# Presentation: 415122

## Conservative Interventions for Treatment of Overweight and Obesity in Children

**Deanna M. Hoelscher, PhD, RD, LD, CNS**
**University of Texas Houston Health Science Center**
**School of Public Health**
**Human Nutrition Center/Center for Health Promotion &**
**Prevention Research**
**November 16, 2005**

## Outline of Talk

- Definitions & prevalence of child overweight
- Why use conservative approaches?
- Different methods
- Diet
- Protein Sparing Modified Fasts (PSMF)
- Physical activity
- Behavioral treatments
- Use of pharmacologic agents
- Conclusions/Recommendations

## Overview of Child Overweight and Interventions

- Overweight is defined as _>_ 95th percentile based on CDC BMI chart
- At risk of Overweight is defined as _>_ 85th but  < 95th percentile based on BMI charts
- The prevalence of overweight among children varies by gender and race/ethnicity
- The prevalence of overweight is not a normal distribution, with skew to heavier weights
- Primary aim of overweight interventions is energy balance (energy intake versus energy expenditure)
- Very little data on preschool children
- Practice is not evidence-based (not enough data)

## How Do Children Differ From Adults with Regard to Weight Loss?

- Reliance on parents as gatekeepers for food and physical activity
- Consideration of growth and development from a biological standpoint
- Cognitive/emotional development
- Degree of overweight
- School environment
- Concern for eating disorders
- Critical periods of adiposity increase (adiposity rebound, puberty)

**Source:  Kirk et al., 2005**

## Rationale for Conservative Approaches to Child Overweight

- _Traditional view_:
- Overweight in children is benign or cosmetic
- Children will “grow out” of overweight
- Treatment paradigm:
- Keep weight stable and let “grow into weight”
- Weight loss, if any, should be modest so as to not affect growth and development
- Use diet primarily, together with physical activity and behavioral counseling

## Weight Gain for Children at the 75th Percentile from Age 6.5 to 18.5

**Source:  CDC weight charts, Butte & Ellis, 2003 OW = overweight, N = normal wt**

**OW/OW**

**N/OW**

**N/N**

## Rationale for Conservative Approaches to Child Overweight

- _Current view_:
- Overweight in children is associated with both morbidity & mortality
- Obesity in childhood leads to increased risk for severe obesity in adulthood
- Child BMI tracks over time
- With children at extreme weights (e.g., BMI >35), “growing into weight” is not an option
- Treatment paradigms need to change

**Source:  Dietz, 2004; Kirk et al., 2005; Baker et al., 2005; Kelder et al., 1994**

## How Growth and Weight Relate in Children over Time

| If a boy is age... | and weighs an excess of ...... lbs over his tracking percentile (75th), he cannot “grow into his weight” |
| --- | --- |
| 6.5 | 115.1 lbs |
| 10.5 | 83 lbs |
| 12.5 | 59.3 lbs |
| 14.5 | 33.4 lbs |
| 16.5 | 12.3 lbs |

- Source:  CDC weight charts

## Determination of Energy Intake in Children

- To lose weight, need to determine how much change in energy intake
- Difficult to determine energy intake in growing children
- Estimates from Butte & Ellis, Science, 2003:
- Deficit of about 300 kcal/day to prevent further weight gain in overweight children (range:  204-263 kcal/d)
- Equates to 2, 12-oz sweetened beverages
- Equates to walking about 60-120 minutes/day

- Source:  Butte & Ellis, 2003

## Conservative Interventions:  Overview of Behavior Modification, Diet and Physical Activity Programs

- Many diet and physical activity programs have behavior modification component
- Most programs have all three components:  behavior modification, diet and physical activity
- Studies to date have mostly been conducted in clinic settings

## Conservative Interventions:  Diets in Children

- _Definition:_  Regulation of food intake either through change in macronutrient composition (e.g., fat, CHO content) or reduction in energy intake
- _Duration of treatment (in trials with adolescents):_  several weeks to 3 years
- _Maintenance of effects:_  Limited data
- _Compliance:_  Varies
- _Side effects:_  With Protein-Sparing Modified Fast (PSMF), protein losses, hypokalemia, hypoglycemia, inadequate calcium intake and orthostatic hypotension

- Source:  Baker et al., 2005; Kirk et al., 2005

## Conservative Interventions:  Diets in Children

- _Weight loss achieved:_  1-2 kg (2.2-4.4 pounds)/week, up to 1 kg/week with diet alone
- _Pros:_  Safe for more moderate diets
- _Cons:_  Usually involves a parent, costly, long-term, limited data on effectiveness, side effects for PSMF
- Diets with altered macronutrient content (e.g., low glycemic load diets, low carbohydrate diets) have only been evaluated in small trials for limited periods of time.

- Source:  Baker et al., 2005; Kirk et al., 2005

## Example - Stop Light/Traffic Light Diet

- Uses traffic light colors to characterize foods:
- Green:  low-calorie, high fiber foods, no restrictions
- Yellow:  essential foods, but because of higher nutrient density, eaten in moderation
- Red:  high in fat and/or simple sugars, limit to _<_ 4 servings/d
- Energy goals:  900-1300 kcal/d
- Record all food and drinks
- Adapted in various forms
- Follows U.S. Dietary Guidelines where appropriate

**Source:  Epstein & Squires, 1988**

## Promising Direction?  Reduced Carbohydrate/Glycemic Load Diets

- Ebbeling et al., 2003
- RCT, 6 month intervention and 6 month follow-up, n = 16 obese adolescents, aged 13-21
- Emphasized selection of foods with low to moderate GI, 30-35% energy from fat versus low-fat, 25 to 30% energy from fat
- Difference of 2 kg/m2
- Spieth et al., 2000
- Retrospective cohort, n = 107 obese children, mean age about 10, mean length of time = 4 months
- Low-GI diet versus standard reduced fat diet
- Difference of 1.12 kg/m2 and 2.6 kg
- Summary:  relatively small studies, eliminate sugared beverages, sweets

## Protein-Sparing Modified Fast (PSMF)

- PSMF:  around 1/5 g pro/kg IBW
- For children, usually need a hospital stay, vitamins/minerals, K, calcium
- Involves consistent monitoring of ketones
- Gradual re-introduction of carbohydrates
- Limited period of time (usually 3 months or less)
- In one study with 8 adolescents (age 11-18), mean weight loss of 13.5 kg over 5 weeks
- Published trials with children – few subjects, no RCTs

- Source:  Brown et al., 1983; Merritt et al., 1981; Stallings et al., 1988

## Conservative Interventions:  Physical Activity/Sedentary Activity Interventions in Children

- _Definition:_ Programs designed to promote adolescent weight loss by increasing activity or decreasing sedentary behavior
- _Duration of treatment (in trials with adolescents):_  3 months to 54 weeks  (30-60 minutes/day for 3-7 days/week)
- _Maintenance of effects:_  No data
- _Compliance:_ Varies

- Source:  Gutin et al., 2002; Owens et al., 1999; Epstein et al., 1995

## Conservative Interventions:  Physical Activity/Sedentary Activity Interventions in Children

- _Weight loss achieved:_  Difficult to quantify
- _Pros:_  Easier to maintain than diet over time, builds on usual child activities
- _Cons:_  Safety issues, time and money if parent is involved, sedentary activities are self-reinforcing

- Source:  Gutin et al., 2002; Owens et al., 1999; Epstein et al., 1995

## Examples of Physical Activity and/or Sedentary Activity Interventions

- Owens et al., 1999
- 74 obese children (by TSF), 7-11 years old
- 4 months training, 5 days/week, 40 min/day
- Significant decrease in visceral adipose tissue (VAT) & total body fat mass (BMI not reported)
- Gutin et al., 2002
- 80 obese (TSF), 13-16 years old
- 8 month intervention, 5 days/week, 30 min/day
- Significant decrease in VAT & % body fat
- No differences between moderate and high intensity exercise

## Conservative Interventions:  Use of Behavior Modification in Children

- _Definition:_  Use of behavior modification strategies & counseling techniques (e.g., goal setting, stimulus control, etc.) in modifying dietary habits, physical activity patterns, addressing underlying psychological issues related to food and physical activity
- _Duration of treatment (in trials with adolescents):_ 1 session to 3 years (most are 4-6 months to 1 year)
- _Maintenance of effects:_  Follow up studies (1-10 years) show some maintenance effects
- _Compliance:_ Varies

**Source:  Coates & Thoresen, 1978; Baker et al., 2005; Kirk et al., 2005**

## Conservative Interventions:  Use of Behavior Modification in Children

- _Side effects:_  Few
- _Weight loss achieved:_  4-15 pounds
- _Pros:_  Safe
- _Cons:_  Costly, long-term, personnel intensive, results are not consistent, involve considerable family involvement

**Source:  Coates & Thoresen, 1978; Baker et al., 2005; Kirk et al., 2005**

## Examples of Successful Behavioral Interventions

- Epstein work (Epstein et al.,1994, 1998, 1995)
- 4 RCTs, n = 154 OW children, ages 6-12, 6 month treatment
- Involvement of parents (family counseling)
- Intensive family counseling not otherwise described
- Long-term effects
- 30% no longer overweight after 10 years
- (5 years and 10 years)
- Cons:  specialized population (mostly white), omitted population with “psychological problems”

## School-Based Overweight Tertiary Prevention Interventions

| Author | Study Population | Intervention Type | Duration | Results |
| --- | --- | --- | --- | --- |
| Lansky, 1983 (RCT) | 114 OW junior high | D, PA, B (45-min group/wk with PE teacher) | 12 weeks | ↓ wt & % OW |
| Brownell, 1982 | 77 OW 
5-12 y | D, PA, B (behavior mod with nutr., PE, meals) | 10 weeks | ↓ % OW & ↑ wt loss |
| Foster, 1985 | 84 OW  
2-5th grade | D, PA, B (3 sessions/wk with 8th gr peer counselors) | 12 weeks | ↓ wt, ↓ % OW  |
| Chang, 1998 | 270 OW
9-12 y | D (Nutrition ed sessions, daily records) | 13 weeks | ↓ RI |
| Sasaki, 1987 | 60 OW
11 y | PA (special exercise class 20 m 7x/week) | 2 yr | ↓ % obesity index |

## Promising Direction?  Weight Loss Camps

- Kirschenbaum DS, Craig R.
- Wellspring camps (North Carolina, California, New York), ages 10-23
- _[www.wellspringcamps.com](http://www.wellspringcamps.com/)_
- Camps include diet, physical activity, behavioral therapy 4 x/week, family program, After-Care program online
- Preliminary results- NAASO abstracts, 2005
- Mean weight loss = 1.78 kg/week
- Weight loss continued during 6 month follow-up

- Source:  Kirschenbaum et al., Obesity Res, 2005;13

## Conservative Interventions:  Use of Weight Loss Drugs in Children

- _Definition_:  Use of pharmacotherapy to lose excess body weight
- _Duration of treatment (in trials with adolescents):_  3 months to 54 weeks
- _Maintenance of effects_:  No data
- _Compliance_:  For Orlistat, over 54 weeks, 65% remained in study
- _Side effects_:  Range from HTN to loose stools to risk of fat-soluble vitamin deficiency

- Source:  Molnar, 2005; Chanoine et al., 2005; Berkowitz et al., 2003

## Conservative Interventions:  Use of Weight Loss Drugs in Children

- _Weight loss achieved_: mean difference of 2.61 kg weight change between placebo & control for orlistat (1-2 lbs/wk)
- _Pros:_  Consistent weight loss, little parental involvement, little behavioral change necessary
- _Cons:_  Long term safety has not been evaluated, side effects
- Other drugs proposed, including metformin
- Most pharmacologic regimes work best in combination with behavioral diet and physical activity changes

- Source:  Molnar, 2005; Chanoine et al., 2005; Berkowitz et al., 2003;
- Freemark & Bursey, 2001

## Drugs Currently Approved for Treatment of Obesity in Adults & Children in the U.S.

| Generic name | Mechanism | Side effects |
| --- | --- | --- |
| Phendimetrazine | Noradrenergic | Palpitations, tachycardia, insomnia, HTN, dry mouth, constipation |
| Benzphetamine | Noradrenergic | Same |
| Diethylpropion | Noradrenergic | Same |
| Phentermine | Noradrenergic | Same |
| Sibutramine | Noradrenergic & seotoninergic | HTN, tachycardia, headache, insomnia, dry mouth, constipation |
| Orlistat* | GI lipase inhibitor | Loose stools, increased defecation, oily discharge, fecal urgency, def. of fat-soluble vitamins |

- Source:  Molnar, 2005

- * Approved for use in children in 2003

## Drug Studies in Adolescents

- _Orlistat_
- Chanoine et al., JAMA 2005:293:2873-2883
- Multicenter, 54-week RCT, double blind, n = 539 obese adolescents, BMI _>_ 2 units above 95th percentile, 12-16 years old
- 120- mg dose of orlistat, plus mildly hypocaloric diet (30% kcal from fat), exercise, behavioral therapy
- Results:
- Difference in  0.86 BMI units (2.61 kg)
- 35% attrition

## Drug Studies in Adolescents

- _Sibutramine_
- Berkowitz et al., JAMA 2003;289:1805-1812
- RCT, double-blind (n = 82, 13-17 year olds, BMI = 32-44), 6 months, then open label for additional 6 months
- Family-based behavioral program with sibutramine versus behavioral treatment
- Difference of 4.6 kg between groups

## Conclusions

- There are limited data on obesity treatment and/or prevention studies conducted using preschool children.
- Pharmacologic treatment has been evaluated on adolescents only (ages 12 and older).
- Behavior modification programs that target diet and physical activity have been evaluated and are effective in children younger than 12, but need family involvement.
- Increases in physical activity and decreases in sedentary activity are promising intervention strategies.

## Conclusions

- Children with extreme BMI/weight or have associated morbidity associated with overweight may need to engage in more aggressive interventions than those presented here.
- Currently, conservative interventions are not complemented by a supportive environment for food availability and physical activity in most schools and communities.

## Acknowledgements

- Steve Kelder, MPH, PhD
- Denny Bier, MD, PhD
- William Klish, MD
- Kristi King, MPH, RD
- Tom Baranowski, PhD
- Children’s Nutrition Research Center, Baylor College of Medicine, Houston, TX

**   **

## Contact Information

- Deanna M. Hoelscher, PhD, RD, LDAssociate ProfessorUniversity of Texas-Houston School of Public Health1200 Herman Pressler, RAS W942Houston, TX  77030713.500.9335713.500.9329 (fax)_[Deanna.M.Hoelscher@uth.tmc.edu](mailto:Deanna.M.Hoelscher@uth.tmc.edu)_
- Website for SPAN survey:  _[http://www.sph.uth.tmc.edu/hnc/SPANproject/SPAN%20Home.htm](http://www.sph.uth.tmc.edu/hnc/SPANproject/SPAN%20Home.htm)_

## References

- Chanoine et al.  Effect of orlistat on weight and body composition in obese adolescents.  JAMA 2005;293:2873-2883.
- Berkowitz et al., Behavior therapy and sibutramine for the treatment of adolescent obesity.  JAMA 2003;289:1805-1812.
- Freemark M & Bursey D.  The effects of metformin on body mass index and glucose tolerance in obese adolescents with fasting hyperinsulinemia and a family history of type 2 diabetes.  Pediatrics 2001;107:55.

## References

- Ebbeling et al.  A reduced-glycemic load diet in the treatment of adolescent obesity.  Arch Pediatr Adolesc Med 2003;157:773-779.
- Spieth et al.  A low-glycemic index diet in the treatment of pediatric obesity.  Arch Pediatr Adolesc Med 2000;154:947-951.
- Gutin et al., Effects of exercise intensity on cardiovascular fitness, total body composition, and visceral adiposity of obese adolescents.  Am J Clin Nutr  2002;75:818-826.

## References

- Owens et al.  Effect of physical training on total and visceral fat in obese children.  Med Sci Sports Exercise 1999;31:143-148.
- Kirk et al., Pediatric obesity epidemic:  treatment options.  J Am Diet Assoc.  2005;105:S44-S51.
- Baker et al., Overweight children and adolescents:  A clinical report of the North American Society for Pediatric Gastroenterology, Hepatology and Nutrition.  JPGN  2005;40:533-543.
- Coates TJ & Thoresen CE.  Treating obesity in children and adolescents:  A review.  Am J Public Health 1978:68:143-151.

## References

- Brown et al., A high protein, low calorie liquid diet in the treatment of very obese adolescents:  long-term effect on lean body mass.  Am J Clin Nutr 1983;38:20-31.
- Stallings et al., One-year follow-up of weight, total body potassium, and total body nitrogen in obese adolescents treated wth the protein-sparing modified fast.  Am J Clin Nutr. 1988;48:91-94.
- Merritt et al.  Consequences of modified fasting in obese pediatric and adolescent patients:  effect of a carbohydrate-free diet on serum proteins.  Am J Clin Nutr.  1981;34:2752-2755.

## References

- Butte N & Ellis K.  Comment on “Obesity and the environment:  Where do we go from here?”   Science.  2003;301:598b.
- Epstein et al.  Ten-year follow-up of behavioral family-based treatment for obese children.  JAMA 1990;264:2519-2523.
- Epstein et al.   Ten-year outcomes of behavioral family-based treatment for childhood obesity.  Health Psychol. 1994;13:373-383.
- Epstein et al., Treatment of pediatric obesity.  Pediatrics.  1998;101:554-570.

## References

- Epstein et al., Do children lose and maintain weight easier than adults:  A comparison of child and parent weight changes from six months to 10 years.  Obesity Res.  1995;3:411-417.
- Epstein LH & Squires S.  The Stoplight Diet for Children.  Toronto, CA:  Little, Brown & Company, 1988.
- Dietz WH.  Overweight in childhood and adolescence. NEJM 2004;350:855-857

## References

- Molnar D.  New drug policy in childhood obesity.  Int J Obes 2005;29:S62-S65.
- Kirschenbaum et al.  The first significant weight losses during a follow-up period in an evaluation of weight loss camps for young people:  Highly consistent self-monitoring at Wellspring Camps predicts even better long term results.  Obes Res. 2005;13:A205.