement

Praise Contingency contracting Point system

Reduction of negative reinforcement Increase use of extinction for problematic behaviors

Treatment Structure
Family Family-based:
Group process Cognitive C Cognitivei i -behavioral b h i l Social learning (Interventionist serves as model of parenting behaviors)

Sessions:
Review of assigned homework (group process and social learning) Presentation and discussion of new topic (cognitive behavioral parenting behaviors/practices) Assignment of new homework

14

Treatment Structure
6-months of treatment (Parent + child)
Weekly sessions for 12 to 16 weeks
Group session for parents Group session for children 15 minute individual parentparent-child meeting with an interventionist

For remaining 2 to 3 months of treatment, frequency of sessions drops to either one or two meetings/month

Assessments at 0, 6, 12 months (DV = percent overweight or zBMI)

Childhood Obesity Treatment

These evidenceevidence-based interventions targeting children hild aged d8t to 12 years produces d significant reductions in percent overweight (-15 to -20%), with 10 10-year followfollow-up showing almost 1/3 of treated children no longer overweight and a mean reduction in percent overweight of -10% in treated children (Epstein, Epstein
Paluch, & Raynor, 2002; Epstein, Paluch, Kilanowski, Raynor, 2004; Raynor, Kilanowski, Esterlis, & Epstein, 2002 )

15

Maternal and Child Health Bureau Recommendations for Treatment in a Primary Care Setting 1 Start treatment in children as young as 3 1. years of age 2. Apply a familyfamily-based model in treatment 3. Use behavior modification techniques 4. Help families make small changes 5. Target changing 2 or 3 eating and activity behaviors at a time

Childhood Interventions
Behaviors recommended to target in primary care settings
Fast Fast-food intake (limit) Sweetened drink intake (limit) Sweet and salty snack foods (limit) Low Low-fat dairy (2 servings per day) Fruits & vegetables (1.5 c fruits & 2.5 c vegetables/day) Physical activity (60 minutes per day) TV watching (< 2 hrs/day)

16

Childhood Interventions
Will these recommendations be effective at treating young children who are overweight? AND What are the best behaviors to target?

Pediatric Obesity Treatment

Child HELP and Kids CAN
Two research programs funded by the A American i Di Diabetes b t A Association i ti and d th the National Institutes of Health For children between the ages of 4 to 9 years, > 85th percentile BMI, with at least one problematic eating or activity behavior

17

Pediatric Obesity Treatment

Both programs randomly assign families to one of f three, th 6 month th interventions i t ti
Behavioral parenting program (2 different parenting programs in each study) Newsletter

Anthropometric assessments conducted every 3 months (to 12 month followfollow-up) with feedback to families and pediatrician

Child HELP
Increase Fruits and Vegetables (2 servings fruit and 3 servings vegetables/day) Low Low-fat dairy (2 servings/day) energygy-dense foods Low Low-energy increase feelings of fullness and may displace consumption of low low- nutrient nutrientdense foods Decrease Sweet/salty snack foods (< 3 servings/week) Sweetened drinks (< 3 servings/week) Decrease intake of foods that are low in nutrientnutrientdensity and high in energyenergydensity

102 families randomized

18

2.8 2.6 2.4 2.2 2 1.8 1.6 1.4 1.2 1 0.8 0.6 0.4 0.2 0 0 6 Months 12

Newsletter Increase Decrease

zBMI

Kids CAN
Traditional Physical Activity (60 min/day) Sweetened drinks (<3 servings/week) Traditional behaviors that target increasing energy expenditure and decreasing energy intake Substitution TV watching (<2 hours/day) Low Low-fat milk (2 servings/day) Focusing on substitute behaviors for targeted behaviors may enhance feelings of choice for engaging in targeted behavior

81 families randomized

19

2.6 2.4 2.2 2 1.8 1.6 1.4 1.2 1 0.8 0.6 0.4 0.2 0 0 6 Months 12

Newsletter Traditional Substitute

Measures of weight status

Provides regulatory feedback

Parenting focus
Children that do better have parents that are doing better
Self Self-monitoring Modeling Stimulus control Pre Pre-planning, problemproblem-solving

zBMI

Important Components of Treatment

Programs that target parents only also show good outcomes

Caloric prescription appears to be needed to produce clinically relevant weight status improvements

20

ADA-Evidence Analysis Library

Adult weight management
Weight loss and weight maintenance therapy should be based on a comprehensive weight management program including diet, physical activity, and behavior therapy. The combination th therapy i is more successful f l th than using i any one intervention alone.
Rating: Strong

ADA-Evidence Analysis Library

A comprehensive adult weight management program should make maximum use of multiple strategies for behavior therapy (e.g. self monitoring, stress management, stimulus control, problem solving, contingency management, cognitive restructuring, and social support). Behavior therapy in addition to diet and physical activity leads to additional weight loss. Continued behavioral interventions may be necessary to prevent a return to baseline weight.
Rating: Strong

21

Adult Obesity Treatment

Since 1996, 1996 most adult behavioral obesity treatments achieve a mean weight loss of 10 kg over 6 months of treatment, but have a weightweight -loss regain of 38% over a mean f/u of 18 months (Wing, 2002) How can weight loss maintenance be improved?

Adult Obesity Interventions

Behavioral Targets
Low Low-calorie diet (1200 (1200-1500 kcals/day)
Low Low-fat diet (20% to 30% kcals/fat) Strong focus on increasing structure of the diet

Physical activity
200 minutes of moderatemoderate-intense activity/week 10,000 steps/day

22

Behavior Modification
Strategies for Antecedents: - Change Ch the th home h environment i t (stimulus ( ti l control)
Eating Leisure Leisure-time behaviors

Problem-solving and pre Problempre-planning Goal setting Cognitive restructuring Relaxation

23

24

25

Behavior Modification
Strategies for behaviors:
Self Self-monitoring
Goals of program
Kcals, fat Physical Activity Weight

Tie weight change to behavior change to d demonstrate t t relationship l ti hi b between t behaviors and weight Feedback on self self-monitoring is important

26

27

Behavior Modification
Strategies for consequences:

Positive reinforcement

Weight loss vs. maintenance Reinforcing value of food

Structure of Treatment
As longer duration of contact improves outcomes, standard length of intervention is 18 months
Weight loss interventions
Weekly for 6 months 60 minute group sessions 2 times/month for months 7 7-18 - 60 minute group sessions i

Assessments at 0, 6, 12, 18 months (DV = wt)

28

Important Components of Treatment

Measures of weight status
Provides regulatory feedback

Regular and longlong-term followfollow-up

Accountability Habit change

Self Self-monitoring Dietary structure

Meal plans, meal replacements, portion controlled foods Variety?

Lots of physical activity!

Materials from DPP

http://www.bsc.gwu.edu/dpp/lifestyle/dp http://www bsc gwu edu/dpp/lifestyle/dp p_part.html

29

Macronutrient Content of the Diet

30

Macronutrient Composition and Weight Loss Maintenance

800 p participants p Randomly assigned to 1 of 4 diets: the targeted percentages of energy derived from fat, protein, and carbohydrates in the four diets were 20, 15, and 65%; 20, 25, and 55%; 40, 15, and 45%; and 40, 25, and 35% - diets consisted of similar foods and met guidelines for cardiovascular health F/U over 2 years Received behavior modification, and had a physical activity goal of 90 min/week

31

32

Dietary Structure

33

Do meal replacements help with weight loss?

Meal Replacements:
Foods of fixed calorie and nutrient content that are designed to take the place of a meal or snack Portion Portion-controlled and nutritionally balanced Shakes, Shakes soups soups, meal/snack bars bars, and prepared meals Typical recommendation is to replace 2 meals with a meal replacement

Do meal replacements help with weight loss?

Lets Let s look at the research research Purpose: To examine whether using meal replacements improves weight loss in adults enrolled in a weight loss program. Participants: 100 overweight and obese men and women randomly assigned to 2 different diet groups. Length of weight loss program: 27 months

34

Do meal replacements help with weight loss?

First 3 months:
Diet A: 1200 1200-1500 calories/day, with participants eating regular foods Diet B: 1200 1200-1500 calories/day, with participants using meal replacements for 2 meals and 2 snacks each day

Last L t 24 months: th
Both groups followed the same 12001200-1500 kcals/day diet and used meal replacements for 1 meal and 1 snack per day

Weight Loss Maintenance Using Meal Replacements

0
Percentage e reduction in initial we eight

2 4 6 8 10 12

Standard then Meal Replacement

Meal Replacement

0 2 4 6

10 12 14 16 18 20 22 24 26 28
Time (months)

Ditschuneit et al., AJCN; 1999; 69: 198-204

35

Why are meal replacements effective for weight loss?

Advantages of using meal replacements:
Convenient Portion Portion-controlled Removes work of estimating portion size and calories Encourages structured eating Widely available Easy to selfself-monitor

Dietary Variety
Increased dietary variety is associated with increased intake, weight, and body fat in animals (for a review Raynor & Epstein, 2001, Psychological Bulletin) c eased variety a e y within a meal ea is s Increased associated with increased consumption in humans

36

HFF 70 60 Percent variety 50 40 30 20 10 0

LFB 70 60 Percent variety

FOS
70 60 50
70 60 50 Percent variety 40 30 20 10 0

LFM

Before intervention After intervention Registry

Percent variety

40 30 20 10 0

LFV
70 60 Percent variety 50 40 30 20 10 0

50 40 30 20 10 0

Mean percent variety in 5 food groups for recent successful weight losers before and after a standard weight loss intervention (n= 96), and registry participants (n = 2237) (M + SEM). Raynor, H. A., Jeffery, R. W., Phelan, S., Hill, J. O., & Wing, R.R. (2005). Amount of food group variety consumed in the diet and long-term weight loss maintenance. Obesity Research, 13, 883890.

Food Group Variety and Obesity Treatment

Studies suggest that limiting the number of different foods, particularly energyenergy-dense foods, in the diet may help with successful weight loss and longlong-term weight loss maintenance Limiting variety may be especially helpful during maintenance, when selfself-monitoring of intake is less consistent

37

Dietary Variety Prescription

18 month trial testing the effect of limiting snack food variety (R01 - NIDDK) 2 groups: Standard vs. Standard + variety prescription
Can this prescription be adhered to over the longlong-term? Will a greater length of time of limiting variety effect weight loss? What is the mechanism (hedonics and/or stimulus control)?

200 participants

Research Team
Providence, RI Rena Wing, Ph.D. Chantelle Hart, Ph.D. Elissa Jelalian, Ph.D. Patrick Vivier, M.D. Kathrin Osterholt, M.S. Amanda Fine Allison Martir Patty Tellier Holly Manigan Knoxville, TN Betsy Anderson, M.S., R.D. L.D.N. Ashlee Schoch Lusi Martin Shannon Looney, M.P.H. Christen Mullane, M.A. Jess Bachman, M.S., R.D., L.D.N. Emily Van Walleghen, Ph.D. Andrew Carberry Adriana Coletta

38