Evidence-guided approaches to addressing child obesity: what approaches can dietitians use in their everyday practice?

Child obesity was described by the World Health Organisation in 1998 as one of the most pressing public health issues of our time that requires an urgent and informed response. (1) Unfortunately, despite much attention and efforts, the juggernaut that is the child obesity epidemic shows no sign of slowing down.

The most recent representative data from Australia report that around 25% of school-aged children and adolescents (2) and 20% of preschool children (3) are overweight or obese, and that this figure continues to increase, even accelerate, among boys.

The immediate health consequences of child obesity are well known and affect most body systems. (4) From a psychosocial perspective, obese children have poorer quality of life (5) and commonly experience peer prejudice. (6) Because obese children are more likely than their lean counterparts to become obese adults and suffer the associated adverse health outcomes, obese children have an increased risk of mortality and chronic adult health conditions, such as heart disease, diabetes and some cancers. (7)

Clearly, strategies are needed at all levels of society and by all stakeholders if there is to be any hope of turning this problem around. The National Health and Medical Research Council of Australia recommends that simple, well-designed interventions incorporating conventional weight-management strategies and which can be translated into practice are urgently needed in Australia. (8) This seems like a natural and sensible response.

The article by Golley et al. in this issue describes in detail the PEACH (Parenting Eating, Activity, and Child Health) Study. (9) PEACH is a multisite randomised controlled trial (RCT) conducted among parents and overweight and obese children aged 6-9 years in Adelaide and Sydney, Australia. The aim of the study was to examine whether the addition of parenting skills to a healthy lifestyle weight management program results in greater reduction in weight status. While the long-term results are not yet fully published, 6- and 12-month follow-up data published in abstracts show significant and clinically relevant reductions in body mass index (BMI) z-score in both programs, but no difference between the two. (10,11) That is, the addition of parenting skills did not produce a reduction in BMI z-score that was significantly greater than that already achieved through a weight management program focusing on healthy eating, physical activity and reduced small screen time.

One should not automatically conclude from this that parenting skills are an adjunct to paediatric weight management programs, or that they add little to a well-delivered program focusing on the cornerstones of conventional weight management (restricting energy intake or diet, increasing energy expenditure or physical activity, decreasing sedentary activities, parental involvement, and behaviour modification). (8) Rather, it should be concluded that both programs are equally effective in preventing unhealthy weight gain among overweight and obese pre-pubertal children and both should be included in a dietitian's 'tool-box' of evidence-based options in the treatment of childhood obesity.

There is much to be admired about the PEACH program. It is the first multisite RCT in Australia for the treatment of child obesity and has set the benchmark for subsequent studies. It is rigorous in its design and evaluation. It takes two of the recommended components of treatment (parenting skills, and healthy eating and physical activity), and combines two well-tested programs and frameworks in these areas (PPP Parenting program and Australian Guide to Healthy Eating). Much thought has been given to how the program (which has been shown to be efficacious from an RCT evaluation) can be applied in everyday dietetic practice. This translation has been done by dietitians who are aware of the barriers faced by their colleagues and have sought to overcome many of these. For example, the focus on a gradual reduction in frequency of face-to-face meetings, the setting of tasks and follow up of these, and the responsibility for identifying and solving problems and sustaining change resting with the parent.

The PEACH Study reinforces the importance of working predominantly with parents as the agents of change in child obesity treatment programs. Given that parents are the gatekeepers of food and provide most of the cues for physical activity and small screen recreation, it makes sense that interventions target either parents solely or in conjunction with their child. A recent systematic review of dietary interventions in child obesity by Collins et al. showed that of the six studies reviewed that compared child and parent interventions, five reported a greater reduction in adiposity among groups that involved parents separately or with the child, compared with the child alone. (12)

Most child obesity interventions have only found modest effects or have methodological limitations which make it difficult to determine the true efficacy of the intervention. (13) A criticism of many RCTs is that as so much attention is needed to reduce potential bias and maximise internal validity, the replication or generalisability of the study to community-based practice is minimalised. (14) There is a need to develop programs that are not only efficacious but also transferable to practices such as dietetic clinics and private practices. Golley et al. provide dietitians with all the information they require to start implementing a parent-focused program in their setting. (9) This is a good indication of the effectiveness of an intervention; that it can be transferred to the community or clinical setting, increasing its sustainability and dissemination. (15) It would be beneficial if dietitians who are searching for evidence-guided programs to use in their real-world settings could implement either PEACH or other dietary modification programs designed for families with overweight or obese children that follow the Australian Guide to Health Eating, (16) and write up their case reports as the authors have done in this article. The potential pooling of a large number of case reports from a number of dietetic settings would further strengthen the effectiveness of these programs in community settings.

Currently there is little-to-no dissemination of programs that have been shown to be efficacious or effective. This is urgently needed in every community in Australia and New Zealand where there is a severe shortage of resources and programs to treat child obesity. This is a key step in the important process of determining the effectiveness of efficacious programs, which in turn will hopefully facilitate research into how to best disseminate programs such as PEACH for which effectiveness has been established.

Anthony D. Okely, EdD, BEd (Hons)

Director, Child Obesity Research Centre and Senior Lecturer, Physical and Health Education

University of Wollongong 

REFERENCES

1 World Health Organisation. Obesity: Preventing and Managing the Global Epidemic. Report of a WHO Consultation on Obesity. Geneva: WHO, 1998.

2 Booth ML, Dobbins T, Okely AD, Denney-Wilson E, Hardy LL. Trends in the prevalence of overweight and obesity among Australian children and adolescents 1985-1997-2004. Obesity 2007; 15: 1089-95.

3 Wake M, Hardy P, Canterford L, Sawyer M, Carlin JB. Overweight, obesity and girth of Australian preschoolers: prevalence and socioeconomic correlates. Int J Obes 2007; 31: 1044-51.

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5 Williams J, Wake M, Hesketh K, Maher E, Waters E. Health-related quality of life of overweight and obese children. JAMA 2005; 293: 70-76.

6 Latner JD, Stunkard AJ. Getting worse: the stigmatization of obese children. Obes Res 2003; 11: 452-6.

7 Must A. Morbidity and mortality associated with elevated body weight in children and adolescents. Am J Clin Nutr 1996; 63: S445-7.

8 National Health and Medical Research Council. Clinical Practice Guidelines for the Management of Overweight and Obesity in Children and Adolescents. Canberra: NHMRC, 2003.

9 Golley R, Perry R, Magarey R, Daniels LA. Family-focused weight management program for five- to nine-year-olds incorporating parenting skills training with healthy lifestyle information to support behaviour modification. Nutr Diet 2007; 64: 144-50.

10 Daniels LA, Perry R, Magarey AM, Baur LA, Steinbeck KS, Hills AP. PEACH RCT: a family focused weight management program for 5- to 9-year-olds--impact on maintenance of reduction in adiposity 6 months post intervention (Abstract). Int J Obes 2007; 31: S145.

11 Magarey AM, Perry R, Baur LA, Daniels LA, Steinbeck KS, Hills AP. Effectiveness of the PEACH RCT: a family focused weight management program for 5- to 9-year-olds: 6 month outcomes (Abstract). Obes Rev 2006; 7 (Suppl. 2): 114.

12 Collins CE, Warren J, Neve M, McCoy P, Stokes BJ. Measuring effectiveness of dietetic interventions in child obesity: a systematic review of randomised trials. Arch Pediatr Adolesc Med 2006; 160: 906-22.

13 Summerbell C, Ashton V, Campbell K, Edmunds L, Kelly S, Waters E. Interventions for treating obesity in children. Cochrane Database Syst Rev 2003; 3: CD001872.

14 Victora CG, Habicht J-P, Bryce J. Evidence-based public health: moving beyond randomized trials. Am J Public Health 2004; 94: 400-405.

15 Franks AL, Kelder SH, Dino GA et al. School-based programs: lessons learned from CATCH, planet health, and not-on-tobacco. Prev Chronic Dis [Serial online.] 2007 April. (Cited 11 Jun 2007.) Available from URL: http://www.cdc.gov/pcd/issues/2007/apr/06_0105.htm

16 Jones RA, Okely AD, Collins CE et al. The HIKCUPS trial: a multi-site randomized controlled trial of a combined physical activity skill-development and dietary modification program in overweight and obese children. BMC Public Health 2007; 7: 15.