A pilot evaluation 1 Title: A pilot evaluation of appetite-awareness training in the treatment of childhood overweight and obesity Running Head: A PILOT EVALUATION OF APPETITE-AWARENESS TRAINING

Objective: The aim of this study was to conduct a preliminary evaluation of Children‟s Appetite Awareness Training (CAAT), a treatment for childhood obesity which encourages overweight children to eat in response to internal appetite cues. Method: Overweight children (ages 6 – 12 years old) were randomized to either the CAAT treatment group (N=23), to receive one-hour treatment sessions over six weeks, or a wait-list group (N=24). Weight and height of children and parents in both groups were assessed at preand post-treatment (or equivalent time for wait-list control) and at a six-month follow-up for those in the CAAT group. Results: The intervention had a significant, short-term effect on the BMI of children who participated. Although at six-month follow-up, children‟s BMI has not increased significantly, the difference between pre-treatment and follow-up BMI was no longer significant. Discussion: These results are encouraging for the use of CAAT with overweight children. Long-term effectiveness could be enhanced through increasing the duration of the program, adding booster sessions and increased involvement of parents. A pilot evaluation 3 A pilot evaluation of appetite-awareness training in the treatment of childhood overweight and obesity: A preliminary investigation Childhood obesity is the most prevalent nutritional disease in developed countries (1) and has been designated a global epidemic (2, 3). In Australia, the prevalence of children who are either obese or overweight has increased over the last 25 years. Recent Australian studies have found that 5.9% of girls and 5.3% of boys are obese and a further 16-18% of girls and 14-16% of boys are overweight (4, 5). Childhood obesity usually continues into adulthood and has been associated with an increased risk of multi-systemic disease, including orthopaedic, gastrointestinal, immunological, metabolic, respiratory and sleeprelated problems (1, 6-10). Thus, there is a critical need to develop treatment and prevention strategies in childhood. Epstein (11) has commented that methods for improving the selfregulation of energy intake amongst children have been almost entirely neglected, despite evidence that overweight children are poorer at regulating their own food intake compared to normal-weight children (12, 13). Such emphasis is particularly imperative given broad, detrimental changes to the environment that promote food overconsumption (e.g. portion sizes, food advertising, pervasive environmental cues to eat, easy accessibility of foodstuffs low in nutrient density). Given that broad policy changes are unlikely to occur quickly enough to impact contemporary children, there is an imperative need to enhance their capacity to resist environmental cues to eat when not biologically hungry. Critically, Johnson (14) found that both children who over-ate and those who under-ate could be A pilot evaluation 4 taught to better regulate their eating from as young as eight years. However, it remains an unknown as to whether treatments based on self-regulation of appetite may be efficacious in the treatment of childhood overweight and obesity. One approach designed to enhance self-regulatory capacities in adults is „Appetite-Focused Cognitive Behavioural Therapy' (CBT-AF) (15). CBT-AF is based on the premise that individuals who are overweight and obese often eat in response to situational or external cues, rather than eating when they are hungry and stopping when they are full (16, 17) CBT-AF teaches participants skills to encourage eating in response to moderate internal hunger and satiety cues thus improving self-regulation of energy intake (15). CBT-AF has been found to reduce binge-eating and reduce weight gain in patients with Binge-Eating Disorder (8, 15, 18). A recent randomized controlled trial using an adapted form of the CBT-AF demonstrated some efficacy (19), but this was evaluated among an adult population. Boutelle et al. (20) compared children‟s appetite awareness training (CAAT), an adapted version of CBT-AF for children, to cue exposure treatment among overweight or obese children (8 to 12 years). Both treatments resulted in significant reductions in binge-eating, indicating that these treatments may have potential in the management of childhood overweight and obesity. However, no changes were found for caloric intake. The authors acknowledged that these data were preliminary and recommended further research into these novel treatments. The aim of this study was to investigate further the efficacy of the CAAT program, in the treatment of childhood overweight and obesity using a A pilot evaluation 5 randomised controlled trial. CAAT is designed to resensitise children to recognize and respond to their internal appetite signals cues (i.e. hunger and satiety) and thereby improve their self-regulation of energy intake. The impact of the intervention on parents‟ weight was also of interest; a recent review of the literature considering the role of parents in their children‟s food choices concluded that despite some innate food preference, the majority of children‟s food behaviours are learned (21). It was therefore hypothesized that children receiving CAAT would have improvements in BMI that were not observed in the children in the control. It was also expected that parental BMI would change more for those in the CAAT group than the control group. Methods Participants Participants were recruited through advertisements in newspapers, magazines and radio interviews. Overweight or obesity in children is defined by an age-related BMI above the percentile passing through BMI values of 25 kg/m2 or 30 kg/m2 at 18 years, respectively (22). Overweight or obese children, between 6 and 12 years were eligible for the study. Children enrolled in another weight control treatment or those with mental health problems (screened for by Psychologists) that warranted treatment were excluded. Ninety-one parents telephoned the clinic to inquire about the program and 45 attended an assessment. Children were stratified by age (6-9, 10-12) and then randomized to the CAAT treatment group or wait-list group. The A pilot evaluation 6 randomization sequence was generated by one of the authors (LS) using the Bernoulli function (0.05) while another author (TB) enrolled participants. At the assessment, each consecutive child was given a participant number linked to a random number that was concealed until after the assessment. Twenty-four children were allocated to the wait-list group and twenty-three to CAAT (See Figure 1). Data for all children in both groups were available for preand posttreatment (or equivalent time for wait-list). Of the children assigned to CAAT, some (n=5) did not attend all sessions or did not attend the six-month follow-up (n = 4). Those in the wait-list group were offered treatment during follow-up.