effectiveness of lifestyle interventions in ... -...

Effectiveness of Lifestyle Interventions in ChildObesity: Systematic Review With Meta-analysis

abstractBACKGROUND AND OBJECTIVES: The effects of lifestyle interventionson cardio-metabolic outcomes in overweight children have not beenreviewed systematically. The objective of the study was to examine theimpact of lifestyle interventions incorporating a dietary component onboth weight change and cardio-metabolic risks in overweight/obesechildren.

METHODS: English-language articles from 1975 to 2010, available from7 databases, were used as data sources. Two independent reviewersassessed articles against the following eligibility criteria: randomizedcontrolled trial, participants overweight/obese and#18 years, comparinglifestyle interventions to no treatment/wait-list control, usual care, orwritten education materials. Study quality was critically appraised by 2reviewers using established criteria; Review Manager 5.1 was used formeta-analyses.

RESULTS: Of 38 eligible studies, 33 had complete data for meta-analysison weight change; 15 reported serum lipids, fasting insulin, or bloodpressure. Lifestyle interventions produced significant weight losscompared with no-treatment control conditions: BMI (21.25kg/m2, 95%confidence interval [CI] 22.18 to 20.32) and BMI z score (20.10, 95% CI20.18 to 20.02). Studies comparing lifestyle interventions to usual carealso resulted in significant immediate (21.30kg/m2, 95% CI 21.58 to21.03) and posttreatment effects (20.92 kg/m2, 95% CI21.31 to20.54)on BMI up to 1 year from baseline. Lifestyle interventions led tosignificant improvements in low-density lipoprotein cholesterol (20.30mmol/L, 95% CI 20.45 to 20.15), triglycerides (20.15 mmol/L, 95% CI20.24 to 20.07), fasting insulin (255.1 pmol/L, 95% CI 271.2 to 239.1)and blood pressure up to 1 year from baseline. No differences werefound for high-density lipoprotein cholesterol.

CONCLUSIONS: Lifestyle interventions can lead to improvements inweight and cardio-metabolic outcomes. Further research is neededto determine the optimal length, intensity, and long-term effectivenessof lifestyle interventions. Pediatrics 2012;130:e1647–e1671

AUTHORS: Mandy Ho, MSc, APD, RN,a,b Sarah P. Garnett,PhD, RNutr, APD,a,b,c Louise Baur, MBBS, PhD, FRACP,a,c

Tracy Burrows, PhD, AdvAPD,d Laura Stewart, PhD, RD,RNutr,e,f Melinda Neve, PhD, APD,d and Clare Collins, PhD,FDAAd

aThe Children’s Hospital at Westmead Clinical School, Universityof Sydney, Sydney, Australia; bInstitute of Endocrinology andDiabetes, and cKids Research Institute, The Children’s Hospital atWestmead, Westmead, Australia; dPriority Research Centre inPhysical Activity and Nutrition, School of Health Sciences, Facultyof Health, University of Newcastle, Newcastle, Australia;ePaediatric Overweight Service Tayside, Perth Royal Infirmary,Perth, United Kingdom; and fThe Children’s Weight Clinic,Edinburgh, United Kingdom

KEY WORDSchild, adolescent, lifestyle interventions, obesity, weight loss,cardio-metabolic risks, systematic review

ABBREVIATIONSCI—confidence intervalHDL—high-density lipoproteinHOMA-IR—homeostasis model assessment of insulin resistanceLDL—low-density lipoproteinWMD—weighted mean difference

All authors were involved in study conception and design,interpretation of data, critical revision, and final approval of thesubmitted manuscript; Ms Ho was involved in qualityassessment, data extraction, data analysis, and manuscriptpreparation; Prof Collins, Dr Baur, and Dr Garnett were involvedin quality assessment, data extraction and study supervision;and Drs Burrow and Steward were involved in qualityassessment and data extraction.

www.pediatrics.org/cgi/doi/10.1542/peds.2012-1176

doi:10.1542/peds.2012-1176

Accepted for publication Aug 7, 2012

Address correspondence to Ms Mandy Ho, Institute ofEndocrinology and Diabetes, The Children’s Hospital at Westmead,Locked Bag 4001, Westmead, NSW 2145, Australia. E-mail: [email protected]

PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).

Copyright © 2012 by the American Academy of Pediatrics

FINANCIAL DISCLOSURE: The authors have indicated they haveno financial relationships relevant to this article to disclose.

FUNDING: Ms Ho is supported by an Australian National Healthand Medical Research Council Dora Lush Postgraduate ResearchScholarship (APP 1017189). Dr Garnett is supported by a CancerInstitute NSW Early Career Development Fellowship Grant (10/ECF/2-11). Dr Neve is supported by a Priority Research Centre inPhysical Activity and Nutrition Postdoctoral Fellowship. ProfCollins is supported by a National Health and Medical ResearchCouncil Career Development Fellowship.

PEDIATRICS Volume 130, Number 6, December 2012 e1647

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Obesity in children and adolescents isa global public health concern and isassociated with a range of short- andlong-term health complications.1–4 Al-though prevention of obesity is impor-tant, so too are effective treatments forthose already affected. Lifestyle inter-ventions, involving a combination ofdiet, exercise, and/or behavior modifi-cation, are an essential element ofobesity management.5–7 Several sys-tematic reviews of childhood obesityhave been published and lifestyle inter-ventions targeting treatment of childand adolescent obesity are reported asefficacious in weight loss in the short tomedium term.8–12 The first specific re-view of dietary interventions, publishedin 2006,13,14 included studies publishedup to 2003, and found positive effects ofinterventions that included a dietarycomponent.14,15

The previously mentioned systematicreviews and others have all presenteddata on weight change outcomes;however, obese children and adoles-cents also carry an increased risk forcardio-metabolic complications, includ-ing dyslipidemia, insulin resistance, andhypertension.15–20 To our knowledge,no systematic review has examinedthe effects of lifestyle interventionson cardio-metabolic outcomes in over-weight children and adolescents.Therefore, the aim of this review was topresent the best available evidencefrom randomized controlled studies oflifestyle interventions incorporating adietary component to assess their im-pact on both weight loss and cardio-metabolic risks. This review coversliterature published between 1975 and2010.

METHODS

The protocol and search strategy forthis systematic review was based onthe previous peer-reviewed protocol13

registered with the Joanna Briggs In-stitute. It involved a 2-stage process.

First, a detailed literature search wasconducted in September 2010 to iden-tify studies published between 2003and 2010. Eligible studies from theprevious review13 covering 1975 and2003 were then combined in the datasynthesis with those from the currentsearch.

Eligibility Criteria

Eligible studies were randomized con-trolled trials of treatment of overweightand obesity in children and adolescents#18 years of age comparing the ef-fectiveness of lifestyle interventionprograms incorporating a nutrition ordietary component with no treatmentor wait-list control, usual care, orminimal advice or written diet andphysical activity education materials.Programs that involved the wholefamily or were directed exclusively atparents of overweight or obese chil-dren and adolescents were also in-cluded. Additional inclusion criteriawere a follow-up period from baselineof at least 2 months, and inclusion ofthe outcome measures of body weightor body composition. Participantswerefree living or attending obesity clinicalunits, community programs, camps,schools, or one-off programs. Studieswere excluded if they were targeted atobesity prevention or maintenance ofweight loss, were drug trials or inter-ventions that dealt with eating dis-orders, or if they focused on childrenwith obesity attributable to a second-ary or syndromal cause. Studies thatwere not written in English, or includedchildren who were within the healthyweight range at baseline, were ex-cluded. No restrictions were placed onintervention settings or who deliveredthe interventions.

Data Source and Search Strategy

The search strategy involved a litera-ture search conducted by a medicallibrarian of published literature in the

English language through CINAHL,Cochrane Reviews, Current Concepts,DARE, Embase, Premedline, andMedline.The Medical Subject Headings of theNational Library of Medicine keywordsearch terms used were dietetic,paediatric (pediatric), child, adoles-cent, family, parent, school, over-weight, obesity, intervention, weightcontrol, weight management, weightloss, and healthy weight (SupplementalAppendix 1). In addition, the referencelists of retrieved articles and key sys-tematic reviews of childhood obesitytreatments were scanned for relevantreferences.8,9,11,12

Study Selection

All studies identified in the databasesearch were assessed for relevancefrom the title and abstract by 2 in-dependent reviewers. Articles thatmet,or appeared to meet, the inclusioncriteria were retrieved. All retrievedstudies were assessed for relevance by2 independent reviewers. In case ofdisagreement, a third independent re-viewer made the final decision.

Quality Assessment

Full copies of all included studies wereassessed for methodological quality by2 independent reviewers using theJoanna Briggs Institute critical ap-praisal of study quality tool (Supple-mental Appendix 2). Studies were ratedas positive, negative, or neutral basedon responses to 10 items. Discrep-ancies were resolved by discussion orconsultation with a third reviewer toachieve consensus.

Data Extraction

Data in relation to methodology, in-tervention effect, compliance, and in-tensity were extracted by the firstreviewer by using a standardized formdeveloped specifically for this review.This was verified by a second reviewerfor accuracy and a consensus reached

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where disagreement existed. Data de-scribing interventions that were re-ported in more than 1 article wereextracted together.

Data Synthesis

Review Manager (RevMan5.1, TheCochrane Collaboration, Oxford, England)was used for meta-analyses. All theoutcomes in this review were continu-ous outcomes and a weighted meandifference (WMD) was calculated if thesame measurement scale was used.When different outcome measurementscales were reported, we conductedthe meta-analysis by using the stan-dardized mean difference approach.Heterogeneity was assessed by I2 sta-tistics. Heterogeneity is considered tobe low if I2 is #40%, and high if I2 is$75%.21 We used a random effectsmodel for meta-analysis if there wassignificant heterogeneity (I2 .40%),and fixed effects for homogeneous(I2 # 40%). BMI and BMI z score wereused as the primary weight loss out-comes. We also examined the effects ofinterventions on body composition byusing percentage body fat. By usingthe last time point of weight lossmeasurement for each study, we per-formed meta-analyses among sub-groups by age (child defined as meanage at baseline #12 years and ado-lescent as .12 years), and the lengthof the follow-up from baseline. Wherekey details or data were missing, au-thors were contacted, or data im-puted based on methods described inthe Cochrane Handbook.21 The follow-ing cardio-metabolic outcomes wereexamined:

serum lipids, including total choles-terol, low-density lipoprotein (LDL)cholesterol, high-density lipoprotein(HDL) cholesterol, and triglycerides;

fasting glucose, fasting insulin, andinsulin resistance as determined bythe homeostasis model assessmentof insulin resistance (HOMA-IR); and

systolic and diastolic blood pres-sures.

Where outcomes could not be quantita-tively combined in a meta-analysis, theyare described in a narrative summary.For forest plots with sufficient studiesincluded (.10), we generated funnelplots to examine for the publication bias.

RESULTS

Search Result

The literature search identified 4713references (Fig 1), and 434 full articleswere retrieved. Forty-one articles re-lating to 30 different studies met allinclusion criteria.22–62 Eight additionalstudies (12 articles) from the previousreview that met the comparison crite-ria were also included.63–74 The totalnumber of studies included in this re-view is 38.

Description of Included Studies

Study characteristics and weight-related outcomes are summarized inTable 1. Nearly half of the studies wereconducted in the United States (n =18),22,24,29,33,41,46–49,50,56,63,64,66–69,71 5 inAustralia,25,30,35–37 and the others in Israel(n = 3),39,43,44 Germany (n = 2),32,51 theUnited Kingdom (n = 2),34,40 Belgium,65

China,28 Finland,42 Iran,45 Korea,31

Mexico,38 Taiwan,26 and Tunisia.23 Eigh-teen studies targeted obese children ex-clusively,22,23,26,28,29,31,34,38,40–42,44,46,51,64–66,71

whereas the others targeted both over-weight and obese children. Most studies(n = 14) were conducted in a hospitalenvironment,22,25,29,32,36,38,40–41,43–44,46,63,65,68

followedby thecommunity (n=6),23,27,33–35,51

school (n = 6),26,42,48–50,64 and primarycare setting (n = 6).30,37,39,47,67,69 Thir-teen studies were conducted in chil-dren,25,30,33–35,37,40–42,44,47,50,66 7 inadolescents,22–24,28,29,31,36 and othersenrolled both children and adoles-cents.26,27,32,38,39,43,45,46,48,49,51 Only 1 studyincluded children aged,5 years.35 Fouradolescent studies specifically targetedgirls.24,29,31,45 The sample size of included

studies ranged from 16 to 258, witha median of 72 participants per study.Twenty-seven studies had 2 study arms, 9had 3 study arms, and 2 had 4 studyarms (Table 1). Among the no treatmentor wait-list control comparisons (n = 22)(Table 1), the intervention lengthsvaried from 1 month (n = 1) to 2 years.Twelve studies did not follow the par-ticipants after the intervention pro-gram ended.22–24,26,28,29,31,32,36,63,64,68 Forthe comparison of lifestyle interventionwith usual care (n = 11), the inter-vention lengths varied from 3 months to1 year, and 6 studies conducted sub-sequent follow-up,41–43,45,65,69 rangingfrom 2 months to 4 years from the endof the active intervention component.Among the 5 written information studies,1 had a varied intervention length, 2 hadan intervention length of 6 months,48,49

and another 2 were 1-year50,51 interven-tion programs with the outcome evalua-tion at the end of the intervention.

Methodological Quality

No studies fulfilled all requirementslisted in the study quality critical ap-praisal tool, although 8 studies met 8of the 10 requirements25,27,30,32,37,40,49,69

(Table 2). Twenty-four studies didnot specify the method of randomi-zation.22–24,26,28,29,31,33,36,39,42,45,46,48–51,63–68,71

Details of allocation conceal-ment23,24,26,28,29,31,33–36,41,43–46,50,51,63,66–68,71 andstudy blinding24,27–31,33,36,37,39,41–43,45,48,50,51,63–69,71

were not adequately reported for moststudies. Blinding of participants in di-etary and lifestyle interventions isusually not possible. Only 5 studiesreported that outcome assessors wereblinded to participants’ treatment al-location.25,30,37,38,40 Overall, retention ratesfor all included studies ranged from 38%to 100%. Most studies (29/38) had a re-tention rate of $70% at 6 months or.60% at 1 year. Only 9 studies usedintention-to-treat analysis.32,41,44,46,47,62,67–69

Six studies did not report dropout ratesand it was therefore not clear if they usedan intention-to-treat analysis.23,26,35,45,48,63

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Dietary Interventions

Ten studies used the Traffic Light ormodified Traffic Light diet as their di-etary intervention.27,28,32,38,40,41,48,49,66,69

The Traffic Light diet is a calorie-controlled approach in which foods ineach category are color-coded ac-cording to their calorie density peraverage serving: green for low-caloriefoods that can be eaten freely; yellowfor moderate-calorie foods that can beeaten occasionally; and red for high-calorie foods that should be eatenrarely. Four studies used a hypocaloricdiet or a calorie restriction approach.Two aimed for a 30% of reported en-ergy intake deficit or 15% less thanestimated daily requirements.43,44 Onestudy targeted 500 kcal less than the

reported baseline energy intake,23 andanother imposed caloric restrictionson snacks and beverages.22 One-fifthof the included studies inadequatelydescribed the details of dietary inter-ventions.31,33,36,39,48,50,71 Other studiesprovided general healthy eating ad-vice (Table 1). A dietitian was reportedto be involved in the delivery of thedietary interventions in 13 stud-ies.25,35,38,40,42–47,51,63,67

Exercise Interventions

Nineteen studies conducted super-vised physical activity sessions orexercise training as part of the inter-vention,22–26,31,32,34,42–46,48,49,51,63,64,68 althoughthe intensity and variety varied. The totalduration of physical activity sessions

ranged from 20 minutes per month25

to 6 hours per week,23 most providing∼1.5 to 2.0 hours of training each week(Table 1). Three studies used pedome-ters to promote physical activity.27,33,36

Effects of Lifestyle InterventionCompared With No Treatment orWait-Listed Control

Eighteen of the 22 studies that com-pared lifestyle intervention with notreatment or a wait-listed controlgroup reported a positive effect onweight loss22,23,25–28,31,32,34–36,63,64,66–69,71

(Table 1). In the meta-analysis, whichincluded 19 studies (24 comparisons)and 1234 participants, there wasa significantly larger effect on weightand body composition (standardized

FIGURE 1Flowchart for identification of trials for inclusion in a systematic review of lifestyle interventions incorporating a dietary component in overweight and obesechildren and adolescents. aCollins CE, Warren JM, Neve M, McCoy P, Stokes B. Systematic review of interventions in the management of overweight and obesechildren which include a dietary component. International Journal of Evidence-Based Healthcare. 2007;5(1):2–53.


TABLE1

StudyCharacteristicsandWeight-Related

Outcom

es(Structuredby

Year

ofPublication)

Study,Program

Name(When

Applicable),

Setting,Country

Participants

Intervention

Length,

Follow-up

From

Baseline

StudyArmsand

StudyComponents

Interventions

Retention

Rate

c

Weight-Related

Outcom

eReported

Significance

Difference

Between

Groups

d

Na

Gender

Age,y

Selection

Criteriab

Lifestyleinterventioncomparedwith

no-treatm

entorwait-listcontrol

Botvin1979,64

,e,

School,USA

119

F+M

12to

17Obese(120%

oftheir

idealBW)

10wk,

10wk

(1)Control

(2)DA

+PA

+BM

(2)Weeklysession(1

classperiod

each)

conductedby

alliedhealthprofessionalsand

byschoolfaculty

mem

bers.

DA:Healthyfood

selection,prudentd

iet,pre-

planning

andchanging

eatingpatterns.

PA:10-minsupervised

sessioneach

week

(jogging,jum

ping

rope,bicycling)

(1)74%

(2)100%

%ofparticipants

$130%

and

,130%

ofideal

weight

Yes:Significant

decrease

in%overweight

ofthe

intervention

(P,

.05)

Nosignificant

change

in%

overweightof

thecontrol

group

Epstein

1984,66

,70,73,e,

Setting:

unclear,USA

53families

F+M

8to12

Obese($

20%

overweightand

tricep

skinfolds

.85th

percentile)

6mo, 1,5,

and10

y

(1)Wait-list

control

(2)DA

(3)DA

+PA

(2)15

treatm

entsessions,parent

andchild

inseparategroups

(session

1–8:weekly;

session9–11:biweekly;session12–15:

monthly).Parentsencouraged

tolose

weight

too.TrafficLightDiet(1200–1500

kcal/d,limit

to4redfoods/wk).

Overall:

94%at1y

Change

in%

overweight

%overweight:Yes

(3.1at6mo)

(3)DA:asgroup2

PA:lifestylechange

exercise

program-increase

energy

expenditure

200–400kcal/d

Kirshenbaum

1984,71,

Setting:

unclear,USA

40families

F+M

9to13

Obese($

20%

overweight)

9wk, 3and

12mo

(1)Wait-list

control

(2)DA

+PA

+CBT

(Childonly)

(3)DA

+PA

+CBT

(Parent&

child)

(2)9weekly90-mintreatm

entsessions.Focus

oncognitive-behavioraltreatment.

DAandPA:nodetails

given.Onlychildren

attended

thegroup(6–9childrenpergroup)

(3)as

group2,both

parentsandchildren

attended

allsessionstogether

(4–5dyads

pergroup)

(1)89%

(2)67%

(3)87.5%

%overweight,

adjusted

weight

%overweight:Yes

at3mo(2.1)

Mellin

1987,67

“Shapedown

Program,”

Primarycare,

USA

66 F+M

12to

18Overweight

andobese

(113%to213%

relativeweight)

3mo, 6and

15mo

(1)Control

(2)DA

+PA

+CBT

(2)14

weeklysessions

(90mineach)for

adolescentsp

lus2

parentsessions.Usesself-

directed

change

form

atandencourages

participantstomakesuccessive,

sustainable,sm

allm

odifications

indiet,

exercise,lifestyles,and

attitudes.Avoidvery

lowcalorieor

restrictivediets.

Overall:84%

Change

inrelative

weight

Relativeweight:

Yes(2.1)

Becque

1988,63

Hospital

environm

ent,

USA

36 F+M

12to

13Overweight

andobese

(BWandtriceps

skinfold.75th

percentile)

20wk,

20wk

(1)Control

(2)DA

+BM

e

(3)DA

+BM

+PA

(2)D

A:Am

erican

DieteticAssociationExchange

Programwith

kcalprescriptiontogive

weightloss

of1–2lb/wk.Weeklynutrition

educationmaterialsandadjustmentof

eatingpatternandkcalintake.

(3)DA:asgroup2

PA:50minflexibility,m

usclestrengtheningand

aerobicexercise

for(3

times/wk)

NR%body

fat

(hydrostatic

weighing)

%body

fat:Yes

(3.1)

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TABLE1

Continued

Study,Program

Name(W

hen

Applicable),

Setting,Country

Participants

Intervention

Length,

Follow-up

From

Baseline

StudyArmsand

StudyComponents

Interventions

Retention

Rate

c

Weight-Related

Outcom

eReported

Significance

Difference

Between

Groups

d

Na

Gender

Age,y

Selection

Criteriab

Rocchini1988,68

,74

Hospital

environm

ent,

USA

72 F+M

10to17

Overweightand

obese(Weight

forheight

.75th

percentile;

tricepsand

subscapular

skinfolds

.80th

percentile)

20wk,

20wk

(1)Control

(2)DA

+BM

e

(3)DA

+PA

+BM

(2)Weekly1-hclass

DA:m

odified

kcalexchange

programto

produceaweightlossofapproximately

1lb/wk

(3)DA:asgroup2

PA:supervisedexercise3tim

es/wk(1heach,10

minstretching

andmusclestrengthening

exercise

plus

40minaerobicexercise)

(1)82%

(2)85%

(3)92%

%body

fat

(hydrostatic

weighting)

%body

fat:Yes

(3.1)

Balagopal

2003,22

,52,53

“Shapedown

Program,”

Hospital

environm

ent,

USA

16 F+M

14to18

Obese(BMI$

30)

3mo,

3mo

(1)No-treatm

ent

control

(2)DA+PA+SB+B

M

(2)DA:caloricrestriction(snacksand

beverage);metwith

anutritionistonce/wk

PA:45min3tim

es/wk;1monitoredPA

session/

wkinthepresence

ofparent

SB:limiting

TVview

ing

Overall:95%

BMI,%body

fat

(DXA)

BMIand

%body

fat:Yes(2.1)

Jiang2005,28

Family,China

75families

F+M

7thto9th

grade

Obese(Chinese

references

weightfor

height

$120%

)

2y,

2y

(1)No-treatm

ent

control

(2)DA+PA+SB+B

M

(2)Homevisitb

ypediatrician

once

permonth

DA:m

odified

trafficlight

diet

PA:20–30

min/d,4

d/wk

SB:generaladvice

(1)90%

(2)92%

BMI

BMI:Yes(2.1)

Rooney

2005,33

,e,

“Growing

HealthyFamily

study”,

Community,USA

98families,

353people

F+M

5to12

Overweightand

obese(CDC

Grow

thChart

BMI.

84th

percentile)

12wk,

1y

(1)No-treatm

ent

control

(2)PA

(3)DA+PA

(2)family

mem

bers

received

apedometer

and

instructed

towalk10

000stepsdaily

and

received

abiweeklynewsletter

(3)as

group2plus

attended

6,1-hbiweekly

sessions

concerning

nutrition,physical

activity,and

otherparentingissues.

Overall:89%

BMIpercentile

No

Golley2007,25

,54

Hospital

environm

ent,

Australia

111

F+M

6to9

Overweightand

obese(IO

TFcut-

offand

BMIz

score#

3.5)

6mo,

12mo

(1)Wait-list

control

(2)PS

(parents

only)e

(2)Parentattended4weekly2-hgroupsessions

onparentingskillstraining

(fam

ilylifestyle

change)followed

by4weekly,then

3monthly

15-to20-minindividualtelephonesessions.

(1)86%

(2)78%

(3)82%

BMIz

score,WCz

score

BMIz

score:No

WCzscore:Yes

(2.1;3.

1)

(3)PS

+DA

+PA

(3)Parentscompleted

thesameparentingskills

training

asgroup2plus

anadditional7

intensivelifestylesupportgroup

sessions.

Childrenattended

7supervised

activity

sessions

(focused

onaerobicactivity

and

motor

skillsdevelopm

ent).

DA:generaleatingguidelines

andcore

food

serverecommendations


TABLE1

Continued

Study,Program

Name(When

Applicable),

Setting,Country

Participants

Intervention

Length,

Follow-up

From

Baseline

StudyArmsand

StudyComponents

Interventions

Retention

Rate

c

Weight-Related

Outcom

eReported

Significance

Difference

Between

Groups

d

Na

Gender

Age,y

Selection

Criteriab

Huang2007,26

School,Taiwan

120

F+M

10to

13Obese(Taiwanese

referenceBM

I$95th

percentile)

12wk,

12wk

(1)No-treatm

ent

control

(2)DA

+PA

nutrition

(2)DA:childrenreceived

30-minnutrition

instructiontwice/wkatschool

PA:40-minclassroom-based

noncom

petitive

aerobicactivities

3tim

es/wk

NRBM

I,%body

fat

(BIA)

BMIand

%body

fat:Yes(2.1)

McCallum

2007,30

,58

“LEAPtrial,”

Primarycare,

Australia

163

F+M

5.0to

9.9

Overweightand

obese(IO

TFcut-

offand

BMIz

score,3.0)

12wk,

9mo,

15mo

(1)No-treatm

ent

control

(2)DA+PA+SB

(2)4standard

consultations

bygeneral

practitioners

assisted

bya20-page“fam

ilyfolder”written

ata12-y-oldreadinglevel,

targetingchange

innutrition,physical

activity,and

sedentarybehavior.

(1)85%

(2)94%

BMI,BM

Izscore

No

Park

2007,31

Setting:unclear,

Korea

44 F13

to15

Obese(Korean

referenceBM

I$95th

percentile)

12wk,

12wk

(1)No-treatm

ent

control

(2)DA+PA+BM

(2)Lifestyleeducationofferedby

atrained

counseloronce/wk.

DA:generaladvice

PA:w

alking

6d/wk(10minfor3dand30

to40

minfor3d)

(1)95%

(2)91%

BMI,%

fat(BIA),WC

andwaist/hip

ratio

BMI,%

bodyfatand

waist/hipratio:

Yes(2.1)

Shelton2007,35

Community,

Australia

43 F+M

3to10

Overweightand

obese(CDC

grow

thchart

BMI$

85th

percentile)

4wk,

3mo

(1)Wait-listcontrol

(2)DA+PA+BM

(parentonly)

(2)Parentsattended

4,2-hweeklygroup

sessions

andreceived

parent

treatm

ent

manual.

NRBM

IBM

I:Yes(2.1)

Janicke2008,27

,55,56

“ProjectSTORY”,

Community

(rural

setting),USA

93 F+M

8to14

Overweightand

obese(CDC

grow

thchart

BMI.

85th

percentile)

4mo,

10mo

(1)Wait-list

control

(2)DA+PA

(3)DA+PA

(parents

only)

(2)Weeklygroupsessions

(90mineach)for8

wk,followed

bybiweeklyfor8wk.Parentand

child

participated

inseparategroups,then

broughttogetheratthe

endofeach

sessionto

developgoalsforthewkandspecificplans.

(1)81%

(2)73%

(3)77%

BMIz

score

BMIz

score:Yes

(2.1;3.

1)

DA:m

odified

versionoftheStoplight

Diet

PA:pedom

eter-based

step

program

(3)asgroup2,butonlyparentsattended

group

meetings.

Tsiros

2008,36

“ChooseHealth

program,”

Hospital

environm

ent,

Australia

47 F+M

12to

18Overweightand

obese(IO

TFcut-off)

20wk,

20wk

(1)No-treatm

ent

control

(2)D

A+PA+BM+CBT

(2)Coreprogram(first10wk):8clinicsessions

(1heach)plus

1phone-callsessionand

provided

with

abook

onhealthyeating

andtheAustralianGuidetoHealthyEating.

Maintenance

phase(10wk):4

fortnightly

phonecalls.

DA:AustralianGuidetoHealthyEating

PA:providedwith

apedometer

Overall:38%

BMI,WC,body

fat

(DXA)

BMI,body

fatand

abdominalfat:

Yes(2.1)

REVIEW ARTICLE


TABLE1

Continued

Study,Program

Name(When

Applicable),

Setting,Country

Participants

Intervention

Length,

Follow-up

From

Baseline

StudyArmsand

StudyComponents

Interventions

Retention

Rate

c

Weight-Related

Outcom

eReported

Significance

Difference

Between

Groups

d

Na

Gender

Age,y

Selection

Criteriab

Davis2009,24

Setting:unclear,

USA

50 F14

to18

Overweightand

obese(CDC

grow

thchart

BMI.

84th

percentile)

16wk,

16wk

(1)No-treatm

ent

control

(2)DA

e

(3)DA

+PA

(strength

training)

(4)DA

+PA

(strengthand

cardiotraining)

(2)Weekly90-mindietarysessionplus

4motivationalinterview

sessions.

DA:#

10%ofenergy

from

addedsugarplus

atleast14g·1000

kcal21ofdietaryfiberaday

(3)dietaryinterventionas

group2plus

twice/

wk60

minstrength

training.

(4)as

group3but30mincardioand30

min

strength

training.

Overall:82%

BMI,BM

Izscores,

BMIpercentile

andfatm

ass

(DXA)

BMI:Yes(1.3;

1=4)

BMIzscoreandfat

mass:No

Kitzman-Ulrich

2009,29

Hospital

environm

ent,

USA

4212

to15

Obese(CDC

4mo,

(1)Wait-list

control

(2)DA:FoodGuidePyramid

Overall:83%

BMIz

score

NoF

grow

thchart

BMI.

95th

percentile)

4mo

(2)DA+PA+BM

PA:generaladvice

(3)DA+PA+BM

+Multifam

ilytherapy

(3)as

group2plus

attended

a45-min

multifam

ilytherapygroup.

Wake2009,37

“LEAP2trial,”,

Primarycare,

Australia

258

F+M

5to9.99

Overweightand

obese(IO

TFcut-offand

BMIz

score

,3.0)

12wk,

6mo,

12mo

(1)No-treatm

ent

control

(2)DA+PA+SB

(2)4standard

consultations

bygeneral

practitioners

assisted

bya16-page“fam

ilyfolder”written

ata12-y-oldreadinglevel,

targetingchange

innutrition,physical

activity,and

sedentarybehavior.

(1)98%

(2)96%

BMI

No

BenOunis2010,23

Community,

Tunisia

28 F+M

Meanage

13.160.8

Obese(BMI.

97th

percentile,

referencenot

specified)

8wk,

8wk

(1)No-treatm

ent

control

(2)PA

+DA

(2)Nutrition

educationprogram4h/wk

DA:calorierestriction(500

kcalless

than

the

reported

energy

intake

atbaseline,15%

energy

from

protein,55%carbohydrate,30%

fat)

PA:supervisedexercise

training

4tim

es/wk(90

mineach)

NRBM

I,%body

fat

(skinfold)

BMIand

%body

fat:Yes(2.1)

Reinehr2010,32

“Obeldicks

Light”

Program,Hospital

environm

ent,

Germ

any

71 F+M

8to16

Overweightand

obese

(Germany

reference

BMI90thto97th

percentile)

6mo,

6mo

(1)Wait-list

control

(2)DA+PA+SB+B

M

(2)Intensivephase(3

mo):6

nutrition

groups

(1.5heach)educationsessionforchildren

(stratified

bygender

andage)plus

6parent

eveningsessions

(1.5h)

plus

30min

individualdietarycounseling;Establishing

phase(3

mo):1

individualnutrition

counselingsessionplus

3counseling

sessions.

(1)84%

(2)97%

BMI,BM

Izscore,

WC,%body

fat

(BIA)

BMIz

score,WC

and%body

fat:

Yes(2.1)

DA:Optimized

mixed

diet(food-baseddietary

guideline)

andTrafficLightsystem

PA:w

eeklyphysicalactivity

training

(1.5heach,

mainlyaerobicexercise)for6mo

SB:generaladvice


TABLE1

Continued

Study,Program

Name(When

Applicable),

Setting,Country

Participants

Intervention

Length,

Follow-up

From

Baseline

StudyArmsand

StudyComponents

Interventions

Retention

Rate

c

Weight-Related

Outcom

eReported

Significance

Difference

Between

Groups

d

Na

Gender

Age,y

Selection

Criteriab

Sacher

2010,34

MENDprogram,

Community,

UnitedKingdom

116

F+M

8to12

Obese(UK1990

reference

dataBM

I.98th

percentile)

6mo,

12mo

(1)Wait-list

control

(2)DA+PA+B

M+12-

wkfree

family

swim

pass

(2)18,2-hbiweeklysessions

forchildrenand

theirparentsandsiblings.

DA:8

sessions,generalnutrition

educationand

nondietingapproaching

PA:16sessions

(1heach),noncom

petitivegroup

play

(1)68%

(2)70%

BMIand

BMIz

score

BMIand

BMIz

score:Yes

(2.1)

Lifestyleinterventionprogramcomparedwith

usualcareor

minimaladvice

Braet1997,65,72,e,

Hospital

environm

ent,

Belgium

259children

(1yfollow-

upstudy)

136children

(4.6y

follow-

upstudy)

F+M

7to17

Obese($

20%

overweight)

Varied,

1.0and4.6y

(1)Minimal

therapeutic

contact:DA,PA

(2)Individual

treatm

ent:CBT,

DA,PA

(3)Group

treatm

ent:CBT,

DA,PA)

(4)Summer

camp

training:CBT,

DA,PA

(1)Advicein1session(3h)andgiventreatm

ent

manualfor

parentsandworkbookfor

children

(2)R

eceivedthesameinform

ationpackages

asgroup1plus

childrenreceived

7sessions

of90

min(twice/mo)

and7monthlyfamily

follow-upsessions

onan

individualbasis.

DA:Healthyeating+3mid-mealsnacks.

Unhealthymealslim

itedto1/moor

small

amount

weekly.No

kcalcounting.

PA:m

oderateexercise

30min/d

(3)sameas

group2butonagroupapproach

(4)10-dsummer

camp:Balanced

healthyfood

1500

kcal/dplus

daily

lifestyleexercises5h/

dandfamilies

encouraged

toattend

monthly

follow-upsessions

for1y

Overall:81%

at1y

80%at4.6y

1yfollow-uppaper,

Mean%weight

loss

4.6yfollow-up

paper,%

overweightand

mean%weight

loss

No:Significant

decrease

in%

overweightin

allgroupsat3,6

mo,1.0and4.6y

Saelens2002,69

,

Primarycare,USA

44 F+M

12to

16Overweight

andobese

(20%

to100%

abovethe

medianforBM

I)

4mo,

7mo

(1)Typicalcare:

DA,PA

(2)Intensive

follow-up:DA,

BM,PA,SB

(1)Singleappointm

entwith

apediatrician

atbaseline(nontailoredcounselingsession)

DA:FoodGuidePyramid

PA:60min/d

(2)Computer-basedprogram:assessm

entof

eating,PA

andSB.Atbaseline,apediatrician

provided

tailoredcounselingsessionbased

onthecomputer-generatedindividualized

actionplan.W

eeklytelephonecounselingfor

8wkthen

biweeklyuntil14

to16

wk.Also

received

behavior

modificationmanual.

DA:1200–1500

kcal/d

andweeklygoalof40

green(#

1gfat,,150kcalandnutrient

dense)

and,15

redfoods(5

gor

morefat

ordietversions

ofhigh-fatfoods)

PA:$

60minmoderateintensity

exercise

5d/wk

SB:generaladvice

(1)90%

(2)78%

BMI,%overweight

BMI:Yes(2.1)

REVIEW ARTICLE


TABLE1

Continued

Study,Program

Name(When

Applicable),

Setting,Country

Participants

Intervention

Length,

Follow-up

From

Baseline

StudyArmsand

StudyComponents

Interventions

Retention

Rate

c

Weight-Related

Outcom

eReported

Significance

Difference

Between

Groups

d

Na

Gender

Age,y

Selection

Criteriab

Nemet2005,43

,60

Hospital

environm

ent,

Israel

54 F+M

6to16

NR3mo,

1y

(1)M

inimaladvice:

DA,PA

(1)Atleast1

ambulatory

nutritional

consultationplus

generalexerciseadvice.

(1)67%

(2)83%

BMI,%body

fat

(skinfold),BM

Ipercentile

BMIand

%body

fat

Yes(2.1)

(2)Lifestyle

program:DA,PA

(2)D

A:hypocaloricdiet(30%

deficientbased

onreported

intake

or15%less

than

estim

ated

daily

requirem

ent).M

etdietitian

6tim

esin3

mo(2.5hintotal).

PA:twice-weeklytraining

(mostly

endurance

training,1

h/session)

Gillis2007,39

Primarycare,

Israel

27 F+M

7to16

Overweightand

obese(BMI

$90th

percentile,

referencenot

specified)

6mo,

6mo

(1)M

inimaladvice:

DA,PA

(2)Lifestyle

program:DA,PA

(1)A0.5-htalkon

exercise

anddietatbaseline

(2)Talksof0.5hatbaselineand3mo,plus

weekly

followup

phonecalls.Also,instructed

torecord

dietandexercise

on1dayofeach

wk

(1)54%

(2)79%

BMIz

score

No

Kalavainen

2007,42

,59

School,Finland

70 F+M

7to

9Obese(Finnish

reference

weightfor

height

120%

to200%

)

6mo,

12mo

(1)Routine

Program:DA

(2)Lifestyle

program:DA,

PA,SB,BM

,CBT

(1)2individualcounselingsessions

byschool

nurse(30mineach)plus

inform

ation

bookletsforfamily.

(2)Family-based

grouptreatm

ent,15

sessions

(90mineach)with

separatesessions

for

parentsand

childrenand1jointsession.First

10sessions

wereheldweeklyandthen

fortnightly.

DA:generalhealthyeating

PA:noncompetitiveactivities

(1)100%

(2)97%

BMIand

BMIz

score

BMIand

BMIz

score:Yes

(2.1)

Savoye

2007,46

,61

“YaleBright

Bodies

Weight

Managem

ent

Program”,

Hospital

environm

ent,USA

209

F+M

8to16

Obese(CDC

grow

thchart

BMI.

95th

percentile)

1y,

1y

(1)Standard

care:

DA(1)Metdietitian

every6mo,generalhealthy

eatingandphysicalactivity

advice.

(1)64%

(2)71%

BMIand

%body

fat(BIA)

BMIand

body

fat:

Yes(2.1)

(2)Lifestyle

program:DA,

PA,BM

(2)Intensivefamily-based

nutrition

and

behavior

modification(weekly40

minforthe

first6mothen

everyotherwk).

DA:a

nondietingapproach,focused

onbetter

food

choices

PA:twice50-minsessions

ofhigh-intensity

aerobicexerciseforthe

first6mofollowed

by100mintwice/month.Plusencouraged

toexercise

3additionaldaysathomeperwk


TABLE1

Continued

Study,Program

Name(When

Applicable),

Setting,Country

Participants

Intervention

Length,

Follow-up

From

Baseline

StudyArmsand

StudyComponents

Interventions

Retention

Rate

c

Weight-Related

Outcom

eReported

Significance

Difference

Between

Groups

d

Na

Gender

Age,y

Selection

Criteriab

Hughes

2008,40

,57

“SCOTT,”Hospital

environm

ent,

UnitedKingdom

134

F+M

5to11

Obese(UK

referenceBM

I$98th

percentile)

12mo,

12mo

(1)Standard

care:DA

(2)Lifestyle

program:DA,

PA,BM

(1)3

to4appointm

entswith

dietitian

over6to10

mo(1.5hintotal).

DA:generalhealthyeatingandmainlydirected

towardparents.

(2)Family-centeredlifestyleintervention

program,8

appointm

entsover

26wk(5hin

total).

DA:m

odified

TrafficLightguide

PA:notspecified

SB:#

2hperday

(1)63%

(2)65%

BMIz

score,

WCzscore

No:bothgroups

hada

significant

decrease

inBM

Izscore.

Nemet2008,44

Hospital

environm

ent,

Israel

22 F+M

8to11

Obese(CDC

grow

thchart

BMI.

95th

percentile)

3mo,

3mo

(1)M

inimaladvice:

DA,PA

(2)Lifestyle

program:DA,

PA,BM

(1)Atleast1

ambulatory

nutritional

consultationplus

generalexerciseadvice.

(2)D

A:hypocaloricdiet(30%

deficientbased

onreported

intake

or15%less

than

estim

ated

dailyrequirem

ent).The

childrenmetwith

the

dietitian

weeklyandtheparentsmet

separatelywith

thedietitian

biweekly.

PA:twice-weekly1-htraining

(mostly

endurance

training)

Overall:

100%

BMI,%body

fat

(BIA),BM

Ipercentile

BMI:No

%body

fat

andBM

Ipercentile:Yes

(2.1)

Kalarchian

2009,41

Hospital

environm

ent,USA

192

F+M

8to12

Obese(CDC

grow

thchart

BMI.

97th

percentile)

6mo,

12mo,

18mo

(1)Usualcare:DA

(2)Lifestyle

program:DA,

PA,SB,BM

(1)2nutrition

sessions

basedon

Stop

Light

eatingplan

(2)First3mo:20

groupmeetings

(60mineach).

Parentsandchildreninseparategroup,then

joined

tosetw

eeklygoals

6to

12mo:3groupsessions

plus

3telephone

follow-up

12–18

mo:no

contacts

DA:m

odified

Stop

Lighteatingplan

SB:,

15h/wk

(1)85.3%

(2)83.5%

BMI,WC,and%

body

fat(DXA)

At6mo,BM

Iand

%body

fat:Yes

(2.1)

At12

and18

mo,%

body

fat:Yes

(2.1)

Sarvestani

2009,45

,e

Setting:

unclear,Iran

60 F11

to15

NR16

wk,

6mo

(1)Standard

care:

DA,PA,BM

(1)3behavioralmodificationintervention

sessions

(sam

eprogramas

group2).

NRBM

IBM

I:Yes(2.1)

(2)Lifestyle

program:DA,

PA,BM

(2)16

behavioralmodificationintervention

sessions

(2hbehavior

modificationor

dietaryinstructionplus

2hyoga

therapy).

Plus

4individualdietsessions

andrequired

tokeep

24-hfood

records.

REVIEW ARTICLE


TABLE1

Continued

Study,Program

Name(When

Applicable),

Setting,Country

Participants

Intervention

Length,

Follow-up

From

Baseline

StudyArmsand

StudyComponents

Interventions

Retention

Rate

c

Weight-Related

Outcom

eReported

Significance

Difference

Between

Groups

d

Na

Gender

Age,y

Selection

Criteriab

Diaz

2010,38

Shapedow

nProgram,Hospital

environm

ent,

Mexico

76 F+M

9to17

Obese(CDC

grow

thchart

BMI.

95th

percentileor

BMI.

90th

percentilewith

WC.90th

percentile)

12mo,

12mo

(1)Usualcare:DA

(2)Lifestyle

program:DA,

PA,SB,BM

(1)Monthly10-to15-minconsultations

with

primarycare

physician

(1)58%

(2)55%

BW,BMI,BM

Izscore,WC,

body

fat(DXA)

BMI,BM

Izscore,

WC,andbody

fat:Yes(2.1)

DA:FoodGuidePyramid

PA:30minmostd

aysofthewk

SB:#

2h/d

(2)12

weekly2-hbehavior

groupprogramand

weeklydietitian

counselingsessions

forthe

first3

mo,then

monthlyuntil12

mo.Plus

12monthlyphysicianconsultations.Parents

received

6educationsessions

andwere

encouraged

tolose

weightifthey

were

overweight.

DA:TrafficLightdietapproachplus

educationon

glycem

icindexandprovided

with

anindividualized

dietplan

of1200

to1800

kcal/d

PA:notspecified

SB:notspecified

Face-to-face

educationcomparedwith

written

educationmaterials

Fullerton

2007,48

School,USA

80 F+M

6thand7th

graders

Overweightand

obese(CDC

grow

thchart

BMI$

85th

percentile)

6mo,

6mo

(1)Written

materials

(1)To

followa12-wkparent-guidedmanualof

Trim

Kids.

NRBM

Izscore

BMIz

score:Yes

(2.1)

(2)Intensive

instructor-led

intervention

group:DA,PA,

BM

(2)Childrenreceived

aninstructor-leddaily

interventionduring

schooldays

(1nutrition

classand4physicalactivity

classesweekly)

for12

wk,then

monthlyboostersessions.

Parentsofferedmonthlyeveningtraining

sessions.

Johnston

2007,49

,62

School,USA

71 F+M

10to

14Overweightand

obese(CDC

grow

thchart

BMI$

85th

percentile)

6mo,

6mo

(1)Written

materials

(1)To

followa12-wkparent-guidedmanualof

Trim

Kids.

(1)88%

(2)95%

BMIand

%body

fat(BIA)

BMI:Yes(2.1)

%body

fat:No

(2)Intensive

instructor-led

intervention

group:DA,

PA,BM

(2)Childrenreceived

aninstructor-leddaily

intervention(1nutrition

classand4physical

activity

classesweekly,35

to40

mineach)

for12

wk,then

biweeklyduring

thelast

period

ofschool.Plusreceived

snackbars

foradaily

afternoonschoolsnackand

acerealforbreakfast.Parent

attended

monthlymeetings.


TABLE1

Continued

Study,Program

Name(When

Applicable),

Setting,Country

Participants

Intervention

Length,

Follow-up

From

Baseline

StudyArmsand

StudyComponents

Interventions

Retention

Rate

c

Weight-Related

Outcom

eReported

Significance

Difference

Between

Groups

d

Na

Gender

Age,y

Selection

Criteriab

DA:foodgroups

werelabeled“safety”

(most

fruitsandnonstarchy

vegetables),“caution”

(low

-fatm

eat,low-fatd

airy

andcomplex

carbohydrate)and“danger”

($5gram

sof

fator$

15gram

sofsugarperserving)zone

food

PA:2-stage

approach,wk1to6aimed

todevelop

abasiclevelofphysicalfitness;wk7to12

tofocuson

sportskilldevelopm

ent

Weigel2008,51

Community,

Germ

any

73 F+M

7to15

Obese(WHO

grow

thstandard)

1y,

1y

(1)Written

dietary

advice:DA

(2)Group

sessions:DA,PA,

BM

(1)Written

advice

(FoodGuidePyramid)from

apediatrician

during

anoutpatient

visitat

baselineand6mo.

(1)83%

(2)97%

BMI,BM

Izscore

BMIz

scoreand

BMI:Yes(2.1)

(2)Childrenreceived

weeklygroupnutrition

education(adapted

from

theFood

Guide

Pyramidfruitand

vegetabletemplate,45–60

min/session)andcoping

strategy

training.

Parentsreceived

monthly2hsupport

sessions.

PA:w

eeklysession,alternatingsw

immingand

indoor

sports

REVIEW ARTICLE


TABLE1

Continued

Study,Program

Name(W

hen

Applicable),

Setting,Country

Participants

Intervention

Length,

Follow-up

From

Baseline

StudyArmsand

StudyComponents

Interventions

Retention

Rate

c

Weight-Related

Outcom

eReported

Significance

Difference

Between

Groups

d

Na

Gender

Age,y

Selection

Criteriab

Estabrooks

2009,47

Primary

care,USA

220

F+M

8to12

Overweightand

obese(CDC

grow

thchart

BMI$

85th

percentile)

Intervention

length

varied,

followup

at6

and12

mo

(1)Written

materials:DA,

PA,SB

(2)Written

materials+

Groupsession

with

dietitian:

DA,PA,SB,BM

(3)Written

materials+

Groupsession

with

dietitian

+interactive

voiceresponse

technology:DA,

PA,SB,BM

(1)Received

a61-pageworkbookdesigned

toprom

otephysicalactivity,increase

consum

ptionoffruitsandvegetables

and

decreasedsugareddrinks,TVview

ing,and

sedentarybehavior.

(2)As

group1

plus

2weeklysm

allgroup

educationsessions

(2heach).

(3)As

group2plus

10weeklyfollow-upphone

calls

delivered

byinteractivevoiceresponse

system

andbasedon

goalssetb

ythe

participants.

(1)72%

(2)66%

(3)74%

BMIz

score

BMIz

score:Yes

(3.1;1.

2)

Resnick2009,50

,e,

CHEERProgram,

School,USA

46families

F+M

Kindergarten

and5th

graders

Overweight

andobese

(CDC

grow

thchartB

MI

$85th

percentile)

1y,

1y

(1)Written

materials

(2)Written

materials+

homevisitor

phonecall

(1)6

mailingsofeducationalm

aterialsat∼5-wk

intervals.

(2)As

group1plus

atleast1

homevisitor

phonecallby

thecommunity

health

workers.

(1)100%

(2)86%

BMIpercentile

No:bothgroups

lostweight

F,female;M,m

ale;BW

,bodyweight;DA,dietaryadvice;PA,physicalactivity;BM,behavioralm

odification;kcal,kilocalorie;CBT,cognitive

behavior

therapy;NR

,notreported;SB,sedentarybehavior;DXA,dual-energyx-rayabsorptiometry;CDC

,Centers

for

DiseaseControland

Prevention;IOTF,InternationalObesityTaskforce;WC,waistcircum

ference;PS,parentingskill;BIA,bio-im

pedanceanalyzer;ProjectSTORY,Projectsensibletreatm

entofobesityinruralyouth;SCOTT,ScottishChildhood

Overweight

Treatm

entTrial;WHO

,WorldHealth

Organization;CHEERProgram,Com

municatingaboutHealth,Exercising,andEatingRightProgram.

aNumberofparticipantsatrandom

ization.

bClassificationofoverweightandobesity

standardized

usingthefollowingdefinitions:Overw

eight=BM

I85thto95th

percentileforageandsex;obese=BM

I$95th

percentileforageandgender

orweight$

120%

ofaverageweightforheight.

cRetentionratesreported

postinterventionifno

follow-up,or

atlatestpointoffollow-up.

d2.

1means

group2hadagreaterreductionthan

group1(P

,.05).

eNotincluded

inthemeta-analyses.


mean difference20.97, 95% confidenceinterval (CI)21.39 to20.55) for lifestyleinterventions compared with controlover 2 years (Supplemental Fig 8).However, the studies were significantlyheterogeneous (I2 = 90%) and the effectsize varied by age and length of study.There was no evidence of publicationbias or small-study effects with visualinspection of the funnel plot.

We also conducted meta-analyses of12 studies (899 participants) that re-ported BMI (Fig 2A) and 7 studies (493participants) that reported BMI z score(Fig 2B). There was a pooled BMI re-duction of 1.25 kg/m2 (95% CI: 0.32–2.18, I2 = 98%) and a 0.10 BMI z scorereduction (95% CI: 0.02–0.18, I2 = 0%–50%) greater for the lifestyle in-tervention compared with the controlcondition.

The short-term study of children withthegreatestpostinterventioneffectwasa 6-month community-based program(mean BMI difference = 2.10 kg/m2) inwhich parents and children attendedeighteen 2-hour group education andexercise sessions held twice weekly insports centers and schools, followedby a 12-week free family swimmingpass (Table 1).34 However, the greatestBMI reduction in the studies of ado-lescents (mean BMI difference 4.30kg/m2) was in a 2-month community-based intensive exercise training pro-gram (4 times per week, 90 minuteseach) combined with dietary restric-tion (500 kcal/d less than the reportedbaseline energy intake).23

Effects of Lifestyle InterventionProgram Compared With UsualCare or Minimal Intervention

Eight of the 11 studies reported a posi-tive effect of the lifestyle intervention ascompared with usual care or minimalinterventions.38,41–46,69 The overall effectsize in the meta-analysis, which included7 studies (586 participants),38,41–44,46,69

was a decrease in BMI of 1.30 kg/m2 atthe end of active intervention (95% CI:1.03–1.58, I2 = 0% to 48%) (Fig 3A). Stud-ies with longer intervention periods (.6months)41,42 showed greater weight lossthan shorter term interventions.41–44,69

Four studies followedupparticipants at 7months to 1 year from baseline and thepooled results indicate that weight losswas sustained after program completion(Fig 3B). Similar observations were ob-tained for percentage body fat change,with the lifestyle intervention group los-ing 3.2% more body fat (95% CI: 1.39–5.01) than the usual care groupat the endof active intervention (Supplemental Fig9A).The fat loss effect was sustained at1 year follow-up (Supplemental Fig 9B).Four studies38–40,42 reported BMI z scorechange after the active intervention, withthe pooled weight loss being 0.09 BMIz score greater (0.02 to 0.15, I2 , 40%)in the lifestyle intervention comparedwith usual care (Supplemental Fig 9C).

Effects of Lifestyle InterventionProgram Compared With WrittenEducational Materials

Two of the 5 studies reported BMI and3 reported BMI z score. There was

a 2.52 kg/m2 greater reduction inpooled BMI (95% CI: 0.91–5.95, I2 =97%) and 0.06 greater reduction inpooled BMI z score (95% CI: 0.02–0.10,I2 = 99%) for the lifestyle interventionprograms compared with written ed-ucational materials only over 1 year(Fig 4A and B).

Effects of Lifestyle Interventions onCardio-metabolic Outcomes

Table 3 summarizes the metabolicoutcomes reported by each study.Fifteen of the 38 studies reportedat least 1 cardio-metabolic outcome.22,24,26,28,31,32,34,39,41,43,46,49,51,63,68 All except 2small studies (with 7 to 15 participants ineach study arm)24,39 reported a positiveweight loss effect of lifestyle inter-ventions compared with control groups.Eight studies reported blood lipidsresults26,28,31,39,43,46,49,63; 6 studies re-ported results of fasting glucose, fast-ing insulin, or HOMA-IR,22,24,26,31,46,49;and 12 studies reported blood pres-sure findings.26,28,31,32,34,41,43,46,49,51,63,68

Total Cholesterol and Triglycerides

Meta-analysis of 5 studies including 440participants between 8 and 16 yearsold (Supplemental Fig 10) showed thatlifestyle intervention had a significantlygreater impact on total cholesterol im-provement compared with no treatment/wait-list control, usual care, or writteneducational materials, both in the short-term (WMD20.40mmol/L, 95% CI:20.51to 20.30; I2 = 0%; study length: 4 to 6

TABLE 2 Selected Methodological Quality of Included Studies: Results Are Presented as Number of Studies (%)

TrueRandomization

AllocationConcealment

Blinding of OutcomeMeasurement

BaselineComparability

Retention Rate $70% at6 mo or $60% at 1 y

Intention-to-Treat Analysis

Lifestyle interventions comparedwith no-treatment/wait-listcontrol, n = 22 studies

Yes 7 (32) 5 (23) 3 (14) 18 (82) 16 (73) 3 (14)No 0 (0) 0 (0) 2 (9) 1 (4) 1 (4) 13 (59)Unclear 15 (68) 17 (77) 17 (77) 3 (14) 5 (23) 6 (27)

Lifestyle interventions comparedwith standard care/minimaladvice, n = 11 studies

Yes 5 (45) 3 (27) 2 (18) 10 (91) 8 (73) 4 (36)No 0 (0) 1 (0) 1 (9) 1 (9) 2 (18) 5 (46)Unclear 6 (55) 7 (73) 8 (73) 0 (0) 1 (9) 2 (18)

Lifestyle interventions comparedwith written education materials,n = 5 studies

Yes 2 (40) 1 (20) 0 (0) 4 (80) 4 (80) 2 (40)No 0 (0) 0 (0) 0 (0) 1 (20) 0 (0) 2 (40)Unclear 3 (60) 4 (80) 5 (100) 0 (0) 1 (20) 1 (20)

REVIEW ARTICLE








FIGURE 2Meta-analysis of studies comparing lifestyle intervention with no-treatment or wait-list controls.


months)26,31,49 and the longer-term stud-ies (WMD 20.24 mmol/L, 95% CI: 20.30to 20.17; I2 = 0%; study period: 1 to 2years).28,46 The pooled intervention effecton triglycerides for the same group ofstudies (Fig 5A) was20.20 mmol/L in theshort-term studies (95% CI: 20.35 to 20.05, I2 = 59%) and20.09 mmol/L in thelonger-term studies (95% CI:20.11 to20.07, I2 = 0%).

Low-Density Lipoprotein and High-Density Lipoprotein Cholesterol

Meta-analysis of 4 studies including

372 participants with study length

between 4 and 12 months showed a

significant improvement in LDL cho-

lesterol (20.30 mmol/L, 95% CI:20.45

to 20.15, I2 = 59%) favoring lifestyle

intervention (Fig 5B). No differences

were found for HDL cholesterol (P =.22) (Fig 5C).

Fasting Glucose, Fasting Insulin,and HOMA-IR

Meta-analyses of 4 studies including372 participants showed a significantimprovement in fasting insulin (255.1pmol/L, 95% CI: 271.2 to 239.1, I2 =0%) in favor of lifestyle interventions

FIGURE 3Meta-analysis studies comparing lifestyle program to usual care or minimal intervention conditions.

REVIEW ARTICLE


over 1 year (Fig 6A) and no differenceswas found for fasting glucose (P = .08)(Supplemental Fig 11). The pooled dif-ference for HOMA-IR was 22.32 (95%CI:23.25 to21.39) in favor of lifestyleintervention over 1 year; however, theheterogeneitywashigh (I2 = 79%) (Fig 6C).

Blood Pressure

Meta-analyses of 7 studies (554 par-ticipants) showed that lifestyle inter-ventions led to a significantly greaterimprovement in diastolic bloodpressurein the short-term studies (WMD 21.69mm Hg, 95%CI:23.15 to20.24, I2 = 26%,study length: 6months or less) but therewas no difference in the longer-termstudies (Fig 7A). On the contrary, a sig-nificantly greater improvement in sys-tolic blood pressure was shown onlyin the studies with a study length of1 year or more (WMD 23.72 mm Hg,95% CI:24.74 to22.69, I2 = 0%) (Fig 7B).Five studies were not included in themeta-analyses, as they reported theabsolute values only at baseline andfollow-up.34,43,51,63,68 These studies re-ported a similar trend as those includedin the meta-analyses.

The study that achieved the greatest im-provement across all cardio-metabolic

outcome measures, including blood lip-ids, fasting glucose and insulin, HOMA-IR,and blood pressure, was a 12-weekintensive school-based lifestyle inter-ventionprogram targeting10- to 13-year-old obese students.26 The participantsreceived 30-minutes of nutrition in-struction twice per week at school plus40-minutes of classroom-based non-competitive aerobic activity 3 timesper week. The mean BMI and bodyfat percentage difference betweenthe intervention group and the no-treatment control at the end of activeintervention was 21.5 kg/m2 and21.2% respectively.

DISCUSSION

This systematic review reports on life-style intervention trials incorporatinga dietary component aimed at treatingoverweight and obesity in children andadolescents published between 1975and September 2010 (n = 38). It is thefirst review to summarize the effectsof lifestyle interventions on cardio-metabolic outcomes in this age groupand provides an improved understand-ing of the effects of lifestyle interventionson weight loss and cardio-metabolicoutcomes. The results support the

importance of lifestyle interventionsincorporating a dietary component as acritical part of treatment of childhoodobesity.

The meta-analyses indicate that life-style interventions incorporating a di-etary component led to significantweight loss when compared with notreatment. These results support pre-vious reviews,8,9,11–14 and extend theevidence base on the use of lifestyleinterventions in the treatment of child-hood obesity, as this review includesmore trials, uses clearly defined no-treatment, or wait-list controls, andextends ascertainment to September2010. Studies comparing lifestyle inter-ventionswith usual care also resulted insignificant immediate and posttreat-ment effects on BMI up to 1 year frombaseline. The meta-analysis shows thatweight loss was greater when the du-ration of treatment was longer than6 months. Lifestyle interventions alsoproduced significant treatment effectson BMI and BMI z score, compared withwritten information only, over a 6- to12-month intervention period.

Meta-analyses showed that lifestyleinterventions resulted in significant

FIGURE 4Meta-analysis of studies comparing lifestyle intervention program with written education materials.



TABLE3

Effectsof

LifestyleInterventions

onAnthropometricandMetabolicOutcom

es(Structuredby

Year

ofPublication)

Study

Timeof

Measurementa

Anthropometric/Body

Composition

Metabolic

BMI

BMIz

Score

Body

Fat%

Waist

Circum

ference

Total

Cholesterol

LDL

HDL

Triglyceride

Fasting

Glucose

Fasting

Insulin

Insulin

Resistance

iSBP

DBP


no-treatm

entorwait-listcontrol

Becque

1988

6320

wk

✓b,d

✓✓

✓b

✓✓

✓b

Rocchini1988

6820

wk

✓b,d

✓b

✓b

Balagopal20032

23mo

✓b

✓b,e

✓b,c

✓b,c

Jiang2005

2824

mo

✓b

✓b

✓b

✓b

✓b

Huang2007

2612

wk

✓b

✓b,f

✓b

✓b

✓b

✓b

✓b

✓b

✓b

✓✓

Park

2007

3112

wk

✓b

✓b,f

✓b

✓b

✓b

✓✓

b✓

b✓

b✓

b✓

b✓

Davis2009

2416

wk

✓b

✓✓

✓

Reinehr2010

326mo

✓b

✓b

✓b,f

✓b

✓b

✓b

Sacher

2010

346mo

✓b

✓b

✓g

✓b

✓✓

b


usualcare

Nemet2005

433mo

✓b

✓b,h

✓b

✓b

✓✓

✓✓

b

Nemet2005

4312

mo

✓b

✓b,h

Gillis2007

396mo

✓✓

✓✓

Savoye

2007

466mo

✓b

✓b,f

✓b

✓✓

✓✓

✓b

✓b

✓✓

Savoye

2007

4612

mo

✓b

✓b,f

✓b

✓✓

✓✓

✓b

✓b

✓✓

Kalarchian

2009

416mo

✓b

✓b,e

✓b

✓b

✓

Kalarchian

2009

4112

mo

✓✓

b,e

✓b

✓b

✓


written

educationmaterialsonly

Johnston

2007

496mo

✓b

✓f

✓b

✓b

✓✓

✓✓

✓✓

Weigel20085

112

mo

✓b

✓b

✓b

✓

DBP,diastolic

bloodpressure;SBP,systolic

bloodpressure;✓

,the

outcom

eswerereported.

aCountedfrom

baseline.

bIndicatesastatisticallysignificant

improvem

entinthat

outcom

ewhencomparedwith

no-treatm

entcontrol/usualcare/written

educationmaterials.

cFindings

reported

ingraph.

dBody

fat%measuredby

hydrostatic

weighting.

eBody

fat%measuredby

dual-energyx-rayabsorptiometry.

fBody

fat%measuredby

bio-impedanceanalyzer.

gBody

fat%determ

ined

bydeuteriumdilution.

hBody

fat%determ

ined

byskinfolds.

iInsulin

resistance

determ

ined

bythehomeostasismodelassessmentofinsulin

resistance

(HOM

A-IR).

REVIEW ARTICLE


improvements in total cholesterol andtriglycerides up to 2 years from base-line, as well as improvements in fastinginsulin and HOMA-IR up to 1 year frombaseline; however, the improvementswere not uniformly associated with theextent of weight loss or body fat re-duction. It is uncertain whether thepositive effects were attributable toweight loss per se or attributable toaspects of the lifestyle intervention thatwere independent of weight loss, suchas reduction in saturated fat intakeor increased physical activity. Somestudies have reported that lifestyle in-

tervention resulted in improvement inplasma lipid concentrations, insulinsensitivity, and blood pressure in obesechildren, even in the absence of weightloss or body composition change.75,76

The absence of individual participants’data on weight and cardio-metabolicoutcome changes makes it impossibleto characterize the relationship be-tween the extent of weight loss andchanges in various cardio-metabolicoutcomes. Although most studiesshowed a significant improvement intotal cholesterol (6/7)26,28,31,43,46,49 orLDL cholesterol,26,31,43,49 fewer than half

demonstrated significant improvementsin triglycerides26,28,31 or HDL choles-terol.26,63 High triglycerides and lowHDL cholesterol levels are the impor-tant risk factors of cardiovasculardisease. Future studies should ex-plore effective strategies to improvetriglycerides and HDL cholesterolconcentrations.

The impact of lifestyle interventions onblood pressure is less certain from theincluded studies. Most overweight orobese children are likely to be normo-tensive. In addition, blood pressure is

FIGURE 5a, Forestplot ofmeandifferences in triglycerides concentrations (mmol/L). B, Forestplot ofmeandifferences in LDLcholesterol concentrations (LDL,mmol/L). C,Forest plot of mean differences in HDL concentrations (HDL, mmol/L).


strongly related to age and height77–79 inchildren and adolescents, and thereforedirect comparison of blood pressurereading possibly underestimates theintervention effects and limits our abil-ity to draw definitive conclusions on theeffects of lifestyle interventions on bloodpressure.

Features of Effective Interventions

The heterogeneity of the includedstudies makes it difficult to give de-finitive recommendations for practice.However, the studies provide evidenceto support a variety of dietary andlifestyle components in treating child-hood obesity across a wide range oftreatment settings, age groups, andseverity of obesity.

Family Involvement

Family involvement in treatment ofchildhood obesity is widely advocatedand discussed.9,80,81 Our review demon-strated that almost all effective inter-ventions (particularly in studies thatenrolled children ,12 years of age)reported including a family component,including separate education sessionsfor parent and child,25,27,32,41,42,44,48,49,51,66

targeted parents as the sole agent ofchange,35 encouraged parents to loseweight if they were overweight,38,66 orprovided a free family swim pass toparticipants.34

Dietary Intervention

We found that dietary interventionswere rarely evaluated as a sole com-ponent of treatment in comparisonwitha waited-list or no-treatment controlgroup. Dietary interventions wereusually part of a broader lifestyle in-tervention program. Not all studiesadequately described the dietary in-tervention. The most commonly re-ported dietary interventions were themodified Stop/Traffic Light approachand a hypocaloric diet/calorie re-striction approach. Both dietary ap-proacheswere demonstrated to achieveeffective relative weight loss acrossdifferent age groups, settings, andcountries.22,23,27,32,38,41–44,66 The influen-ces on weight were sustained up to 1year from baseline.27,41–43

Exercise Intervention

Another frequent feature of effective stud-ies is involvement of a structured exer-

cise training component.22,31,43,46,48,49,64,68

Again, the varied strategies, intensity,and duration of intervention make itdifficult to conduct direct comparisonsand to identify the most effective exer-cise intervention for weight loss in thisage group.

Strengths and Limitations

This review comprehensively includedlifestyle intervention trials publishedbetween 1975 and 2010 during whichtime childhood obesity became preva-lent. Strengths of the study include thereporting of mean differences in BMIandpercentagebody fat,weight changeindicators commonly used by clini-cians, as well as cardio-metabolic out-comes, Also, separate meta-analyseswere conducted to compare lifestyleinterventions with clearly defined no-treatment or wait-list controls, usualcare, orminimal advice andwrittendietand physical activity education mate-rials respectively. This provides clini-cally meaningful information for futurepediatric obesity treatment serviceplanning.

A number of limitations of the presentanalyses should be acknowledged.

FIGURE 6a, Forest plot of differences in mean fasting insulin (pmol/L). B, Forest plot of mean differences in homeostasis model assessment of insulin resistance(HOMA-IR).

REVIEW ARTICLE


First, this review was confined to pub-lished literature written in English; thismay have introduced publication biasand an overrepresentation of effectiveinterventions. Second, a high degree ofclinical and statistical heterogeneityamong the included studies means theresults should be interpreted withcaution. We addressed statistical het-erogeneity by using a random effectsmeta-analysis andbysubgroupanalysis.The potential sources of heterogeneityinclude variations in the participantpopulations, the intensity and durationof interventions, and the variety of dietandexercise regimensused. The reviewwasalso limitedby the less thanoptimalmethodological quality of the included

studies and the lack of isolation ofthe effects of the dietary interventioncomponents. In addition, there wereinadequate data reported to allow in-clusion of some studies in meta-analyses, and almost 40% of includedstudies (n = 19) reporting only abso-lute values of weight outcome. Forthese studies, we calculated weightchange from absolute values and usedimputation methods to estimate the SDof the change. To facilitate future sys-tematic reviews and meta-analyses,authors should be encouraged to re-port both weight change and SD data.Finally, the review was also limited bythe use of intermediate outcomes, suchas lipoprotein and blood pressure, in

the absence of longer-term cardiovas-cular morbidity data.

CONCLUSIONS

Thebodyof researchreviewedsuggeststhat lifestyle interventions incorpo-rating a dietary component along withan exercise and/or behavioral therapycomponent are effective in treatingchildhood obesity and improving thecardio-metabolic outcomes under awiderange of conditions at least up to 1 year.To draw firm clinical recommendations,future studies should provide details ofall intervention components, participantcharacteristics, and the study design,including the method of randomization,

FIGURE 7a, Forest plot of differences in mean diastolic blood pressure (mmcHg). B, Forest plot of differences in mean systolic blood pressure (mmcHg).


blinding, allocation concealment, andattrition rates. Further work is requirednot only to determine the optimal length,intensity, and long-term effectivenessof lifestyle interventions, but also to

determine what magnitude of weightreduction in the pediatric population iscompatible with clinically significant ben-efits. Further, cost-effectiveness analysesneed to be conducted.

ACKNOWLEDGMENTWe thank Ms Debbie Booth, librarian,Faculty of Health, The University of New-castle, for assistance with the search-and-retrieve strategies.

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