jump to first page what dietitians can do about pediatric overweight position of the ada...
TRANSCRIPT
Jump to first page
What Dietitians Can Do about Pediatric OverweightWhat Dietitians Can Do about Pediatric Overweight
Position of the ADAPosition of the ADA ----Introduction, Methods, and School-Introduction, Methods, and School-and Community-based Interventions--and Community-based Interventions--
Pediatric Weight Management TeleconferencePediatric Weight Management Teleconference November 14 & 17, 2006November 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 Berkeley2 Michael & Susan Dell Center for Advancement of
Healthy Living, Univ of Texas School of PH3 Louisiana State Univ Health Science Center
Jump to first page
OutlineOutline 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?
Jump to first page
Main Objective:Main Objective:
Describe recommended
approaches for overweight
prevention and treatment
in children
www.adaevidencelibrary.comJ Am Diet Assoc. 2006;106:925-45Tables at www.eatright.org/ada/Appendices_A-B-C.pdf
Jump to first page
Dietitians Integral Dietitians Integral to Intervention Effortsto Intervention Efforts
Leadership role in both prevention and treatment programs
Rely on empirical evidence from research studies to inform best practices
Jump to first page
Childhood Overweight is Increasing at a Staggering Pace
0
5
10
15
20
2-5 Years 6-11 Years 12-19 Years
1963-70
1971-74
1976-80
1988-94
1999-2002Perc
ent
Jump to first page
Health Health ConcernsConcerns
High blood pressure
Dys-lipidemia
Insulinresistance
Breathingdifficulties
Advancedmaturation
GI problems
Psychosocialproblems
Tracking ofOverwt
Joint/bone stress
Jump to first page
Obesity Related Annual Hospital Costs for Youth
(in millions of dollars)
$0
$20
$40
$60
$80
$100
$120
$140
1979-81 1997-99
Jump to first page
As overweight among children tripled…As overweight among children tripled…
“Do no harm”
What works?What to do first?
What has been tried?
How old should child be?
Jump to first page
ADA Evidence AnalysisADA 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 ADA’s 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
Jump to first page
Steps in Evidence AnalysisSteps in Evidence Analysis
1) Select the evidence analysis project teamproject team
2) Formulate the problem as a questionquestion
3) Search for and identify relevant evidenceidentify relevant evidence
4) Analyze and evaluate evidenceevaluate evidence
5) Formulate and evaluate the strength of summary and conclusion statementssummary and conclusion statements
6) Develop recommendationsrecommendations
Jump to first page
Steps in Evidence AnalysisSteps in Evidence Analysis1) Select the evidence analysis project team
2) Formulate the problem as a question
3)3) Search for and identify relevant Search for and identify relevant evidenceevidence
Jump to first page
Selection Criteria for StudiesSelection 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
Jump to first page
Exclusion Criteria for StudiesExclusion Criteria for Studies Conducted in developing country Published in journal/books not peer-reviewed No outcome measure of adiposity Involving exclusively children <2 y or teens >18 y 3º prevention trials:
< 8 wk duration (not including follow-up) < 30 subjects total (or <15 in intervention group) Involving surgery or medications
1º/2º prevention trials: < 6 mo duration (not including follow-up) < 60 subjects total (or <30 in intervention group)
Jump to first page
Steps in Evidence AnalysisSteps in Evidence Analysis
1) Select the evidence analysis project team
2) Formulate the problem as a question
3) Search for and identify relevant evidence
4)4) Analyze and evaluate evidenceAnalyze and evaluate evidence
Jump to first page
Abstraction of StudiesAbstraction 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
Jump to first page
Rating Study QualityRating 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?
Jump to first page
Categorization of Studies Categorization of Studies Unit of InterventionUnit of Intervention
Community-based
School-based
Family-based
Individual-based
44 - 144 - 1º/2º º/2º prevention trialsprevention trials
44 - 344 - 3ºº prevention trialsprevention trials
Jump to first page
Steps in Evidence AnalysisSteps in Evidence Analysis
1) Select the evidence analysis project team
2) Formulate the problem as a question
3) Search for and identify relevant evidence
4) Analyze and evaluate the evidence
5)5) Formulate and evaluate the Formulate and evaluate the strength of summary and strength of summary and conclusionconclusion statementsstatements
Jump to first page
Grading Conclusion StatementsGrading Conclusion StatementsGrade I: GoodEvidence is consistent from studies of strong design
Grade II: FairEvidence 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 OnlyNo or limited studies but based on expertise
Grade V: Not AssignableNo studies
Jump to first page
Steps in Evidence AnalysisSteps in Evidence Analysis
1) Select the evidence analysis project team
2) Formulate the problem as a question
3) Search for and identify relevant evidence
4) Analyze and evaluate the evidence
5) Formulate and evaluate the strength of summary and conclusion statements
6)6) Develop recommendationsDevelop recommendations
Intervention
Type or Component
Recommendation
Jump to first page
Community-Based Interventions:Community-Based Interventions:DefinitionDefinition
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
Jump to first page
Community-Based Interventions:Community-Based Interventions:What was FoundWhat was Found
Many community-based interventions
BUT not designed for overweight prevention and/or adiposity measures not included
Adults only
Youth included
Reviews
EXAMPLES:Minnesota Heart Health Program (Kelder, 1993;1995)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)
Jump to first page
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 (P=0.0002) Several other interventions underway, but results
not yet available
Community-Based Interventions:Community-Based Interventions:What was FoundWhat was Found
Jump to first page
Research priority: community-based programs, including studies of built environment, marketing and policy on children’s 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
Community-Based Interventions:Community-Based Interventions:RecommendationRecommendation
(Evidence Grade IV)
Jump to first page
Overview of School-based StudiesOverview 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
Jump to first page
Primary Prevention StudiesPrimary 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)
Jump to first page
Primary Prevention StudiesPrimary 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
Jump to first page
Primary Prevention StudiesPrimary Prevention StudiesNutrition 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
Jump to first page
Primary Prevention StudiesPrimary Prevention StudiesPhysical 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
Jump to first page
Primary Prevention StudiesPrimary Prevention StudiesParent/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
Jump to first page
Primary Prevention StudiesPrimary Prevention StudiesMedia 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
Jump to first page
Primary Prevention StudiesDelivery 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
Jump to first page
Primary Prevention StudiesPrimary 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 time—varied from few months to years
Jump to first page
Multicomponent school-based primary prevention programs are effective, particularly for adolescents
Key results
Jump to first page
Added bonus: School-based interventions are effective in
changing student knowledge, attitudes, and behaviors around food and activity.
Jump to first page
Recommended Components of School- Recommended Components of School- Based InterventionsBased Interventions
Family Environment
SedentaryBehaviors (TV/video)
PA Education/Environment
Behavioral Counseling
PrimaryPrevention
Adiposity Outcomes
Nutrition Education
c enter fo reight &
ealthh University of California, Berkeley
Jump to first page
Summary and Recommendations for Summary and Recommendations for School-Based Programs – School-Based Programs –
Primary PreventionPrimary PreventionOf 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-1990’s) Inadequate dose or length of intervention Lack of standardized definition of child overweight
Jump to first page
Summary and Recommendations for Summary and Recommendations for School-Based Programs – School-Based Programs –
Primary PreventionPrimary 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
Jump to first page
Secondary Prevention StudiesSecondary 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
Jump to first page
Summary and Recommendations for Summary and Recommendations for School-Based Programs – School-Based Programs –
Secondary PreventionSecondary 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.
Jump to first page
Conclusions: Conclusions: Critical to Prevention InterventionsCritical to Prevention Interventions
Early & often Long-term Family involved Specific behaviors targeted Comprehensive & multi-component Community-wide Environmental emphasis
Jump to first page
Contact InformationContact InformationLorrene Davis Ritchie
Director of Research
Center for Weight and Health
9 Morgan Hall
University of California
Berkeley, CA 94720
www.cnr.berkeley.edu/cwh