Evaluation of contemporary treatment programs for childhood obesity

CHILDHOOD OBESITY & NUTRITION

EVALUATION of CONTEMPORARY TREATMENT PROGRAMS

The purpose of this work is to evaluate the available treatments and preventions for childhood obesity and clarify the pros and cons of the most prevalent treatments being used by today's medical professionals. The National Institute for Health Care Management Foundation states that maintenance of a balance "between energy intake and energy expenditure is a critical factor in regulating body weight. The majority of obesity-related academic research, government funding, media attention and parental concern has focused on nutrition and dietary contribution to child and adolescent overweight." (NIHCM, 2003) According to the NIHCM Foundation the advantages of prevention of childhood obesity include: (1) the ability to maintain optimal metabolic physiology; (2) Applying prevention strategies at the populations level; (3) early counseling or behavior modification therapy in addressing the root cause(s) of eating and activity behaviors; and (4) secondary beneficial effects such as general disease risk reduction and preventative behaviors have limited or not hard to a child or adolescent." (NIHCM, 2003) the NIHCM Foundation states that requirements in prevention and treatment of child obesity include the introduction of healthy behaviors, the modeling of healthy behaviors and the reinforcement of healthy behaviors in early childhood. Screening procedures are reviewed in this work as well as the treatment models being used for individuals, groups, in communities and schools.

CHILDHOOD OBESITY & NUTRITION

AN EVALUATION of CONTEMPORARY TREATMENT PROGRAMS

Introduction

Childhood obesity, particularly in the United States, is at an all time high and the problem is one that appears to be only growing. This work will evaluate the available medical treatments of child obesity and clarify the pros and cons of the most prevalent treatments for child obesity by today's medical professionals.

Behavioral Treatment of Childhood Obesity

Treatments of childhood obesity include Behavioral Treatment which "can be implemented at several different levels: (1) individual; (2) interpersonal; (3) organizational; and (4) societal." (Ibid) the NIHCM Foundation states that "Research has shown success in intensive group programs, however, this approach is not easily translated into an office visit. According to the NIHCM Foundation, the work of "Robinson and others" suggests that "the most effective behavioral treatment programs have certain components that result in successful, long-term weight loss..." (Ibid) Those identified components are: (1) parent involvement including parent education about critical behavior areas; (2) frequent meetings or sessions; (3) sustained treatment duration; (4) group format with individual behavior counseling; (5) a simple diet that produces a calorie deficit; and (6) physical activity intervention that allows for personal choice;) Emphasis on reducing sedentary behavior; (8) Home and family environmental change that increase cues for physical activity and reduces cues for calorie intake and inactivity; (9) Self-monitoring, goal setting, and behavior contracts; and (10) Education regarding skills for behavior maintenance and relapse prevention." (NIHCM, 2003)

Recommendations Actions in the Evaluation and Treatment of Obesity in Children

According to the NIHCM Foundation report, there are designated actions required in the evaluation and treatment of obesity in children according to recommendations of the expert committee. These designated actions are listed in Figure 3: Obesity Evaluation and Treatment: Expert Committee Recommendations. The first of the actions listed is 'Identify', which includes calculation of the BMI or body-mass index, and those with a BMI in the 95th percentile should undergo a medical assessment. The second listed action is "Assess" at which time genetic or endocrinologic causes are assessed as well as any possible medical complications, the degree the child is overweight and finally make a determination if the child should be referred to a specialist in this area. Third is the 'Evaluation' as to the 'readiness to change' of the obese child; the child's history of physical activity; and the child's diet history. (Ibid; paraphrased) the fourth action is stated to be that of: "Setting Goals" in relation to behavioral, medical and weight focused goals. The final two steps have to do with therapy both family and individual.

Obesity Evaluation and Treatment: Expert Committee Recommendations

Source: Childhood Obesity - Advancing Effective Prevention and Treatment: An Overview for Health Professionals (2003)

These same components are identified in the work of Moran who states the components required include: (1) reasonable weight-loss goal; (2) dietary management; (3) physical activity; (4) behavior modification; and (5) family involvement." (1999) Moran states that it has been demonstrated in many studies that a "familial aggregation f risk factors for obesity exist and the family "provides the child's major social learning environment." (1999)

Surgical and Pharmacological Treatment

There is very little conclusive research in the area of surgical and pharmacological treatment of child and adolescent obesity. These types of treatments are generally considered by HCPs to be "last resorts" (NIHCM, 2004) the use of gastric bypass surgery has been shown to have a lasting effect on weight loss for up to 10 years with an average weight loss of 50 kg being reporting representing around 59% of the "initial excessive weight." (Ibid) Adolescent weight loss was shown to significantly improve hypertension and sleep apnea. The work of Sugarman et al. found that "five to ten years post-surgery, one third of patients had regained most of their weight while the remaining two thirds maintained the loss for up to fourteen years after having had the surgery. The pharmacological therapy has included the following medications:

Phentermine: an appetite suppression (short-term treatment of up to 12-weeks)

Meridia (sibutramine hydrocholoride monohydrate) a neurotransmitter uptake inhibitor that works by manipulating the appetite-control centers in the brain. This drug has caused significant elevation in blood pressure in some people.

Xenical (Orlistat) This drug works in the gastrointestinal track to block the body's absorption of dietary fat. Orlistat also diminishes the absorption of fat-soluble vitamins so daily vitamin supplements must be taken.

Phenylpropanolamine (Acutrim and Dextrim) Available without a prescription, this drug works by increasing the level of a nervous system chemical called catecholamine that increases metabolic rate. Use of this product can increase heart rate, BP, and glucose levels.

Leptin and leptin receptors: Leptin is a hormone produced primarily in adipose tissue that can alter hunger and energy homeostasis. (NIHCM, 2004)

Programs and Intervention

Interventions which have been shown effective in weight loss include the program referred to as "KidShape." The mission of KidShape is "to increase awareness and promote adoption of a health lifestyle, including health eating, physical activity participation and building positive self-esteem for entire families with overweight or obese children." (Ibid) This program was established in 1987 and attempts to meet the needs of families that are diverse through creation of an environment that is supportive with the primary objective being to: (1) increase the awareness of and adopt of healthy eating habits; (2) increase awareness of and participation in regular physical activity; (3) Increase awareness of and self-appreciation of positive aspects of each participant; and (5) set realistic goals and be rewarded for achieving them with the family." (Ibid) This program is an eight-week program for ages 6-14 that is divided into two interdependent four-week modules in both English and Spanish. Also shown to be effective is a program developed by the University of California - San Francisco named SHAPEDOWN. SHAPEDOWN is a family-based intervention in which individuals participate in meetings that are educational in nature and have a design for enhancement of self-esteem and peer relationships and the adoption of healthier habits with genetic and environmental influences being considered. This program last ten weeks with each weekly session lasting 2 1/2 hours. Weight loss is gradual in this program. This program uses integration of cultural economic and ethnic differences in the workbook materials that are inclusive of broad ranges of examples of types of families. A third program named "Committed to Kids" (CTK) was established in 1986. This program uses an individualized approach to weight management and is conducted in an outpatient, group setting. This program was developed by the Louisiana State University Medical Center Department of Pediatrics and uses a "team-based approach including a physician, registered dietician and exercise physiologist, and behavior specialist." (Ibid) the duration of this program is one-year and is delivered in four phases depending on how severely overweight the child is. The participants are given a comprehensive physical, exercise and nutritional evaluation before staring the program. The exercise component is referred to as the MPEP (Modern Intensity Progressive Exercise Program) and is inclusive of aerobic, strength and flexibility training" presentations through use of video and educational materials. This program is inclusive of weekly group meetings which children and families attend for educational session, behavioral discussions and other activities for reinforcement of behavioral change. The SUNY Buffalo Childhood Weight Control Program is another program shown to be effective. This program is a six-month program and is implemented two or three times each year in which the participants attend 1 1/2 hours week session for eight weeks, then attend eight-week bi-weekly sessions and finally attend monthly session. This program includes "individual counseling and group education session that focus on behavioral choice theory." (Ibid) This program uses the Stoplight Diet to assist decrease of the intake of energy dense foods in children ages 6 to 12 years. The Healthworks! Intervention program for obsess children ages five to 10 and adolescents ages 11 to 19 is part of the Heart Center at Cincinnati Children's Hospital Medical Center. In the HealthWorks! Program the participants have to meet certain weight criteria and be referred through a physician to the program. This program uses a team-based management treatment which includes: "...a physician, a registered dietician, a psychological, a nurse, an exercise physiologist, an exercise instructor, the child and the family." (Ibid) the components of the program include: (1) diet modification and individual nutrition counseling; (2) lifestyle physical activity promotion and group exercise sessions; (3) behavioral intervention strategies; (4) parental involvement; (5) comprehensive clinical evaluation (pre-, during and post-screen); and (6) group education for adult family members." (Ibid) Other effective treatment programs include: (1) L.E.S.T.E.R. (Let's Eat Smart Then Exercise Right) This program is one of the University of Alabama at Birmingham (UAB) Department of Clinical Nutrition for children between the ages of 6 and 11 years of age. This is an eight-week program that has two individual and six group session and follow-up at six and twelve months. The treatment team is composed of clinical nutritionists, a child life therapist, and family members. This program components are inclusive of: (1) an instructors' manual; (2) parent and child notebooks, (3) board games; and (4) 12 monthly follow-up newsletters. The LESTER program is unique in that a scholarship bund has been established by the UAB Children's Auxiliary for reduction of the expense of the program.

Treatment and prevention programs also include school programs and community programs. The school environment is considered to be an ideal setting for development and testing of health behavior interventions. One of these interventions is "Healthy Start" which is a comprehensive preschool health curriculum. Another program is the "Take 10" program which was developed by the International Life Sciences Institute Center for Health Promotion. This program is a classroom-based curriculum tool that is an integration of 10 minutes of "...moderate-to-vigorous physical activity with grade-specific academic learning objectives to reinforce required concepts and skills." (Ibid) Three more school programs include: (1) a Coordinated Approach to Child Health: CATCH; (2) Pathways; and (3) the SPARK Programs (Sports, Play and Active Recreation in Kids. All of these programs focus on education, physical activity, and nutritional adjustments. Finally, the Planet Health Program developed at Harvard University through NIH funding is a school-based intervention for students in 6th, 7th and 8th grades. This program integrates health sessions into regular school classes with a focus on 'decreasing television viewing, decreasing consumption of high-fat foods, increasing fruit and vegetable intake, and increasing moderate and vigorous physical activity." (Ibid) Results of the study of Planet Health is stated to have: "demonstrated a reduction in obesity prevalence among girls, but not among boys; reduced television viewing among girls and boys, and increased fruit and vegetable consumption among girls." (Ibid) Community-based approaches to management of weight include inventions that are conducted at worksites and in homes and include as well "...multi-modal community programs in a variety of regional locations." (Ibid) These types of treatment programs have been shown to produce "only modest weight loss." (Ibid)

The work of Sonia Caprio entitled: "Treating Child Obesity and Associated Medical Conditions" states that the first step in treatment is with "a thorough medical exam, an assessment of nutrition and physical activity, an appraisal of the degree of obesity and associated health complications, a family history, and full information about current medicals." (2006) Caprio believes that "for the severe forms of obesity, the future lies in developing new and more effective drugs." (2006) Carprio states that the most effective obesity treatment programs today are those with an approach "that combines a dietary component, behavioral modification, physical activity and parental involvement." (2006) the Medical association, in order to ensure "that pediatricians are well trained in implementing such programs....is working with federal agencies, medical specialty societies and public health organizations to teach doctors how to prevent and manage obesity in both children and adults. " (2006) There is a problem identified by Caprio in reimbursement for treatment of obesity. Caprio states that: "Despite the health risks of obesity, patients get little support from health insurers, thus putting long-term weight-management programs beyond the reach of most." (2006) Caprio presents the argument that "obesity should be recognized as a disease and receive coverage for its treatment just as other diseases do." (2006) Caprio relates that fact that while children of the African-American and Hispanic groups "have higher prevalence rates of obesity than do white children and adolescents...they receive less care." (2006) Additionally stated is that this disparity is "...particularly disconcerting because black and Hispanic children are at a greater risk for obesity-associated complications, such as type 2 diabetes, than are white children." (2006) Caprio recommends that development and implementation of ethnicity-based management programs for children and adolescents "with diverse ethnic, racial and cultural backgrounds..." (2006) should be focused upon by health professionals. The Food and Drug Administration (FDA) has approved the prescription drug sibutramine (Meridia) which is an appetite suppressant being prescribed for weight loss and maintenance "in conjunction with reduced caloric intake and adults and adolescents over the age of sixteen. Clinical trials have shown the drug to be effective when part of a comprehensive diet and behavioral program however, this drug has side effects of a serious nature including hypertension and tachycardia. Another drug, Orlistat (Xenical) which decreases nutrient absorption and cuts intestinal fat absorption (up to 30%) has been approved by the FDA for use in children over twelve years of age. In a one-year randomized placebo controlled trial in 539 obese adolescents, this drug was fond to significantly reduce BMI.. A third class or drugs is being used which target insulin resistance and high insulin levels which tend to be present in obsess children. This drugs works through the promotion of lipid storage. It is stated by Caprio that "...targeting insulin resistance may have a dual effect -preventing further weight gain and improving the associated metabolic complications." (2006) the drug Metformin, is used in the treatment of type 2 diabetes and has been approved fro adolescents. Two randomized trials testing metaformin have found small "but statistically significant effects on BMI and significant effects on fasting blood sugar, insulin and lipids." (Caprio, 2006) the role of healthcare providers is recommended by Caprio (2006) to be better focused on prevention of childhood obesity rather than on treatment alone. Required will be training of the labor force including physicians, managed care organizations and third-party payers in recognition of obesity as: "...a complex disorder that involves appetite regulation and energy metabolism and that carries with it risks of various diseases." (Caprio, 2006)

Discussion

As reviewed at the beginning of this work successful treatment prevention and intervention programs for childhood obesity requires inclusion of several program components as identified by the Expert Committee of the NIHCM Foundation Report. Those components have been shown to be the components of: (1) parental involvement and education; (2) frequent meetings; (3) sustained treatment duration; (4) a group format with individual behavior counseling; (5) a simple diet that produces a calorie deficit; (6) physical activity intervention that allows individual choice of activity with an emphasis on the reduction of sedentary behavior; (7) a home environment that simultaneously reduced cues for calorie intake while increasing cues for physical activity; (9) self-monitoring, setting of goals and contracts for behavior; and (10) Education regarding skills for maintenance of behavior and prevention of relapse. The National Institute for Health Care Management Foundation states that the advantages for prevention of obesity in children include the ability for maintenance of optimal metabolic physiology; application of prevention strategies at the population level; early counseling or behavior modification therapy for addressing the root causes of obesity including eating activities and activity levels in children and finally included are benefits of reduction and prevention in risk of disease.

Different types of interventions which this work has reviewed are individual; interpersonal; organizational; and societal. interventions. It has been noted in this work that components that are necessary for inclusion in successful program formats focused toward childhood obesity are education of the child and family in relation to nutritional factors, family involvement, activities and exercise, behavior modification. Successful programs are generally of a duration of several weeks or months. Surgical and Pharmacological treatments are also used although only in the most severe cases. Gastric bypass surgery has been shown to have a lasting effect for up to 14 years and by 2/3 of participants in the study. The problem with many of the prescription medications are in the adverse effects that these medications are known to cause however, use of these medications has been shown to be very effective in certain groups of obese individuals.

Conclusion

There is presently no one sure method of addressing the problem of childhood obesity however, this work has shown that medical assessment, education, individual behavioral therapy and family inclusive intervention and education programs are the types of programs effective in addressing the treatment and prevention of childhood obesity. In order for the physician to prescribe the optimal treatment and/or prevention program addressing childhood obesity the physician should conduct a full medical examination and assessment of the individual, should consider family history, genetics, and should have a full dietary history of the individual. It is important that practitioners and researchers focus toward the development of new and more effective medications for use in the treatment and prevention of childhood obesity.