Lorrene D' Ritchie, PhD, RD1

1
What Dietitians Can Do about Pediatric
OverweightPosition of the ADA --Introduction,
Methods, and School-and Community-based
Interventions--
Pediatric Weight Management Teleconference
November 14 17, 2006

• Lorrene D. Ritchie, PhD, RD1
• Deanna M. Hoelscher, PhD, RD2
• Melinda S. Sothern, PhD3
• Patricia B. Crawford, DrPH, RD1
• 1 Center for Weight and Health, UC Berkeley
• 2 Michael Susan Dell Center for Advancement of
• Healthy Living, Univ of Texas School of PH
• 3 Louisiana State Univ Health Science Center

2
Outline

• Why this topic?
• What was done?
• What was found?
• Community-based interventions (1º prevention)
• School-based interventions (1º 2º prevention)
• Individual- and Family-based interventions
• (3º prevention)
• What was recommended?

3
Main Objective

• Describe recommended
• approaches for overweight
• prevention and treatment
• in children

• www.adaevidencelibrary.com
• J Am Diet Assoc. 2006106925-45
• Tables at www.eatright.org/ada/Appendices_A-B-C.pd
  f

4
Dietitians Integral to Intervention Efforts

• Leadership role in both prevention and treatment
  programs
• Rely on empirical evidence from research studies
  to inform best practices

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Childhood Overweight is Increasing at a
Staggering Pace
Percent
6
Dys- lipidemia
High blood pressure
Tracking of Overwt
Insulin resistance
Health Concerns
Psychosocial problems
Breathing difficulties
Advanced maturation
GI problems
Joint/bone stress
7
Obesity Related Annual Hospital Costs for Youth
(in millions of dollars)
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As overweight among children tripled
Do no harm
What to do first?
What works?
What has been tried?
How old should child be?
9
ADA Evidence Analysis

• Since 2000, evidence-based approach used to
  develop clinical practice guidelines for
  nutrition care
• This is first of new position papers developed
  using ADAs EA protocols
• Maintain an ADA Evidence Analysis Library website
  (http//www.adaevidencelibrary.com)
• Method overview paper in JADA coming soon
• Evidence-based practice guide on pediatric weight
  coming soon

10
Steps in Evidence Analysis

• Select the evidence analysis project team
• Formulate the problem as a question
• Search for and identify relevant evidence
• Analyze and evaluate evidence
• Formulate and evaluate the strength of summary
  and conclusion statements
• Develop recommendations

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Steps in Evidence Analysis

• Select the evidence analysis project team
• Formulate the problem as a question
• Search for and identify relevant evidence

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Selection Criteria for Studies

• Studies published 1982 2004
• Identified using Pubmed, other primary research
  articles, or literature reviews
• English language
• Involving children (2-12 y) /or teens (13-18 y)
• Healthy population
• Intervention studies only
• 1º, 2º, or 3º prevention
• Any design (RCT, non-randomized, non-controlled)
• Included outcome measure of adiposity

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Exclusion Criteria for Studies

• Conducted in developing country
• Published in journal/books not peer-reviewed
• No outcome measure of adiposity
• Involving exclusively children lt2 y or teens gt18
  y
• 3º prevention trials
• lt 8 wk duration (not including follow-up)
• lt 30 subjects total (or lt15 in intervention
  group)
• Involving surgery or medications
• 1º/2º prevention trials
• lt 6 mo duration (not including follow-up)
• lt 60 subjects total (or lt30 in intervention group)

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Steps in Evidence Analysis

• Select the evidence analysis project team
• Formulate the problem as a question
• Search for and identify relevant evidence
• Analyze and evaluate evidence

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Abstraction of Studies

• Study Design/Class
• Inclusion Criteria
• Exclusion Criteria
• Study Protocol
• Recruitment methods
• Blinding used
• Intervention
• Study protocol
• Statistical analysis
• Data Collection
• Variables
• Timing

• Study Population
• Sample size
• Demographics
• Location
• Results
• Author Conclusion
• Reviewer Comments
• Strengths
• Weaknesses
• Quality Rating

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Rating Study Quality

• Research question clear?
• Selection of subjects free from bias?
• Study groups comparable?
• Withdrawals?
• Blinding?
• Intervention described in detail?
• Outcomes clearly defined?
• Measurements valid and reliable?
• Statistical analysis appropriate?
• Conclusions supported by results?
• Funding or sponsorship?

MINUS NEUTRAL PLUS
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Categorization of Studies Unit of Intervention

• Community-based
• School-based
• Family-based
• Individual-based

44 - 1º/2º prevention trials
44 - 3º prevention trials
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Steps in Evidence Analysis

• Select the evidence analysis project team
• Formulate the problem as a question
• Search for and identify relevant evidence
• Analyze and evaluate the evidence
• Formulate and evaluate the strength
  of summary and conclusion statements

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Grading Conclusion Statements

• Grade I Good
• Evidence is consistent from studies of strong
  design
• Grade II Fair
• Evidence from studies of strong design is not
  always consistent or evidence is consistent but
  based on studies of weaker design
• Grade III Limited
• Evidence from a limited number of studies
• Grade IV Expert Opinion Only
• No or limited studies but based on expertise
• Grade V Not Assignable
• No studies

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Steps in Evidence Analysis

• Select the evidence analysis project team
• Formulate the problem as a question
• Search for and identify relevant evidence
• Analyze and evaluate the evidence
• Formulate and evaluate the strength of summary
  and conclusion statements
• Develop recommendations

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Community-Based InterventionsDefinition

• Goal of intervention
• Overweight prevention
• Include outcome adiposity measure
• Methods of behavior change
• Policy
• Social marketing
• Environmental change
• Targets of intervention
• Members of certain community groups (ad hoc or
  formal)
• Community members at large
• Excluding schools

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Community-Based InterventionsWhat was Found

• EXAMPLES
• Minnesota Heart Health Program (Kelder,
  19931995)
• Pawtucket Heart Health Program (Carleton, 1995)
• Salud para su Corazon project (Alcalay, 1999)
• Sandy Lake Health and Diabetes Project (Hanley,
  1995)
• Stanford Five-City Project (Farquhar, 1990)
• EXAMPLES
• CardioVision 2002 (Kottke, 2000)
• FitWIC (Crawford, 2004)
• Hearts N Parks (Moody, 2004)
• EXAMPLES
• Communities of color (Yancey, 2004)
• Physical activity (King, 1998)
• Nutrition and PA in youth (Pate, 2000)
• Food marketing to children (IOM, 2006)
• Social marketing campaigns (Alcalay, 2000)

• Many community-based interventions
• BUT not designed for overweight prevention and/or
  adiposity measures not included
• Adults only
• Youth included
• Reviews

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Community-Based InterventionsWhat was Found

• Community interventions are feasible
• Can alter eating and physical activity behaviors
• Only ONE included adiposity outcome in ADULTS
  Heart to Heart Project (Goodman, 1995)
• 1986-1990
• Aim to reduce CVD risk
• 600 community activities
• Change in overweight 0.3 in intervention vs.
  3.2 in control community (P0.0002)
• Several other interventions underway, but results
  not yet available

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Community-Based InterventionsRecommendation

• Research priority community-based programs,
  including studies of built environment, marketing
  and policy on childrens eating and physical
  activity patterns
• Intervention although not yet evidence-based,
  community-based interventions recommended as
  among the most feasible ways to support healthful
  lifestyles for greatest numbers

(Evidence Grade IV)
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Overview of School-based Studies

• 44 total papers identified
• 37 were primary prevention
• 23 were RCT
• 14 were studies of other design
• 7 were secondary prevention
• Targeted high-risk students through the school
  setting
• 1 was RCT
• Several articles described the same study so
  were combined for the evidence analysis (final n
  28 studies)
• CATCH, SPARK, Know Your Body New York,
  Washington, Crete, Zuni Diabetes Prevention
  Program

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Primary Prevention Studies

• Multi-component programs
• Evidence Grade II (Fair)
• Include multiple coordinated units, with both
  nutrition and physical activity
• Examples of studies with positive effects
• Vandogen, 1995
• Sallis, 2003 (M-SPAN)
• Gortmaker, 1999 (Planet Health)
• Killen, 1989
• Muller, 2001 (KOPS)
• Manios, 1999 (Know Your Body in Crete)

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Primary Prevention Studies

• Behavioral Counseling
• Evidence Grade II (Fair)
• Use of theory to change individual health
  behaviors
• Social Cognitive Theory was most widely used, as
  it incorporates individual and environmental
  level constructs
• Often see changes in behavioral constructs prior
  to actual behavioral change

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Primary Prevention Studies

• Nutrition Education
• Evidence Grade II (Fair)
• In most studies, nutrition ed.and dose were not
  described
• Most were combined with
• multi-component programs
• Physical Activity Education
• Evidence Grade II (Fair)
• Included in most multi-component programs
• One study showed a total of 1 ¼ hours of
  physical activity/school day compared with 3
  ½-hour periods/week
• Optimal level of PA not known

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Primary Prevention Studies

• Physical Activity Environment
• Evidence Grade II (Fair)
• Includes increasing PA opportunities
• or restructuring PE classes
• Most linked with PA education programs
• Sedentary Behaviors
• Evidence Grade II (Fair)
• Targeted TV and video watching
• Strong studies, but few
• Evidence Grade V (Lack Evidence)
• No studies on sedentary activities such as
  homework, reading or computer use

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Primary Prevention Studies

• Parent/family involvement
• Evidence Grade II (Fair)
• Generally not well described
• Dose was difficult to determine
• Delivery of program Grade level
• Evidence Grade II (Fair)
• Although successful programs were seen at both
  elementary and secondary levels, a greater
  percentage of secondary school prevention studies
  (71) found effects compared to elementary level
  studies (33)
• No preschool-age trials

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Primary Prevention Studies

• Media influences
• Evidence Grade III (Limited)
• TV or video watching time was targeted, but not
  other forms of influence
• (e.g., commercials, ads, etc.)
• School food environment
• Evidence Grade III (Limited)
• Usually linked with nutrition education
• Most studies have looked at nutrient intake
  rather than body size as an outcome

32
Primary Prevention Studies

• Delivery of program Individual versus multi
  component
• Evidence Grade III (Limited)
• Virtually none of the studies were conducted in
  way that effectiveness of individual components
  could be compared
• Coordinated multi-component programs are
  effective, but which components are most
  effective is not known

33
Primary Prevention Studies

• Delivery of program Personnel
• Evidence Grade V (Lack Evidence)
• No comparison of teacher-delivery
• versus study personnel delivery
• Delivery of program Length of time
• Evidence Grade V (Lack Evidence)
• No study that examined optimum length of
  timevaried from few months to years

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Key results

• Multicomponent school-based primary prevention
  programs are effective, particularly for
  adolescents

35
Added bonus

• School-based interventions are effective in
  changing student knowledge, attitudes, and
  behaviors around food and activity.

36
Recommended Components of School- Based
Interventions
Nutrition Education
Family Environment
PA Education/ Environment
Primary Prevention
Sedentary Behaviors (TV/video)
Behavioral Counseling
Adiposity Outcomes
37
Summary and Recommendations for School-Based
Programs Primary Prevention

• Of the large number of school-based studies
• About half are strong design
• About half showed positive effects on body size
• Fewer secondary school studies
• May be more difficult to conduct
• More likely to show effects
• Why so many non-significant studies?
• Relatively low prevalence of overweight at time
  study was conducted (prior to mid-1990s)
• Inadequate dose or length of intervention
• Lack of standardized definition of child
  overweight

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Summary and Recommendations for School-Based
Programs Primary Prevention

• Future studies
• Optimal dose and duration of intervention
• Most effective mode of delivery
• How program elements can be tailored to meet
  needs of various age, cultural and SES groups
• Replication of successful programs in other
  high-need groups

39
Secondary Prevention Studies

• All but one of seven studies saw a significant
  effect on some measure of adiposity
• Evidence grade III (Limited Evidence)
• Only one was a RCT
• One targeted junior high two additional studies
  targeted children of multiple ages
• 4 were conducted outside the U.S., one was a
  parochial school, and 2 were U.S. public schools
• Did not address effects of stigmatizing children
  in these studies

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Summary and Recommendations for School-Based
Programs Secondary Prevention

• As effective or more effective than primary
  prevention studies
• Contraindications for implementation
• Increasing rates of overweight
• Stigmatization of children
• Recommended approach
• Secondary prevention within a primary prevention
  program for all children
• Conduct population-level program, but base
  outcome on high-risk population.

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Conclusions Critical to Prevention
Interventions

• Early often
• Long-term
• Family involved
• Specific behaviors targeted
• Comprehensive multi-component
• Community-wide
• Environmental emphasis

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Contact Information

• Lorrene Davis Ritchie
• Director of Research
• Center for Weight and Health
• 9 Morgan Hall
• University of California
• Berkeley, CA 94720
• Lorrene_Ritchie_at_sbcglobal.net
• www.cnr.berkeley.edu/cwh