treating children and adolescents with overweight and ... · overweight or obesity in pre -school...

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Treating children and adolescents with overweight and obesity:

WHAT WORKS…

Dr Louisa J Ells: [email protected] Reader in Public Health & Obesity, Teesside University

Specialist Advisor to the Public Health England

mailto:[email protected]

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The problem • Child & adolescent overweight and obesity presents a global public health crisis. • In 2016: 41 million under 5’s overweight:

• 2025 estimates: 70 million under 5yr and 268 million 5-17yrs

IF LEFT UNTREATED!!

low-income

lower-middle-income

upper-middle-income

high-income

Most recent rapid increases in low- and lower-middle-income countries

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The problem • In the WHO European region:

I in 3 11 year olds: overweight or obese • Inequalities exist: variation by SES, geography & ethnic group, disabilities, sex, age

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WEIGHT STATUS IN RECEPTION PREDICTED WEIGHT STATUS IN YEAR 6 UNDERWEIGHT:

HEALTHY WEIGHT:

OVERWEIGHT:

OBESE:

SEVERELY OBESE:

Underweight; Healthy weight, Overweight, Obese, Severely Obese (% rounded to nearest 10%)

Weight tracking between 4-5 and 10-11 years Makes the case for prevention, early intervention and treatment for Primary school age children

PREVENTION EARLY 0-5 TREATMENT 6-11 TREATMENT

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SURGERY: Energy restriction, malabsorption & hormone regulation. Most common procedures for adolescents: Laparoscopic gastric bypass & adjustable gastric band, sleeve gastrectomy becoming more popular

DRUGS: Orlistat – oral lipase inhibitor (reduces fat absorption) Others withdrawn (most countries) or used off licence: Metformin, Sibutramine, Fluoxetine

LIFESTYLE MODIFICATION: Improve dietary quality, increase activity levels and reduce sedentary behaviours.

Treatment options:

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Diet Physical activity Behaviour-change

• Structure (meal and snacks time)

• Healthy eating plate • Fruit and vegetable

consumption • Fiber-rich starchy

carbohydrate consumption • Zero/low sugar beverages • Portions size control • Reducing eating speed • Help when eating out • Emotional eating • Food promotion • Availability of unhealthy food

at home • Food labelling • Cooking classes

• Leisure-time physical activities (i.e. games, sports) with friends and family

• Active transports (i.e. walking, biking, stairs)

• School physical education • Individually adapted exercise

programmes (cardio-respiratory fitness, muscle strength, coordination, speed, balance)

• Screen time reductions (TV, electronic games, computer, tablet, smartphone)

• Sitting time reductions (school, home)

• Activities during holiday

• Provide instruction (e.g. parental guidance / family therapy sessions)

• Goal setting • Feedback support • Self monitoring • Problem solving • Role modelling • Social and emotional support

(e.g. addressing Stigmatization and teasing, self esteem, body image)

Example intervention components

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Does treatment work? Cochrane Evidence

• Oude Luttikhuis (2009) provided the last review on the treatment of childhood obesity: identifying 64 trials (10 drug trials, 54 lifestyle trials in school age children)

• Given the size of the current evidence base a comprehensive update was conducted across 6 reviews: – Surgery (Ells, 2015); – Drugs (Mead, 2016); – lifestyle (diet, physical activity and behaviour change):

• Child/family programmes in preschool (0 up to 6yrs) (Colquitt, 2016); • Child/family programmes in primary school (6-11yrs) (Mead, 2017); • Child/family programmes in adolescent (12-17yrs) (Al-khudairy; 2017) • Parent only programmes in children 5-11yrs (Loveaman, 2015)

All available: http://www.cochranelibrary.com/

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Review PICOs: surgery drug Parent only Lifestyle:

0-6 Lifestyle 6-11

Lifestyle 12-18

Participants Obese children <18yrs

Obese children <18yrs

Overweight or obese children 5-11yrs

Overweight or obese children 0 up to 6yrs



Intervention Surgery Drug Parent only diet, pa & behaviour change

diet, pa & behaviour change: preschool age

diet, pa & behaviour change: primary school age

diet, pa & behaviour change: adolescents

Comparator No treatment, usual care**, concomitant intervention conducted in both treatment and intervention arms

Outcome Primary: BMI/BMIz, body weight, adverse events Secondary: HrQL, all cause mortality, morbidity, behaviour change, fat

distribution, participant views, socio-economic effects (all reviews) & parenting (parent only 0-6 & 12-18 reviews)

*not critically ill, syndromic obesity, pregnant or breast feeding ** defined by study author or reviewer

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WHAT DOES THE EVIDENCE REVEAL?

- Results presented focus on changes in BMI / BMI-z Additional information on body fat distribution provided at the end of the presentation

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Overview of included studies • Trials conducted 1968 – 2016: most published last 2 decades. • All RCTs with at least 6mths data from baseline, & aimed to treat

excess weight • Totals across reviews:

– 163 studies (19,756 participants) – 30 countries: 45% USA, 27% Europe – ONLY 10% studies conducted in upper middle income countries

remainder in high income countries – More than half (n85) were set in primary or secondary care. – Individual trial sample sizes ranging from 10-686 – BMI-z reported using a range of growth references – SES reported in only 58 trials using different methods – Ethnicity reporting was limited: not reported in over half – Secondary outcomes were often poorly or inconsistently reported often using different measurement tools

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Surgery for the treatment of obesity in children and adolescents

• 1 Australian (2010) 24 mth RCT: laparoscopic adjustable band vs multi-component lifestyle intervention

• Mean age: 16 years, Mean BMI >40 (~2/3 female), no ethnicity data • Surgery BMI reduction (24 mths):

12.7kg/m2(95%CI: 11.3 to 14.2) (mean kg loss: 34.6kg) • Lifestyle BMI reduction (24mths):

1.3kg/m2(95%CI: 0.4 to 2.9) (mean kg loss: 3kg) • Overall quality of evidence: low: downgraded as only 1 trial and unclear performance & detection bias • Revisional procedure required in 28% of patients. • Some improvements in quality of life observed in the intervention (quality of evidence: very low) • Four ongoing studies identified

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Drug interventions for the treatment of obesity in children and adolescents

• 21 trials (2,484 participants): 11 metformin, 6 sibutramine, 4 orlistat, • Most placebo controlled with concomitant lifestyle intervention • 12 countries (4 upper-middle income, 8 high income), all

secondary care setting (published: 2000 onwards) - Mean: age 10-16yrs (mostly adolescent – median 13.7yr) - female: 45-100%. - BMI 26-42kg/m2; BMI-z not reported • Ethnicity clearly reported in 10 trials = 37-92% white • Most trials reported no post intervention follow up • Completion rates ranged: 36-100% • 8 ongoing studies

BMI Overall Quality: Low

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• Mean difference in BMI (at 6mth [14trials]; 12mth [2trials]*):

-1.3 kg/m2 (95%CI -1.9 to -0.8) in favour of drug intervention

• Split by drug type all showed a BMI reduction in favour of intervention

• No subgroup differences for ITT, funding source, publication date, quality of trial, mean participant age

• >20%/unclear dropout & studies from upper-middle income countries increased the BMI mean difference

• Common adverse events: gastrointestinal (all drugs) and cardiovascular (sibutramine)

• Secondary outcomes often not reported or reported using a range of measures (e.g. body fat).

* End of intervention in all but 1 trial

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Parent only interventions for childhood overweight or obesity in children aged 5 to 11 years

• 20 trials (3,057 participants), 10 ongoing studies • Majority (n=19) published post 2000 in 7 countries (1 upper-middle income, 6 high income)

– 8 reported ethnicity: 54-100% white – % female: 41-100%; – Median of mean age: 8yrs – Median of Mean BMI-z: ~2.2

• Intervention duration ranged from 2 to 24 months • 17 trials included a post intervention follow up (range: 2 to

18mths) • Huge variation in intervention content and comparator

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• Findings were grouped by comparator & overall quality of BMI-z evidence: low • Mean difference assessed at (longest follow up):

– Parent only vs parent child (10-24months): BMI-z: -0.04 (95% CI: -0.15 to 0.08); (3 trials, 267 participants) – Parent only vs min contact (9-12months): BMI-z: -0.01 (95% CI -0.07 to 0.09); (1 trial, 165 participants) – Parent only vs concomitant – to heterogeneous to report (I2=94%) – Parent only vs waiting list control (10-12months): BMI-z: -0.10 (95% CI -0.19 to -0.01); (2 trials, 136 participants)

• Further subgroup analysis were not possible • Adverse events were generally not reported, but where

documented: zero occurrence of serious adverse events • Parent-child relationships assessed in 3 trials: results were inconsistent • Data on morbidity, all cause mortality and socio- economic effects were not reported.

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Lifestyle interventions for the treatment of overweight or obesity in pre-school children up to the

age of 6 years • 7 trials (923 participants) • 1 diet & 6 multi-component trials • Undertaken in 4 countries (1 upper-middle) all

published post 2009 – Median of mean age: ~4.6yrs (range 2-5years) – female: 25-80%; – 5 reported ethnicity: 47-91% white, – Median of Mean BMI-z: 2.25

• Setting, content of intervention & comparator varied

• All included a period of post intervention follow up (6-32mths) (although data available for 5 studies)

• Adverse events not reported in all but one trial with 0 events

Overall Quality: Low BMI-z

*

*

Change in parental weight (kg) – parents had to overweight to be eligible

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• Cluster trial results (possible bias in 6/10 domains)– MD BMI-z reduction (intervention end point): 0.05 units (95% CI -0.14 to 0.04); n/s • Diet only (intervention end point): BMI-z reduction -0.1 (95% CI -0.11 to -0.09); 59 dairy rich; 57 energy deficit. Very low quality • Most studies targeted overweight parents who also

lost a significant weight – which was sustained • Some evidence for improved health related quality

of life (n=3), other secondary outcomes were inconsistent or not reported

• Further subgroup analyses not possible • 4 ongoing studies

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Lifestyle interventions for the treatment of overweight or obesity in school children from the

age of 6 to 11 years • 70 trials (8461 participants), 20 ongoing studies • Undertaken in 21 countries (3 upper-middle income) majority published from 2000

– Median of mean age: 10yrs; only 15 trials with mean age <9yrs – Female: 26-100%; – 30 reported ethnicity: 0-100% white – Median of mean: BMI-z: 2.2; BMI: 26.5

• Post intervention follow up in just over half of all studies (range: 1 to 30mths)

• Setting, intervention content and comparator varied • Most approaches involved both child and care giver (n=65);

most were multi-component: diet, physical activity &/or behaviour change (n=64)

www.tees.ac.uk Last available measure BMI-z Overall Quality: Low

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• No subgroup effects by type of intervention, type of comparator, risk of attrition bias, setting of intervention, parental involvement and severe obesity at baseline • Subgroup analysis for post intervention follow up for BMI

suggest findings weren’t sustained over the longer term (>6months) (2 trials: 6-12mth; 4 trials >12mth)

Findings align with 2 trials examining post intervention maintenance: BMI-z reduction -0.07 units, (95% CI -0.19 to 0.04), 263 participants; 2 trials; low-quality, finding: n/s • 15 concomitant, 4 cluster and 2 maintenance trials:

assessed separately • 35 trial recorded adverse events: 29 had zero occurrence • Secondary outcomes generally poorly and inconsistently reported (no socio-economic-effect, morbidity or all cause mortality)

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Lifestyle interventions for the treatment of overweight or obesity in adolescents aged 12 to 17

years • 44 trials (4781 participants)

• Undertaken in 15 countries (5 upper-middle income, 10 high income) majority published from 2000.

– Median of mean age: 14 years; – Female: 0-100%; – 19 reported ethnicity: 0-100% white – Median of the mean: BMI-z 2.2; BMI 32;

• Post intervention follow up in just over half of all studies (range: 1 to 21mths).

• Setting, intervention content and comparator varied • Most approaches were multi-component (n34)

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• Subgroup analysis by comparator demonstrated larger effects when intervention was compared

to no intervention/usual care than a concomitant intervention

• No significant subgroup differences for: parental involvement, setting, mode of delivery

• Effects were sustained in the 6 trials with follow up at 18-24 months

• Adverse events were only reported in 5 trials: 3x0 events, 1x occurrence 19-24%; 1x adverse events occurred no details provided

• Secondary outcomes were poorly & inconsistently reported • HrQL reported in 7 trials (928 participants, low quality):

Mean Difference in favour of intervention: 0.44 (95% CI 0.09 to 0.80) – moderate improvement

• Most ongoing studies identified (n=50)

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GRADE assessment: BMI: Low; secondary outcome: low/very low Common reasons for downgrade: bias (outline above), inconsistency (heterogeneity) , imprecision (wide confidence intervals)

REVIEW SHORT TITLE (REFERENCE) Surgery (Ells, 2015)

Drug (Mead 2016)

Parent-only (Loveman, 2015)

Lifestyle <6y (Colquitt, 2016)

Lifestyle 6-11y (Mead 2017)

Lifestyle 12-17y (Al-Khudairy, 2017)

BIAS NUMBER OF TRIALS WITH LOW RISK OF BIAS (%)

Random sequence generation 0 (0) 14 (67) 10 (50) 7 (100) 48 (69) 22 (50)

Allocation concealment 1 (100) 15 (71) 5 (25) 3 (43) 49 (70) 11(25)

Performance bias subjective outcomes 0 (0) 14 (67) 0 (0) 0 (0) 3 (4) 1 (2)

Performance bias objective outcomes 0 (0) 14 (67) 1 (5) 1 (14) 3 (4) 1 (2)

Detection bias subjective outcomes 0 (0) 13 (62) 3 (15) 0 (0) 18 (26) 6 (14)

Detection bias objective outcomes 0 (0) 13 (62) 9 (45) 7 (100) 21 (30) 44 (100)

Attrition bias subjective outcomes 0 (0) 2 (10) 5 (25) 3 (43) 22 (31) 11 (25)

Attrition bias objective outcomes 1 (100) 2 (10) 9 (45) 3 (43) 27 (39) 17 (39)

Selective reporting bias 0 (0) 5 (24) 1 (5) 2 (29) 17 (24) 13 (30)

Other bias 1 (100) 0 (0) 1 (5) 4 (57) 6 (9) 33 (75)

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The gaps • No evidence from lower income countries • Lack of cost data • What interventions are effective in children with

disabilities, specific ethnic, religious, culturally diverse groups?

• What is the optimal role of parents and for which age groups? – Dual weight management / relationship with parental weight

status – Parents as role models / controllers of home environment

• What are the key effective components: diet, physical activity, behaviour change?

• Most interventions were face to face – what is the role of remote e-health?

• How do we ensure long term effectiveness across all approaches and ages: weight maintenance?

www.tees.ac.uk BMI Post intervention follow up: 6-11 yr review

www.tees.ac.uk BMI-z Post intervention follow up: 6-11 yr review Same trend as BMI findings but didn’t reach significance!

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What we know: • There is insufficient evidence to make any

recommendation for the use of surgery • Given a lack of long term efficacy & safety data, in

addition to withdrawal or off-licence use of sibutramine and metformin – it is not possible to make any recommendations for the use of drug interventions

• Lifestyle interventions may help to achieve a small reduction in BMI/BMI-z in children of all ages, with low adverse event occurrence

• Adverse event reporting could be improved: Considering linear growth, disordered eating, injuries and psycho-social well being

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NI: no intervention; UC: usual care; CT: concomitant therapy * this was 6-8 post intervention for preschool review

TREATMENT* 0-5yrs vs NI / UC

(n=202)

TREATMENT*parent only (5-

11yrs) vs NI(n=136)

TREATMENT* 6-11yrs NI / UC

(n=4019)

TREATMENT* 12-17yrs NI / UC / CT

(n=2399)

BMI-z score reduction in lifestyleinterventions by age group: mean

difference in favour of intervention atlast available measure*

-0.4 -0.1 -0.06 -0.13

-0.7

-0.6

-0.5

-0.4

-0.3

-0.2

-0.1

0

BMIz

scor

e un

its

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• BMI reduction larger in 2-5 yr age group – Early treatment is important given weight tracking – Small number of trial: low quality – Influence of concomitant parental weight loss

• Smallest reduction in 6-11 age group - Maybe more influenced by environment, than 2-5’s - Maybe more reliant on parental buy-in, than 12-17’s

• Larger reduction in adolescents but within same range

• Sustainability is important and requires more work – a chronic relapsing condition will require ongoing support

• Although small, effects could have substantial public health impact if feasibly achieved across an entire

population and clinical relevance…

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Public benefit & clinical relevance

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What difference has 8 years made? • Last Cochrane review search to May 2008, since

then… – New evidence on surgery and preschool lifestyle

interventions – Number of included lifestyle trials increased from 54

to 141 – Number of drug trials increased from 10 to 21 HOWEVER: - No substantial difference in the overall effect on BMI/BMI-z - studies remain heterogeneous - Similar gaps remain

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When translating evidence… • Identify high risk groups and ensure services are accessible and

appropriate for them – Can reasonable adjustments be made to improve inclusivity?

• Co-production – develop intervention with target populations to tailor them to local needs: – Are language or cultural adaptations required? – Are co-morbidities managed? – Is timing, location and delivery style suited to your target population?

Consider rurality, working patterns, other commitments e.g. child care

• Need for effective communication – How do you reach your target population and referring staff? Consider

available networks, social media, TV, radio, print… • Consider a truly family based approach – supporting all

members with weight concerns. – How can you support parents, siblings… in one programme

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• Consider the influence of: - the wider environment (food taxes, availability of health options, opportunities to be active) - local systems (personal resources and staff training, financial coverage of treatment) • Record adverse events • Consider how treatment effects will be maintained in the

longer term – obesity is a chronic relapsing condition • Consider the needs of complex families (i.e families in

crisis, child protection issues, severe parental or child psychiatric illness – unlikely to participate in trials)

• EVALUATE local implementation for PROCESS, COST & CLINICAL IMPACT – in the short and LONG term

• Use standardised and validated measure so findings can be compared and lessons learnt.

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• Consider measuring body fat distribution as well as BMI/BMI-z • Consider scalability: - cost of the intervention both to the provider and participants • Attrition and compliance are a potential issue – consider way

so improving this: – Ensure interventions are co-produced, and are at times and venues

that fit with participants lives – consider shift work, family commitments, transport availability etc

– Effective communication will help – can we use technology, social media… Consider type and frequency of contact

– Collecting participant views will help – but how do we collect views from those disengaged with the programme

– Recording adverse events may help explain disengagement

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Considerations for Research • Ensure all research addresses inequalities – with representation

from ALL populations at risk • Measure body fat distribution as well as BMI/BMI-z • More research in low and lower-middle-income countries • Consider qualitative research to improve understanding of the

wider influences, barriers and facilitators to weight management within different populations.

• New trials MUST : – observe CONSORT criteria [incl. power calc, robust randomisation and

concealment, ITT analysis] – use standardised, validated outcome measures – Use the TIDieR reporting checklist: provide comprehensive description

of the intervention AND control (important given differences in standard care provisions internationally)

– Ensure long term (>12mth) follow up – Record AND report participate views and adverse events

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Acknowledgements - WHO for funding the completion of the

overview of the 6 reviews and the lifestyle review for 6-11 years.

- Tamara Brown, Emma Mead, Karen Rees, Lena Al-khudairy, Emma Loveman, Louise Baur, Liane Azevedo, Nathalie Farpour-Lambert for their support in this work.

- To all individual review authors - To Public Health England for use of slide 4

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Some useful resources: • WHO Ending childhood obesity report & WHO

growth standard/references: http://www.who.int/end-childhood-obesity/en/

• PHE delivering and commissioning weight management services (children’s resource to be added later this year): https://www.gov.uk/government/collections/adult-weight-management-guidance-for-commissioners-and-providers

• National Obesity Observatory (England) archive: http://webarchive.nationalarchives.gov.uk/20170110165428/https://www.noo.org.uk/

http://www.who.int/end-childhood-obesity/en/

https://www.gov.uk/government/collections/adult-weight-management-guidance-for-commissioners-and-providers



http://webarchive.nationalarchives.gov.uk/20170110165428/https://www.noo.org.uk/

http://webarchive.nationalarchives.gov.uk/20170110165428/https://www.noo.org.uk/

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References: Slide 2: • http://www.euro.who.int/en/health-topics/noncommunicable-

diseases/obesity/data-and-statistics and 2017 UNICEF/WHO malnutrition report

• Lobstein T, Jackson-Leach R. Planning for the worst: estimates of obesity and comorbidities in school age children in 2015. Pediatric Obesity. 2016;11:321-25.

Slide 3: • http://www.euro.who.int/en/health-topics/noncommunicable-

diseases/obesity/data-and-statistics Slide 4: • http://webarchive.nationalarchives.gov.uk/20170110165555/https://www

.noo.org.uk/slide_sets Slide 5: • https://www.gov.uk/government/publications/weight-change-in-

primary-school-age-children

http://www.euro.who.int/en/health-topics/noncommunicable-diseases/obesity/data-and-statistics

http://www.euro.who.int/en/health-topics/noncommunicable-diseases/obesity/data-and-statistics

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Body fat distribution: Surgery review: • The 1 trial measured waist circumference was reduced by 28.2cmin the gastric

banding group and by 3.5 cm in the lifestyle group at two years (MD) - 24.7 cm (95% CI -33.1 to -16.3); P < 0.001.

Drug review: • 18/21 trials reported outcomes which measured body fat distribution. 15 of these

trials measured waist, hip, or both circumferences at baseline and follow-up and 7 trials measured DXA – no meta analysis of this outcome occurred – results are described narratively by drug type on p23 of the review.

Parent only review: • 6 studies examined waist circumference , 1 reported hip circumference – no meta

analyses were conducted – data is described narratively in the review. 1 w 0-6y lifestyle review: • The 1 diet only trial reported waist circumference, of the 6 multi-component trials 2

examined waist circumference, 1 examined hip circumference, arm circumference, fat free mass and % body fat – results are shown from p67 in the review

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Body fat distribution: 6-11y lifestyle review: • For trial comparing intervention vs usual care/no treatment: meta-analysis

demonstrated a reduction in waist circumference in the intervention groups compared with controls at the final follow-up: MD -2.41 cm (95% CI -3.59 to -1.23); P < 0.0001; 11 trials; 1325 participants. 3 trials reported % over weight data that could be meta-analysed. Meta-analysis demonstrated no substantial difference in percentage over weight in the intervention groups compared with controls at the final follow-up: MD -3.27% (95% CI -7.47 to 0.92); P = 0.13; 3 trials; 347 participants). 11 trials reported percentage body fat data that could be meta-analysed and demonstrated no substantial difference in percentage body f at in the intervention groups compared with controls at the final follow-up using (1) bioelectrical impedance analysis: MD -1.25% (95% CI -2.62 to 0.12); P =0.07; 5 trials; 1004 participants; and (2) using dual energy X-ray absorptiometry (DEXA): MD -1.04% (95% CI -2.88 to 0.80); P= 0.27; 5 trials; 443 participants.

• For those trials comparing concomitant interventions with an additional component 14/15 recorded other anthropometric data – these findings are described narratively on p28 of the review.

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Diet, physical activity and behavioural interventions for the treatment of overweight or obese children from the age of 6 to 11 years

Cochrane Database of Systematic Reviews 22 JUN 2017 DOI: 10.1002/14651858.CD012651 http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD012651/full#CD012651-fig-00108

http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD012651/full#CD012651-fig-00108

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Diet, physical activity and behavioural interventions for the treatment of overweight or obese children from the age of 6 to 11 years



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Body fat distribution: 12-17y lifestyle review: • 28 trials reported anthropometric measures other than BMI using objective

measures. 14 trials reported percentage of body fat change that was suitable for meta-analysis and demonstrated a reduction in percentage of body fat in the intervention group compared with the control group at the longest follow-up points (MD -1.08% (95% CI -1.69 to -0.46); P = 0.0006; 1886 participants; 14 studies)

• 3 trials reported other measures of body fat that included percentage of fat, and percentage of body fat-SDS . All three studies found a reduction in body fat in the intervention group compared to the control group.

• Two trials reported data for percentage of trunk fat that was suitable for meta-analysis. Random-effects meta-analysis showed an MD of -0.84% ((95% CI -3.10 to 1.43); P = 0.47; 123 participants; 2 trials;

• 17 trials reported data for waist circumference that was suitable for meta-analysis and demonstrated a reduction in waist circumference in the intervention group compared with the control group at the longest follow-up points (MD -2.26 cm (95% CI -3.80 to -0.72); P = 0.004; 1997 participants; 17 trials)

• 2 studies reported other measures of abdominal adiposity. • 3 trials examined waist to height, and 2 trials examined waist to hip but no significant

effects were found. 1 trial examined hip circumference.

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Body fat distribution: 12-17y lifestyle review cont…: • Two trials reported data for trunk fat mass that was suitable for meta-analysis.

Random-effects meta-analyses showed no substantial reduction in trunk fat mass in the intervention group compared to the control group (MD -0.94 kg (95% CI -2.49 to 0.61); P = 0.24; 184 participants; 2 trials)

• 3 trials reported data for lean mass that was suitable for meta-analysis which showed no substantial increase in body lean mass in the intervention group compared to the control group (MD -0.21 kg (95% CI -0.88 to 0.47); P = 0.55; 417 participants; 3 trials).

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Diet, physical activity and behavioural interventions for the treatment of overweight or obese adolescents aged 12 to 17 years



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