Table 3

Running head: PEDIATRIC EVIDENCE ABSTRACT

1PEDIATRIC EVIDENCE ABSTRACT

2

Pediatric Evidence Abstract

Molly Chaffin

The University of Southern Mississippi

Citation:Nemet, D., Barkan, S., Epstein, Y., Friedland, O., Kowen, G., & Eliakim, A. (2005) Short- and long-term beneficial effects of a combined dietary-behavioral-physical activity intervention for the treatment of childhood obesity. Pediatrics, 115(4). e443-e449.

Study Design:Randomized prospective study

Class:A

Quality Rating:+

Research Purpose:The intention of this study was to analyze the short- (3 months) and long-term (1 year) effects on body weight, physical activity and fitness levels, and lipid panels from a 3-month diet, behavior, and exercise intervention program.

Inclusion Criteria:Obese children (>97%ile for weight) ages 6-16 who volunteered for the study at the Meir General Hospital were included.

Exclusion Criteria:Children who were outside of the 6-16 age range, who were not considered obese, or did not have informed consent from both the child and the parent were excluded from the study. Subjects on medications that may influence weight or subjects with an underlying organic cause for obesity were also excluded.

Description of Study ProtocolSubjects assigned to the control group were referred to an outpatient dietitian at least once and recommended to participate in physical activity at least three times per week.

Subjects assigned to the intervention group participated in four evening lectures over a three-month span regarding obesity in children, general nutrition, exercise, and therapeutic nutrition for childhood obesity. Participants and parents met with a dietitian six times regarding food choices, cooking habits, motivation, and family involvement. Subjects were also prescribed a hypo-caloric diet of approximately 30% deficit from reported intake or 15% deficit from estimated needs. Subjects were enrolled in an exercise program with two one-hour sessions per week with instructions to include 30-45 minutes additional exercise per week.

Outcomes were assessed at baseline, 3 months, and 1 year following the study.

Data Collection Summary:Anthropometric measurements were recorded including height, weight, BMI percentile, and skin fold thickness. A 24-hour recall was conducted prior to the study and 2-day food records were collected at the three data collection times. Physical activity was assessed with a questionnaire. A treadmill test determined fitness and endurance. Blood lipid levels including total cholesterol, triglycerides (TG), high-density lipoprotein (HDL), and low-density lipoprotein (LDL) were taken at the three data collection intervals.

Blinding was not used for this study.

Description of Actual Data Sample:No significant differences were observed at baseline between the intervention or control groups regarding age, gender, BMI, fitness levels, or parental obesity.

Only 67% of the original 30 intervention subjects and 83% of the 24 control subjects completed the program and the one-year follow up.

Summary of ResultsFollowing the three-month intervention, significant (P < 0.05) decreases were seen in body weight (average 63.8 to 61.0 kg), BMI (average 28.5 to 26.8 kg/m2), and body fat percentage (average 40.2% to 36.9%). Significant increases were seen in average body weight (63.4 to 64.5 kg) and average body fat percentage (40.7% to 42.4%) in control subjects. Significant differences were seen in the changes of total cholesterol and LDL cholesterol between the intervention and control group.

At the one-year follow-up, BMI and body fat percentage were significantly lower in the intervention group compared to the control. The fitness level of the intervention group was greater, but not found to be statistically significant (P = 0.056).

Author Conclusion:Behavioral nutrition and exercise interventions provide short- and long-term benefits on weight loss, body fat changes, physical activity habits, fitness levels, and lipid levels in obese children.

Review Comments:This study provided strong evidence supporting nutrition and exercise interventions for obese children. The length of the study and involvement (monthly dietitian sessions and biweekly fitness sessions) also strengthened the results. This study analyzed not only changes during the intervention, but also whether or not the intervention could provide lasting benefit.

One limitations of the study was the low response rate at the one-year follow-up (67 and 83%). While the large age range of the subjects (6-16) provides more generalizability, moderating factors were not considered. Stratifying the data per age group could be interesting to determine if intervention success varies by age.

Nutrition Prescription (The patients/clients individualized recommended dietary intake of energy and/or selected foods or nutrients based on current reference standards and dietary guidelines and the patients/clients health condition and nutrition diagnosis):

Energy needs (35-40 kcal/kg): 2,730-3,120 kcal/day

Protein needs: (1.0-1.2 g/kg): 78-93 g/day

Fluid needs: 2-3 L/day

Assess

Interpret data needed to identify nutrition related problems, their causes, and significancePriorityDiagnosis (PES Statement)

______RT______ AEB_______Intervention

What are you going to do to fix the problem?Monitoring

What data do you need to assess your intervention?Evaluation

Quantifiable goal(s)

Anthropometrics:

13YOWM

Ht: 63.4

Wt: 156.2 lbs

BMI: 30.13 kg/m2>97%ile

Biochemical tests/procedures:Labs:

BUN 13 mg/dL

Glucose 103 mg/dL

Sodium 135 mmol/L (L)

Potassium 4.3 mmol/L

Chloride 99 mmol/L (L)

Calcium 10.4 mg/dL

Albumin 4.9 gm/dLClinical:

Dx: Appendicitis

C/o: abdominal pain in lower left quadrant; vomiting, malaise, lack of appetite

Patient alert/oriented, post-op appendectomy day #2

Reported hx: reflux

Family hx:

-Father cancer/stroke

-Grandmother cancer

-Grandfather CAD/HTNMedications:

Melatonin

Morphine

Ondansetron

Zofran

Diet history:NPO prior 3 days due to symptoms and surgical procedureImprovement in appetite post-op day #1, advanced to clear liquid diet

Reported consuming some of breakfast tray and some cheerios

Regular diet consumed prior to admission/onset of symptoms including McDonalds, chicken, pasta, green beans, juice, milk

Eco-social:

Mother is primary caregiver

Reported no involvement in sports or regular physical activity

1Inadequate oral intake RT decreased appetite secondary to appendicitis AEB reported abdominal pain and vomiting, NPO for three days.-Encourage intake of >75% of meals

-Recommend advancement of diet as patient tolerates (clear liquid, full liquid, to GI soft diet as symptoms resolve)

-Recommend Ensure supplement if patient unable to consume adequate energy and protein-Reported intake according to patient and nurses reports

-Patients tolerance to diet according to reported symptoms and appetite-Intake >75% of all meals and supplements

2Excess energy intake (long-term) RT undesirable food choices AEB >97%ile of weight for height and reported food preferences of energy-dense foods.-Inform patient and family on patients weight status (obesity >97%ile) and health risks

-Determine current diet according to 24-hour recall. Inquire about usual intake and offer recommendations for improvement

-Discuss with parents the importance of preparing healthy meals and addressing this problem as a family unit

-Recommend 2-3 additional outpatient sessions to educate patient and family on a healthy diet (decreased fast food, energy dense foods, increased servings of fruits, vegetables, low-fat dairy, lean meats, whole grains) to promote weight maintenance as the child grows -Follow-up 24-hour recalls

-Patient height, weight, weight percentile according to growth chart

-Improvement in diet according to 24-hour recall (decreased fast food, energy dense foods, increased servings of fruits, vegetables, low-fat dairy, lean meats, whole grains)

-Weight maintenance or gradual weight loss

-Weight-for-height percentile approaching healthy range ( 97% weight for height.-Educate patient and parents on the benefits of regular physical activity combined with a healthy, balanced diet; recommend weight maintenance or very gradual weight loss ~2lbs per month to approach normal weight-for-height percentile

-Recommend regular activity to meet 150-300 minutes per week; suggest involvement in a sports team, swimming, outdoor program, etc.

-Encourage keeping a physical activity log to help meet goals and track progress

-Use motivational interviewing techniques to encourage goal-setting for family-oriented planned activity

-Physical activity minutes per week according to log

-Patient height, weight, weight percentile according to growth chart

-Improvement of physical activity approaching 150 minutes/week and progressing to 300 minutes/week

-Weight maintenance or gradual weight loss

-Weight-for-height percentile approaching healthy range (