0
We're unable to sign you in at this time. Please try again in a few minutes.
Retry
We were able to sign you in, but your subscription(s) could not be found. Please try again in a few minutes.
Retry
There may be a problem with your account. Please contact the AMA Service Center to resolve this issue.
Contact the AMA Service Center:
Telephone: 1 (800) 262-2350 or 1 (312) 670-7827  *   Email: subscriptions@jamanetwork.com
Error Message ......
Review Article |

Measuring Effectiveness of Dietetic Interventions in Child Obesity:  A Systematic Review of Randomized Trials FREE

Clare E. Collins, PhD, BSc, Dip(Nutr&Diet), Dip(ClinEpi), AdvAPD; Janet Warren, PhD, BSc, RD; Melinda Neve, BND, APD; Penelope McCoy, BHSc(Nutr&Diet), APD; Barrie J. Stokes, BSc, MMath
[+] Author Affiliations

Author Affiliations: School of Health Sciences (Drs Collins and Warren and Mss Neve and McCoy) and Discipline of Clinical Pharmacology (Mr Stokes), University of Newcastle, Callaghan, Australia; and Food and Nutrition Australia, Sydney (Ms McCoy).


Arch Pediatr Adolesc Med. 2006;160(9):906-922. doi:10.1001/archpedi.160.9.906.
Text Size: A A A
Published online

Objectives  To assess the effectiveness of dietetic treatment for obese children and to report details of dietary interventions.

Data Sources  English-language articles from 1975 to 2003 available from health and medical databases.

Study Selection  Randomized controlled trials with subjects younger than 18 years of age that included a dietary intervention in isolation or in combination with lifestyle modifications and/or psychological therapies. One person searched the databases; 2 people independently critically appraised the articles for methodological quality and then extracted data using standardized tools.

Data Extraction  Thirty-seven randomized controlled trials met the inclusion criteria; 17 contained sufficient information for a Forest plot of the standardized effects. Eight studies had a true control and were included in a meta-analysis. The random effects model was reported if the Q noncombinability χ2 statistic was significant at the 10% level because it has low power as a strict test of homogeneity.

Data Synthesis  The 2 strongly qualified meta-analyses suggest that interventions that include a dietary treatment do achieve relative weight loss. Details of the dietary intervention or participant food intake are rarely described.

Conclusions  It is not possible to evaluate the effectiveness of dietary treatment for childhood obesity because of the lack of high-quality studies and the heterogeneity of designs, treatment combinations, outcome measures, and follow-up. There is an urgent need to improve the quality of studies in this area because childhood obesity poses major health risks for populations, yet there is limited evidence on which to base treatment strategies.

Figures in this Article

Obesity in children is increasing rapidly around the world. The associated major adverse health consequences have been systematically reviewed1 and the psychological consequences and social marginalization reported.2

Prevention is clearly the ideal solution to the problem. However, for those already overweight or obese, or at an increased risk of becoming so, effective interventions will offer the only chance of reducing the probability of progression to adult obesity, its associated comorbidities, and the increased risk of premature mortality.3 Essential elements of interventions are likely to include diet and food intake modification,4 and these have been identified for adult interventions. The efficacy of such interventions in the pediatric population is not known. An examination of successful interventions along with the key dietary changes achieved by participants would inform the optimal dietary treatment for broad dissemination. Therefore, the objective of this review was to identify and present the best available evidence on the effectiveness of dietetic treatment and management for overweight or obese children and adolescents. A secondary goal was to specifically describe the elements of successful dietary treatments.

SEARCH STRATEGY

We performed a systematic review of the published English-language literature from 1975 to 2003. These limits were set to contain costs and maintain timelines. Because the prevalence of child obesity has increased predominantly since the late 1970s,5 it was considered likely that few relevant studies would have been published before then. An additional author search was carried out in 2004 for the most up-to-date results of specific studies identified in the original search.

Electronic databases were searched (CINAHL [Cumulative Index to Nursing and Allied Health Literature], MEDLINE, PREMEDLINE, DARE [Database of Abstracts of Review of Effectiveness], Cochrane, EMBASE [Excerpta Medica Database], Austrom, Current Concepts, and Dissertation Abstracts). In addition, we searched nutrition and dietetics journals by hand (the Journal of the Dietitians Association of Australia, the International Journal of Obesity, and the Journal of Human Nutrition and Dietetics) and government reports from the United States, United Kingdom, and Australia along with the reference lists and bibliographies of retrieved articles. The MeSH (Medical Subject Headings of the National Library of Medicine) keyword search terms were dietetic, paediatric (pediatric), child, adolescent, family, parent, school, overweight, obesity, intervention, weight control or weight management or weight loss, and healthy weight.

SELECTION OF STUDIES

The current report is limited to the randomized controlled trials (RCTs) identified for a more extensive review undertaken for the Joanna Briggs Institute (JBI), Adelaide, Australia. Any trial that evaluated the effectiveness of nutrition or dietary interventions for treating overweight or obesity in children and adolescents was included for the JBI review.

Participants aged younger than 18 years who were defined as overweight or obese were included. We also included programs that were directed exclusively at parents of overweight or obese children and adolescents. Participants were free-living outpatients; inpatients in clinical obesity units; or students attending community programs, one-off programs, camps, or schools. Studies that reported at least one of the following primary outcomes were included: percentile of body mass index (BMI), calculated as weight in kilograms divided by height in meters squared; BMI z score; percentage of children overweight for age; waist measurement; skin folds; percentage of body fat; or percentage of lean body mass.

We considered interventions aimed at the treatment of elevated body weight delivered by any health professional or nutrition scientist. Initially, the aim was to review only studies that compared dietary modification with a standard control (ie, no treatment). Because of the limited number of such studies, we also reviewed interventions that included dietary modification both as part of an intervention and/or control with various combinations of lifestyle modifications (physical activity and/or sedentary behavior modification) and psychological components (cognitive and/or behavioral therapy).

Studies that did not report a weight-related variable as a primary outcome were excluded from the review. Those studies that were assessed as being of poor methodological quality using the JBI tools6 or that did not meet the inclusion criteria were excluded from the review.

Articles were retrieved if the information contained in the title, abstract, and descriptor/MeSH headings appeared to meet the inclusion criteria. Working independently, 2 reviewers critically appraised the articles for methodological quality using the JBI critical appraisal tools.6 Particular attention was paid to sources of bias in the studies.7 If disagreement between reviewers occurred in any of these steps, a third person repeated the procedure to achieve consensus.

We used Review Manager (RevMan 4.2, The Cochrane Collaboration, Oxford, England) to manage the systematic review. Interventions and study design defined comparability of the studies. Heterogeneity was assessed using the standard Q statistic for heterogeneity and visual interpretation of graphs. Significant heterogeneity was assumed when P<.10. All outcome data reported were continuous, but because studies variously reported changes in percentage overweight, BMI z score, percentage body fat, or body weight, standardized mean differences were used in the analyses. The standardized mean difference has the important property that its value does not depend on the measurement scale. This enabled comparisons of differences in mean weight loss when expressed in percentage body fat, weight for height, or another outcome measure. Studies were excluded from the analyses if they did not report numbers of participants or standard deviations.

There were 1310 articles identified by the search strategy (Figure 1). After excluding studies due to duplication and assessing titles and abstracts to meet inclusion criteria, we retrieved 329 full text articles for reviewing. One hundred twenty-five articles met the inclusion criteria for the main review and details will be reported through JBI publications. After we excluded the nonrandomized trials, there were 49 articles arising from 37 individual studies because some reported the results of the same study more than once. These 37 RCTs are reported here.

Place holder to copy figure label and caption
Figure 1.

Randomized controlled trials (RCTs) for inclusion in a meta-analysis of effectiveness of dietetic interventions in child and adolescent obesity.

Graphic Jump Location

The total number of participants across all studies was 2262. The focus of the interventions was diet with various combinations of modifications to physical activity and/or sedentary behavior or behavioral and/or cognitive therapy. Of the 37 studies, 18 had two intervention arms,825 11 had three,2635 6 had four,3641 and 1 had five arms (Table 1).43 Thirty-two studies814,1621,23,24,2629,3140,42,43 included physical activity as a component of at least 1 of the study arms while 14 studies8,9,11,13,16,18,20,26,27,31,32,34,35,42 included behavioral therapy as a component of at least 1 of the study arms. Six studies8,19,29,31,33,43 included cognitive behavioral therapy specifically as a component of at least 1 of the study arms. Six studies12,14,15,25,28,39 included decreasing sedentary behavior as a component of at least 1 of the study arms. The length of intervention in each RCT ranged from 6 weeks to 18 months with the majority (n = 17) between 3 months and 6 months.1420,2629,34,35,3739,41 Nine studies810,2123,31,33,40 described interventions that were run for up to 3 months, and 7 studies12,13,25,30,32,35,43 had interventions that ran for longer than 6 months. The length of intervention was unclear or varied in 3 studies.11,24,36 The length of follow-up was very diverse among the studies. The shortest was 1 month38 while the longest was 10 years.44 Nine studies17,18,22,23,26,32,37,38,42 included no follow-up of participants postintervention. Table 1 also reports the retention rates at the longest point of follow-up except for the 5 studies with a follow-up exceeding 2 years where interim rates are given.24,25,35,43,45 Studies undertaking intention-to-treat analyses are also highlighted in Table 1. The majority of studies were conducted in the United States (n = 29), 5 were in different European countries,21,24,25,30,43 2 were in Australia,8,17 and 1 was in Hong Kong.23

Table Graphic Jump LocationTable 1. Randomized Controlled Trials Identified in a Systematic Review of the Effectiveness of Dietetic Interventions for Child Obesity

Because of the various combinations of treatments that included a dietary intervention and the variable composition of the control groups, a meta-analysis to show the effectiveness of dietetic interventions per se was not possible. Results of the main weight outcomes for each of the 37 RCTs are presented in Table 2 with the significance indicated. A Forest plot of the standardized effects for the studies that contained sufficient information (n = 17) highlights the heterogeneity of the interventions (Figure 2). It was not appropriate to report a meta-analysis result because only a minority of studies had an adequate control group and the treatments reported were highly diverse. However, a meta-analysis was undertaken on the subset of studies (n = 8) that included both a dietary intervention component and an adequate control group (Figure 3). In these studies, diet was a component of the interventions and the control group either received no intervention, was placed on a waiting list, or received usual care. Caution must be exercised in the interpretation of the analysis because diet was only a component of the interventions, making its contribution difficult to evaluate. In addition, the number of studies is limited. The meta-analysis suggests that interventions that contain a dietary component are effective in achieving relative weight loss in overweight/obese children and adolescents (pooled standardized mean difference, −1.82; 95% confidence interval, −2.40 to −1.23) (Figure 3). The 2 studies with the greatest standardized effect were those of Rochini et al38 and Becque et al26 (Figure 2). Becque et al reported that in adolescents, a reduction in the percentage body fat of approximately 3% was achieved after 20 weeks of treatment with diet and behavior change with or without exercise.26 Postintervention, participants in the study by Rochini et al of obese adolescents significantly decreased their percentage body fat by 3% to 6%38 (Table 2). Only 4 studies had follow-up data, and a meta-analysis of the outcomes of these results suggests a diminishing effect of the intervention over time (pooled standardized mean difference, −0.64; 95% confidence interval, −0.89 to −0.39) (Figure 4).

Place holder to copy figure label and caption
Figure 2.

Heterogeneity among 17 randomized controlled trials of interventions for child obesity highlighting the variability of study components and follow-up periods. BT indicates behavioral therapy; CBT, cognitive behavioral therapy; Ctl, control; DA, dietary advice; PA, physical activity; PI, postintervention; SB, sedentary behavior. * indicates lifestyle education included behavioral therapy plus dietary advice plus physical activity.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 3.

Meta-analysis of 7 randomized controlled trials of interventions for child obesity where a “true” control arm was used and results were reported postintervention. CI indicates confidence interval; SMD, standardized mean difference.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 4.

Meta-analysis of 3 randomized controlled trials of interventions for child obesity where a “true” control arm was used and results were reported after a period of follow-up. CI indicates confidence interval; SMD, standardized mean difference.

Graphic Jump Location
Table Graphic Jump LocationTable 2a. Results of the Main Weight Outcomes in Studies Included in a Systematic Review of the Effectiveness of Dietetic Interventions for Child Obesity
Table Graphic Jump LocationTable 2b. Results of the Main Weight Outcomes in Studies Included in a Systematic Review of the Effectiveness of Dietetic Interventions for Child Obesity

A summary of the dietary interventions and the studies that measured and reported dietary compliance and outcomes is given in Table 3. Sixteen studies816,22,28,29,35,36,39,40 used the Stoplight/Traffic Light diet (or a variation of it) as their dietary intervention. Five studies18,26,3638 included food or calorie exchange programs while only 1 study22 compared 2 different dietary interventions (low fat vs low carbohydrate). Compliance with the dietary intervention was reported in only 3 studies13,22,28 although reported as having been measured by food diaries or records in 23 studies. An attempt to describe the dietary intake of those participating in or completing an intervention was made in most studies, but the level of detail was of variable quality. A dietitian was reported to be involved in the formulation and/or delivery of the dietary intervention in 13 primary studies9,1619,2123,25,26,30,34,35 (Table 3).

Table Graphic Jump LocationTable 3a. Description of Dietary Interventions, Measurement and Report of Compliance, and Dietary Outcomes in Studies Included in a Systematic Review of the Effectiveness of Dietetic Interventions for Child Obesity
Table Graphic Jump LocationTable 3b. Description of Dietary Interventions, Measurement and Report of Compliance, and Dietary Outcomes in Studies Included in a Systematic Review of the Effectiveness of Dietetic Interventions for Child Obesity

All 37 RCTs had at least 1 methodological weakness using the JBI critical appraisal tools.6 Although all studies reported randomization of participants to study groups, the method of randomization was described in a minority of studies. Allocation concealment was unclear in 24 studies, adequate in 11 studies,9,10,13,18,23,25,27,31,34,3941 and not used in 2 studies. The number of participants in the studies varied but was generally low; 16 had fewer than 50 participants and only 2 studies had sample sizes greater than 150.24,43 The nature of dietary and lifestyle interventions prevents the blinding of participants. Only 1 study mentions assessor blinding and this was only for some of the assessments.23 Outcomes were measured using varying scales among the studies but within each study were reported as being measured in the same manner for all participants. The retention rates were greater than 80% for 17 of 37 RCTs; the lowest rate was 63% at 1-year follow-up after a long intervention period of 14 to 18 months.27 The retention rate was unclear in 1 study and difficult to ascertain at various stages of the intervention and/or follow-up in several studies.

The initial aim of this review was to assess the effectiveness of dietary interventions in the management of overweight and obesity in children and adolescents. Only a very limited number of studies (n = 7)17,2123,30,35,41 tested a dietary intervention as the sole component of treatment and compared this with a nonintervention control group or a treatment group with a different approach or intensity. Therefore, we evaluated studies that comprised dietary treatments in combination with other treatments. This resulted in a diverse set of studies that made it impossible to report the effectiveness of dietary interventions in childhood/adolescent overweight and obesity. Although the Forest plot and the results in Table 2 indicate significant reductions in weight in many studies, the study quality, range of outcome measures, and short time span of most studies limit the conclusions that can be drawn. This review further highlights the paucity of quality research in this area that has recently been acknowledged in a Cochrane Review.49 The analyses undertaken suggest that interventions that include a dietary treatment can be effective in this group, but many caveats apply, including most importantly the limited number of quality studies undertaken to date and inadequate long-term follow-up data.

Many studies inadequately described the details of the dietary intervention itself, making replication almost impossible without assistance from study authors. The Stoplight/Traffic Light diet50 was the most commonly reported dietary intervention strategy. It is calorie controlled and categorizes food into different colored groups, red (very limited), green (eat freely), and yellow (limited). It then prescribes a recommended number of daily/weekly servings of each of these food groups. Although the Stoplight diet as described originally by Epstein and Squires51 is frequently used as the dietary prescription in studies conducted in the United States, these studies do predominantly arise from a single research group and the applicability to other settings has not been established. From Table 3, the evolution within the Stoplight/Traffic Light diet is apparent, both in terms of the gradual increase in the number of red foods allowed per week, the reduced focus on tight calorie restriction, a redefinition of the food groups to align more closely to the food pyramid, and the integration of behavioral therapy.

Given that the rationale and objectives of the dietary interventions were rarely described, it was not surprising that the quality of most of the studies was poor in terms of assessing changes in dietary intake in response to the intervention at either the individual or group level. Many studies did not report dietary outcomes, and it is unclear whether food intake data was not collected or was collected but not used because it was of poor quality or because the focus in reporting was only on changes in the primary outcome of weight status.

A challenge for researchers will be in estimating and validating changes in food intake, for example, through the use of dietary biomarkers. The inherent difficulties of dietary assessment in children are well recognized52 and researchers have recently made attempts to validate dietary changes within their studies.22,38

In adult obesity, long-term studies indicate that following a low-fat diet in conjunction with modest daily energy intake restriction (500-1000 kcal/d) results in approximately 5% weight loss after 2 years of follow-up.53 For children, no such evidence is available. Only 3 studies in the meta-analysis had a follow-up of longer than a year. To date, the changes achieved in the dietary intakes of children and adolescents who have successfully lost weight, even in the short-term, have not been described qualitatively or quantitatively. This presents additional challenges when designing dietary interventions for child obesity trials. An attempt to address this gap has been made recently through the use of dietary modeling of food intakes from a reference population to achieve a reduction in energy density.54

In the absence of consensus of expert opinion, a rational approach is to base interventions on observational and epidemiological data. Targeting an increase in fruit and vegetable consumption may be more effective than focusing on a reduction in high-energy, low-nutrient-dense foods.55 Beverage intake may also be a particular problem in children, and consumption of soft drinks has been linked to obesity.48 Behaviors that could be targeted in children to achieve energy reduction and an increase in nutrient density have recently been described.4

METHODOLOGICAL CONSIDERATIONS FOR FUTURE STUDIES

There are practical and ethical considerations about conducting a trial with a no-intervention control. However, the following methodological considerations are important when addressing the significant gaps in the evidence and weaknesses in study design on this serious public health issue. A number of trials in this review have no clear reference arm with the treatment (ie, dietary modification) under test often present in both the treatment and the control arms. This makes it difficult for clinicians to extract meaningful results and strategies applicable in general patient settings.

The variety of outcome measures in the trials included body weight, percentage overweight, BMI, and BMI z score with some investigators using a number of different measures. To make direct comparisons of effectiveness, we recommend that BMI z score be reported in all intervention studies in child obesity as a clinically meaningful outcome measure along with the proportion of subjects whose final (follow-up) BMI z score is in the healthy weight range for the appropriate population demographic.

TRIAL SIZES

The small arm sizes in many of the trials in this study raise statistical concerns. It would seem that a standard power calculation (using readily available freeware such as PS56 available from http://biostat.mc.vanderbilt.edu/twiki/bin/view/Main/PowerSampleSize) is rarely performed. This is important because the large standard deviations commonly reported indicate that sample sizes well in excess of those commonly used would be required to achieve 80% power. We therefore recommend that studies be powered (ie, employ sample sizes) to have an 80% chance of rejecting a null hypothesis or no-intervention effect if the true intervention effect is more than a specified clinically important value.

AGE RANGES

Within the 37 trials reported, the age ranges in the subgroups varied from 3 to 12 years to 12 to 18 years with numerous prepubescent and postpubescent subgroup age ranges. One of the authors (B.J.S.) has previously noticed broadly in medical research this use of incompatible age ranges across studies, often by the same researchers. Such inconsistency makes valid meta-analysis difficult to achieve because the assumption then has to be made that age has no effect on weight outcomes when we know that body composition does indeed vary with age and pubertal status. We recommend that pediatric weight loss researchers seek consensus on age group targets for children and adolescents younger than 20 years so that later meta-analyses can be facilitated.

FOLLOW-UP DURATION

Most of the trials reported results immediately postintervention and at 1 or more follow-up times. There is wide variation in both intervention lengths and the follow-up intervals and duration. Some trials employ follow-up durations as short as 3, 6, or 8 months. We suggest that the success of a weight loss intervention designed ultimately to produce lasting improvements in the health states of obese patients cannot be established clinically, as opposed to statistically, in as short a time frame as 8 months. More consistent intervention and follow-up durations across the field would facilitate informal as well as more formal comparisons of trial results via meta-analysis. We therefore recommend that professional bodies lobby major funding agencies to raise awareness of these issues and advocate for priority funding of large intervention trials with adequate follow-up periods.

GENERAL HETEROGENEITY OF TRIAL DESIGN

The fact that only 2 strongly qualified meta-analyses could be presented in this article is in itself an indication of the significant heterogeneity of interventions for weight management in children and adolescents. Consistency of patient attributes, treatment types, and trial protocols is essential if the meta-analytic calculations are to yield results that can be relied on and incorporated into the knowledge base of the field.

Many trials in weight loss research are small in comparison with other areas, such as cancer treatment research. This may be because funding is generally limited, because it is difficult to recruit into lifestyle interventions particularly for child obesity due to its multifactorial etiology, or because the research is opportunistic.

Although there is insufficient evidence to determine the effectiveness of dietary interventions in treating excessive weight gain in children and adolescents, this systematic review does indicate that interventions that include dietary modification, both as part of an intervention or control and in various treatment combinations, are effective in gaining improvements in weight-related outcomes. This effect appeared to diminish with time. It is difficult to make evidence-based dietary recommendations for child weight management because details of the dietary interventions or the changes made by those who are successful are lacking. The evidence base for pediatric weight management research would increase if researchers considered carefully the methodological quality of their trials, including sample size, at the earliest planning stage. This article has highlighted current gaps in knowledge and limitations in current study designs. Researchers in clinical, public health, and research settings are encouraged to fully describe the rationale and aims of their dietary interventions, evaluate whether subjects adhere to the dietary recommendations, and report dietary outcomes to address the urgent need to develop effective dietary interventions for both childhood obesity treatment and prevention.

Correspondence: Clare E. Collins, PhD, BSc, Dip(Nutr&Diet), Dip(ClinEpi), APD, School of Health Sciences, Mail Box 38, Hunter Building, University of Newcastle, Callaghan, NSW 2308, Australia (clare.collins@newcastle.edu.au).

Accepted for Publication: February 16, 2006.

Author Contributions:Study concept and design: Collins, Warren, Neve, McCoy, and Stokes. Acquisition of data: Collins, Warren, Neve, and McCoy. Analysis and interpretation of data: Collins, Warren, Neve, McCoy, and Stokes. Drafting of the manuscript: Collins, Warren, McCoy, and Stokes. Critical revision of the manuscript for important intellectual content: Collins, Warren, Neve, McCoy, and Stokes. Statistical analysis: Neve and Stokes. Administrative, technical, and material support: Collins, Warren, Neve, McCoy, and Stokes.

Funding/Support: This study was supported by a grant from the Joanna Briggs Institute, Adelaide, Australia.

Acknowledgment: We thank Susan Day, AUDIS, for assistance with search and retrieval strategy; Paul Carless, MMedSc(ClinEpi), for methodological and statistical advice; and Tracy Burrows, BHSc(N&D), and Rachel Sutherland, MPH, for identification and retrieval of references and for creating Figure 1 (T.B.).

Reilly  JJMethven  EMcDowell  Z  et al.  Health consequences of obesity Arch Dis Child 2003;88748- 752
PubMed Link to Article
Strauss  RSPollack  HA Social marginalization of overweight children Arch Pediatr Adolesc Med 2003;157746- 752
PubMed Link to Article
Dietz  WH Childhood weight affects adult morbidity and mortality J Nutr 1998;128411S- 414S
PubMed
Kirk  SScott  BJDaniels  SR Pediatric obesity epidemic: treatment options J Am Diet Assoc 2005;105(suppl 1)44- 51
PubMed Link to Article
Kumanyika  SK Minisymposium on obesity: overview and some strategic considerations Annu Rev Public Health 2001;22293- 308
PubMed Link to Article
 Experimental critical appraisal form 4.1  Joanna Briggs Institute Adelaide, Australia2003;
 Data extraction form 5  Joanna Briggs Institute Adelaide, Australia2003;
Duffy  GSpence  SH The effectiveness of cognitive self-management as an adjunct to a behavioural intervention for childhood obesity: a research note J Child Psychol Psychiatry 1993;341043- 1050
PubMed Link to Article
Epstein  LHWing  RRSteranchak  LDickson  BMichelson  J Comparison of family-based behavior modification and nutrition education for childhood obesity J Pediatr Psychol 1980;525- 36
PubMed Link to Article
Epstein  LHWing  RRPenner  BKress  MJ Effect of diet and controlled exercise on weight loss in obese children J Pediatr 1985;107358- 361
PubMed Link to Article
Epstein  LHWing  RRWoodall  KPenner  BCKress  MJKoeske  R Effects of family-based behavioural treatment on obese 5-to-8-year-old children Behav Ther 1985;16205- 212
Link to Article
Epstein  LHWing  RRKoeske  RValoski  A Effect of parent weight on weight loss in obese children J Consult Clin Psychol 1986;54400- 401
PubMed Link to Article
Epstein  LHMcKenzie  SJValoski  AKlein  KRWing  RR Effects of mastery criteria and contingent reinforcement for family-based child weight control Addictive Behav 1994;19135- 145
PubMed Link to Article
Epstein  LHPaluch  RRaynor  H Sex differences in obese children and siblings in family-based obesity treatment Obes Res 2001;9746- 753
PubMed Link to Article
Epstein  LHPaluch  RAKilanowski  CKRaynor  HA The effect of reinforcement or stimulus control to reduce sedentary behaviour in the treatment of pediatric obesity Health Psychol 2004;23371- 380
PubMed Link to Article
Goldfield  GSEpstein  LHKilanowski  CKPaluch  RAKogut-Bossler  B Cost-effectiveness of group and mixed family-based treatment for childhood obesity Int J Obes Relat Meta Disord 2001;251843- 1849
PubMed Link to Article
Hills  APParker  AW Obesity management via diet and exercise intervention Child Care Health Dev 1988;14409- 416
PubMed Link to Article
Lansky  DBrownell  KD Comparison of school-based treatments for adolescent obesity J Sch Health 1982;52384- 387
PubMed Link to Article
Mellin  LMSlinkard  LAIrwin  CE  Jr Adolescent obesity intervention: validation of the SHAPEDOWN program J Am Diet Assoc 1987;87333- 338
PubMed
Saelens  BESallis  JFWilfley  DEPatrick  KCella  JABuchta  R Behavioral weight control for overweight adolescents initiated in primary care Obes Res 2002;1022- 32
PubMed Link to Article
Schwingshandl  JSudi  KEibl  BWallner  SBorkenstein  M Effect of an individualised training programme during weight reduction on body composition: a randomised trial Arch Dis Child 1999;81426- 428
PubMed Link to Article
Sondike  SBCopperman  NJacobson  MS Effects of a low-carbohydrate diet on weight loss and cardiovascular risk factor in overweight adolescents J Pediatr 2003;142253- 258
PubMed Link to Article
Sung  RYTYu  CWChang  SKYMo  SWWoo  KSLam  CWK Effects of dietary intervention and strength training on blood lipid level in obese children Arch Dis Child 2002;86407- 410
PubMed Link to Article
Nova  ARusso  ASala  E Long-term management of obesity in paediatric office practice: experimental evaluation of two different types of intervention Ambul Child Health 2001;7239- 247
Link to Article
Golan  MWeizman  AApter  AFainaru  M Parents as the exclusive agents of change in the treatment of childhood obesity Am J Clin Nutr 1998;671130- 1135
PubMed
Becque  MDKatch  VLRocchini  APMarks  CRMoorehead  C Coronary risk incidence of obese adolescents: reduction by exercise plus diet intervention Pediatrics 1988;81605- 612
PubMed
Brownell  KDKelman  JHStunkard  AJ Treatment of obese children with and without their mothers: changes in weight and blood pressure Pediatrics 1983;71515- 523
PubMed
Epstein  LHValoski  AMVara  LS  et al.  Effects of decreasing sedentary behavior and increasing activity on weight change in obese children Health Psychol 1995;14109- 115
PubMed Link to Article
Epstein  LHPaluch  RAGordy  CCSaelens  BEErnst  MM Problem solving in the treatment of childhood obesity J Consult Clin Psychol 2000;68717- 721
PubMed Link to Article
Flodmark  CEOhlsson  TRyden  OSveger  T Prevention of progression to severe obesity in a group of obese schoolchildren treated with family therapy Pediatrics 1993;91880- 884
PubMed
Graves  TMeyers  AWClark  L An evaluation of parental problem-solving training in the behavioral treatment of childhood obesity J Consult Clin Psychol 1988;56246- 250
PubMed Link to Article
Gutin  BBarbeau  POwens  S  et al.  Effects of exercise intensity on cardiovascular fitness, total body composition, visceral adiposity of obese adolescents Am J Clin Nutr 2002;75818- 826
PubMed
Kirschenbaum  DHarris  ETomarken  A Effects of parental involvement in behavioural weight loss therapy for preadolescents Behav Ther 1984;15485- 500
Link to Article
Wadden  TAStunkard  AJRich  LRubin  CJSweidel  GMcKinney  S Obesity in black adolescent girls: a controlled clinical trial of treatment by diet, behavior modification, and parental support Pediatrics 1990;85345- 352
PubMed
Epstein  LHMcCurley  JWing  RRValoski  A Five-year follow-up of family-based behavioral treatments for childhood obesity J Consult Clin Psychol 1990;58661- 664
PubMed Link to Article
Senediak  CSpence  SH Rapid versus gradual scheduling of therapeutic contact in a family based behavioural weight control programme for children Behav Psychother 1985;13285- 287
Link to Article
Rocchini  APKatch  VAnderson  J  et al.  Blood pressure in obese adolescents: effect of weight loss Pediatrics 1988;8216- 23
PubMed
Rocchini  APKatch  VSchork  AKelch  RP Insulin and blood pressure during weight loss in obese adolescents Hypertension 1987;10267- 273
PubMed Link to Article
Epstein  LHPaluch  RAGordy  CCDorn  J Decreasing sedentary behaviors in treating pediatric obesity Arch Pediatr Adolesc Med 2000;154220- 226
PubMed Link to Article
Epstein  LHWing  RRKoeske  ROssip  DBeck  S A comparison of lifestyle change and programmed aerobic exercise on weight and fitness changes in obese children Behav Ther 1982;13651- 665
Link to Article
Coates  TJeffrey  RSlinkard  LAKillen  JDDanaher  BG Frequency of monetary contact and monetary reward in weight loss; lipid change and blood pressure reduction Behav Ther 1982;13175- 185
Link to Article
Botvin  GJCantlon  A Reducing adolescent obesity through a school health program J Pediatr 1979;951060- 1062
PubMed Link to Article
Braet  CVan Winckel  M Long-term follow-up of a cognitive behavioral treatment program for obese children Behav Ther 2000;3155- 74
Link to Article
Epstein  LHValoski  AWing  RRMcCurley  J Ten-year outcomes of behavioral family-based treatment for childhood obesity Health Psychol 1994;13373- 383
PubMed Link to Article
Epstein  LHValoski  AWing  RRMcCurley  J Ten-year follow-up of behavioral, family-based treatment for obese children JAMA 1990;2642519- 2523
PubMed Link to Article
Epstein  LHWing  RRKoeske  RValoski  A Long-term effects of family-based treatment of childhood obesity J Consult Clin Psychol 1987;5591- 95
PubMed Link to Article
Golan  MCrow  S Targeting parents exclusively in the treatment of childhood obesity: long-term results Obes Res 2004;12357- 361
PubMed Link to Article
Ludwig  DSPeterson  KEGortmaker  SL Relation between consumption of sugar-sweetened drinks and childhood obesity: a prospective, observational analysis Lancet 2001;357505- 509
PubMed Link to Article
Summerbell  CAshton  VCampbell  KEdmunds  LKelly  SWaters  E Interventions for treating obesity in children Cochrane Database Syst Rev 2003; ((3)) CD001872
PubMed
Epstein  LHMyers  MDRaynor  HASaelens  BE Treatment of pediatric obesity Pediatrics 1998;101(3 II suppl)554- 570
PubMed
Epstein  LHSquires  S The Stoplight Diet for Children  Boston, Mass Little, Brown and Co1977;
Livingstone  MBRobson  PJ Measurement of dietary intake in children Proc Nutr Soc 2000;59279- 293
PubMed Link to Article
National Institute of Health National Heart Lung and Blood Institute, Clinical guidelines on the identification, evaluation, and treatment of overweight and obesity in adults: the evidence report Obesity Res 1998;6(suppl 2)51S- 209Spublished correction appears in Obes Res1998;6- 464
Link to Article
Gehling  RKMagarey  AMDaniels  LA Food-based recommendations to reduce fat intake: an evidence-based approach to the development of a family-focused child weight management programme J Paediatr Child Health 2005;41112- 118
PubMed Link to Article
Epstein  LHGordy  CCRaynor  HABeddome  MKilanowski  CKPaluch  R Increasing fruit and vegetable intake and decreasing fat and sugar intake in families at risk for childhood obesity Obes Res 2001;9171- 178
PubMed Link to Article
Dupont  WPlummer  W PS Power and sample size program available for free on the internet Control Clin Trials 1997;18274
Link to Article

Figures

Place holder to copy figure label and caption
Figure 1.

Randomized controlled trials (RCTs) for inclusion in a meta-analysis of effectiveness of dietetic interventions in child and adolescent obesity.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 2.

Heterogeneity among 17 randomized controlled trials of interventions for child obesity highlighting the variability of study components and follow-up periods. BT indicates behavioral therapy; CBT, cognitive behavioral therapy; Ctl, control; DA, dietary advice; PA, physical activity; PI, postintervention; SB, sedentary behavior. * indicates lifestyle education included behavioral therapy plus dietary advice plus physical activity.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 3.

Meta-analysis of 7 randomized controlled trials of interventions for child obesity where a “true” control arm was used and results were reported postintervention. CI indicates confidence interval; SMD, standardized mean difference.

Graphic Jump Location
Place holder to copy figure label and caption
Figure 4.

Meta-analysis of 3 randomized controlled trials of interventions for child obesity where a “true” control arm was used and results were reported after a period of follow-up. CI indicates confidence interval; SMD, standardized mean difference.

Graphic Jump Location

Tables

Table Graphic Jump LocationTable 1. Randomized Controlled Trials Identified in a Systematic Review of the Effectiveness of Dietetic Interventions for Child Obesity
Table Graphic Jump LocationTable 2a. Results of the Main Weight Outcomes in Studies Included in a Systematic Review of the Effectiveness of Dietetic Interventions for Child Obesity
Table Graphic Jump LocationTable 2b. Results of the Main Weight Outcomes in Studies Included in a Systematic Review of the Effectiveness of Dietetic Interventions for Child Obesity
Table Graphic Jump LocationTable 3a. Description of Dietary Interventions, Measurement and Report of Compliance, and Dietary Outcomes in Studies Included in a Systematic Review of the Effectiveness of Dietetic Interventions for Child Obesity
Table Graphic Jump LocationTable 3b. Description of Dietary Interventions, Measurement and Report of Compliance, and Dietary Outcomes in Studies Included in a Systematic Review of the Effectiveness of Dietetic Interventions for Child Obesity

References

Reilly  JJMethven  EMcDowell  Z  et al.  Health consequences of obesity Arch Dis Child 2003;88748- 752
PubMed Link to Article
Strauss  RSPollack  HA Social marginalization of overweight children Arch Pediatr Adolesc Med 2003;157746- 752
PubMed Link to Article
Dietz  WH Childhood weight affects adult morbidity and mortality J Nutr 1998;128411S- 414S
PubMed
Kirk  SScott  BJDaniels  SR Pediatric obesity epidemic: treatment options J Am Diet Assoc 2005;105(suppl 1)44- 51
PubMed Link to Article
Kumanyika  SK Minisymposium on obesity: overview and some strategic considerations Annu Rev Public Health 2001;22293- 308
PubMed Link to Article
 Experimental critical appraisal form 4.1  Joanna Briggs Institute Adelaide, Australia2003;
 Data extraction form 5  Joanna Briggs Institute Adelaide, Australia2003;
Duffy  GSpence  SH The effectiveness of cognitive self-management as an adjunct to a behavioural intervention for childhood obesity: a research note J Child Psychol Psychiatry 1993;341043- 1050
PubMed Link to Article
Epstein  LHWing  RRSteranchak  LDickson  BMichelson  J Comparison of family-based behavior modification and nutrition education for childhood obesity J Pediatr Psychol 1980;525- 36
PubMed Link to Article
Epstein  LHWing  RRPenner  BKress  MJ Effect of diet and controlled exercise on weight loss in obese children J Pediatr 1985;107358- 361
PubMed Link to Article
Epstein  LHWing  RRWoodall  KPenner  BCKress  MJKoeske  R Effects of family-based behavioural treatment on obese 5-to-8-year-old children Behav Ther 1985;16205- 212
Link to Article
Epstein  LHWing  RRKoeske  RValoski  A Effect of parent weight on weight loss in obese children J Consult Clin Psychol 1986;54400- 401
PubMed Link to Article
Epstein  LHMcKenzie  SJValoski  AKlein  KRWing  RR Effects of mastery criteria and contingent reinforcement for family-based child weight control Addictive Behav 1994;19135- 145
PubMed Link to Article
Epstein  LHPaluch  RRaynor  H Sex differences in obese children and siblings in family-based obesity treatment Obes Res 2001;9746- 753
PubMed Link to Article
Epstein  LHPaluch  RAKilanowski  CKRaynor  HA The effect of reinforcement or stimulus control to reduce sedentary behaviour in the treatment of pediatric obesity Health Psychol 2004;23371- 380
PubMed Link to Article
Goldfield  GSEpstein  LHKilanowski  CKPaluch  RAKogut-Bossler  B Cost-effectiveness of group and mixed family-based treatment for childhood obesity Int J Obes Relat Meta Disord 2001;251843- 1849
PubMed Link to Article
Hills  APParker  AW Obesity management via diet and exercise intervention Child Care Health Dev 1988;14409- 416
PubMed Link to Article
Lansky  DBrownell  KD Comparison of school-based treatments for adolescent obesity J Sch Health 1982;52384- 387
PubMed Link to Article
Mellin  LMSlinkard  LAIrwin  CE  Jr Adolescent obesity intervention: validation of the SHAPEDOWN program J Am Diet Assoc 1987;87333- 338
PubMed
Saelens  BESallis  JFWilfley  DEPatrick  KCella  JABuchta  R Behavioral weight control for overweight adolescents initiated in primary care Obes Res 2002;1022- 32
PubMed Link to Article
Schwingshandl  JSudi  KEibl  BWallner  SBorkenstein  M Effect of an individualised training programme during weight reduction on body composition: a randomised trial Arch Dis Child 1999;81426- 428
PubMed Link to Article
Sondike  SBCopperman  NJacobson  MS Effects of a low-carbohydrate diet on weight loss and cardiovascular risk factor in overweight adolescents J Pediatr 2003;142253- 258
PubMed Link to Article
Sung  RYTYu  CWChang  SKYMo  SWWoo  KSLam  CWK Effects of dietary intervention and strength training on blood lipid level in obese children Arch Dis Child 2002;86407- 410
PubMed Link to Article
Nova  ARusso  ASala  E Long-term management of obesity in paediatric office practice: experimental evaluation of two different types of intervention Ambul Child Health 2001;7239- 247
Link to Article
Golan  MWeizman  AApter  AFainaru  M Parents as the exclusive agents of change in the treatment of childhood obesity Am J Clin Nutr 1998;671130- 1135
PubMed
Becque  MDKatch  VLRocchini  APMarks  CRMoorehead  C Coronary risk incidence of obese adolescents: reduction by exercise plus diet intervention Pediatrics 1988;81605- 612
PubMed
Brownell  KDKelman  JHStunkard  AJ Treatment of obese children with and without their mothers: changes in weight and blood pressure Pediatrics 1983;71515- 523
PubMed
Epstein  LHValoski  AMVara  LS  et al.  Effects of decreasing sedentary behavior and increasing activity on weight change in obese children Health Psychol 1995;14109- 115
PubMed Link to Article
Epstein  LHPaluch  RAGordy  CCSaelens  BEErnst  MM Problem solving in the treatment of childhood obesity J Consult Clin Psychol 2000;68717- 721
PubMed Link to Article
Flodmark  CEOhlsson  TRyden  OSveger  T Prevention of progression to severe obesity in a group of obese schoolchildren treated with family therapy Pediatrics 1993;91880- 884
PubMed
Graves  TMeyers  AWClark  L An evaluation of parental problem-solving training in the behavioral treatment of childhood obesity J Consult Clin Psychol 1988;56246- 250
PubMed Link to Article
Gutin  BBarbeau  POwens  S  et al.  Effects of exercise intensity on cardiovascular fitness, total body composition, visceral adiposity of obese adolescents Am J Clin Nutr 2002;75818- 826
PubMed
Kirschenbaum  DHarris  ETomarken  A Effects of parental involvement in behavioural weight loss therapy for preadolescents Behav Ther 1984;15485- 500
Link to Article
Wadden  TAStunkard  AJRich  LRubin  CJSweidel  GMcKinney  S Obesity in black adolescent girls: a controlled clinical trial of treatment by diet, behavior modification, and parental support Pediatrics 1990;85345- 352
PubMed
Epstein  LHMcCurley  JWing  RRValoski  A Five-year follow-up of family-based behavioral treatments for childhood obesity J Consult Clin Psychol 1990;58661- 664
PubMed Link to Article
Senediak  CSpence  SH Rapid versus gradual scheduling of therapeutic contact in a family based behavioural weight control programme for children Behav Psychother 1985;13285- 287
Link to Article
Rocchini  APKatch  VAnderson  J  et al.  Blood pressure in obese adolescents: effect of weight loss Pediatrics 1988;8216- 23
PubMed
Rocchini  APKatch  VSchork  AKelch  RP Insulin and blood pressure during weight loss in obese adolescents Hypertension 1987;10267- 273
PubMed Link to Article
Epstein  LHPaluch  RAGordy  CCDorn  J Decreasing sedentary behaviors in treating pediatric obesity Arch Pediatr Adolesc Med 2000;154220- 226
PubMed Link to Article
Epstein  LHWing  RRKoeske  ROssip  DBeck  S A comparison of lifestyle change and programmed aerobic exercise on weight and fitness changes in obese children Behav Ther 1982;13651- 665
Link to Article
Coates  TJeffrey  RSlinkard  LAKillen  JDDanaher  BG Frequency of monetary contact and monetary reward in weight loss; lipid change and blood pressure reduction Behav Ther 1982;13175- 185
Link to Article
Botvin  GJCantlon  A Reducing adolescent obesity through a school health program J Pediatr 1979;951060- 1062
PubMed Link to Article
Braet  CVan Winckel  M Long-term follow-up of a cognitive behavioral treatment program for obese children Behav Ther 2000;3155- 74
Link to Article
Epstein  LHValoski  AWing  RRMcCurley  J Ten-year outcomes of behavioral family-based treatment for childhood obesity Health Psychol 1994;13373- 383
PubMed Link to Article
Epstein  LHValoski  AWing  RRMcCurley  J Ten-year follow-up of behavioral, family-based treatment for obese children JAMA 1990;2642519- 2523
PubMed Link to Article
Epstein  LHWing  RRKoeske  RValoski  A Long-term effects of family-based treatment of childhood obesity J Consult Clin Psychol 1987;5591- 95
PubMed Link to Article
Golan  MCrow  S Targeting parents exclusively in the treatment of childhood obesity: long-term results Obes Res 2004;12357- 361
PubMed Link to Article
Ludwig  DSPeterson  KEGortmaker  SL Relation between consumption of sugar-sweetened drinks and childhood obesity: a prospective, observational analysis Lancet 2001;357505- 509
PubMed Link to Article
Summerbell  CAshton  VCampbell  KEdmunds  LKelly  SWaters  E Interventions for treating obesity in children Cochrane Database Syst Rev 2003; ((3)) CD001872
PubMed
Epstein  LHMyers  MDRaynor  HASaelens  BE Treatment of pediatric obesity Pediatrics 1998;101(3 II suppl)554- 570
PubMed
Epstein  LHSquires  S The Stoplight Diet for Children  Boston, Mass Little, Brown and Co1977;
Livingstone  MBRobson  PJ Measurement of dietary intake in children Proc Nutr Soc 2000;59279- 293
PubMed Link to Article
National Institute of Health National Heart Lung and Blood Institute, Clinical guidelines on the identification, evaluation, and treatment of overweight and obesity in adults: the evidence report Obesity Res 1998;6(suppl 2)51S- 209Spublished correction appears in Obes Res1998;6- 464
Link to Article
Gehling  RKMagarey  AMDaniels  LA Food-based recommendations to reduce fat intake: an evidence-based approach to the development of a family-focused child weight management programme J Paediatr Child Health 2005;41112- 118
PubMed Link to Article
Epstein  LHGordy  CCRaynor  HABeddome  MKilanowski  CKPaluch  R Increasing fruit and vegetable intake and decreasing fat and sugar intake in families at risk for childhood obesity Obes Res 2001;9171- 178
PubMed Link to Article
Dupont  WPlummer  W PS Power and sample size program available for free on the internet Control Clin Trials 1997;18274
Link to Article

Correspondence

CME
Meets CME requirements for:
Browse CME for all U.S. States
Accreditation Information
The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians. The AMA designates this journal-based CME activity for a maximum of 1 AMA PRA Category 1 CreditTM per course. Physicians should claim only the credit commensurate with the extent of their participation in the activity. Physicians who complete the CME course and score at least 80% correct on the quiz are eligible for AMA PRA Category 1 CreditTM.
Note: You must get at least of the answers correct to pass this quiz.
You have not filled in all the answers to complete this quiz
The following questions were not answered:
Sorry, you have unsuccessfully completed this CME quiz with a score of
The following questions were not answered correctly:
Commitment to Change (optional):
Indicate what change(s) you will implement in your practice, if any, based on this CME course.
Your quiz results:
The filled radio buttons indicate your responses. The preferred responses are highlighted
For CME Course: A Proposed Model for Initial Assessment and Management of Acute Heart Failure Syndromes
Indicate what changes(s) you will implement in your practice, if any, based on this CME course.
Submit a Comment

Multimedia

Some tools below are only available to our subscribers or users with an online account.

Web of Science® Times Cited: 70

Related Content

Customize your page view by dragging & repositioning the boxes below.

Articles Related By Topic
Related Collections
PubMed Articles