Key elements for the nutrition component of child overweight management interventions in five- to nine-year-old children.

To the Editor: The prevalence of overweight and obesity in children is increasing at an alarming rate both in Australia and internationally (1). Recently published data from South Australian four-year-olds indicate that in 2002 17% males and 21% females were overweight (2). A major consequence of overweight in childhood is the high degree of tracking such that an overweight child is very likely to be an overweight or obese adolescent and adult (3). Thus interventions to prevent and manage overweight in early childhood are urgently required.

Well designed trials of interventions to manage or prevent overweight in children are few (4). While the nutrition component of these trials varies, detailed information is limited and rarely has the nutrition component been independently evaluated. The approach taken in most of these trials has been akin to a diet prescription and thus fails to promote lifelong healthy eating. Although not a randomised controlled trial, a study by Braet et al. (5) reported significant weight change at one year in children participating in a program that used cognitive behaviour therapy involving both parents and children to achieve gradual dietary change towards a healthy diet. Calorie counting was not allowed. The importance of interventions involving families rather that focusing on the individual child is supported by the work of Golan et al. (6,7). This approach places responsibility with the parent for achieving family change in eating and activity behaviour.

In our program, Healthy Eating and Lifestyle through Positive Parenting (HELPP), we combine the successful element of parents as 'agent for change' in family eating behaviour. The goal of that behaviour was healthy eating defined with reference to the Australian Guide to Healthy Eating (AGHE) (8) and the Dietary Guidelines for Children and Adolescents in Australia (9). Key components of HELPP include assessment of the eating pattern of each family member against the AGHE, and goal setting by the family to implement gradual 'whole of family' dietary change that accounts for family eating patterns and habits. Specific food recommendations include encouraging lunch box and snack choices from cereal, vegetable, fruit and dairy food groups, using cereal-based 'extras' sparingly, encouraging water as the primary fluid, limiting juice to 150 ml per day, ensuring two to three serves of dairy foods per day and promoting one to two percent fat choices, limiting ice cream and cheese to once or twice a week and using reduced fat varieties. In addition food behaviours such as defining meal and snack times, eating to appetite, limiting second helpings and eating family meals are targeted.

HELPP is a randomised controlled trial for five- to nine-year-old children. Twelve month measurements are presently being completed in this trial. Parents have reported the program provides the type of help they want (43 of 53 respondents), and they feel the program has helped them to make changes in their child's eating and activity patterns (47 of 53 respondents). The program goals are reflected in the learning outcomes and in changes to family eating reported by parents. They mention behaviours, portion sizes, food labels, referring to changing family food supply, the AGHE, and drinking water, rather than attention to calorie, fat and sugar counting.

The program is currently being implemented as the nutrition component in the Parenting Eating and Activity for Child Health (PEACH) program, an NHMRC funded intervention trial in overweight five- to nine-year-olds in Adelaide and Sydney.

Parents play a critical role in providing healthy food for young children and by acting as role models for healthy eating behaviours. We believe this program gives them the knowledge and skills to achieve the goals of a healthy family eating environment and thus contributes to the management of the obesity epidemic. However the school and wider community environments also play an important role in promoting healthy eating and lifestyle, and the management of the overweight problem should not be placed entirely on parents.

References

1. Lobstein T, Baur L, Uauy R. Obesity in children and young people. A crisis in public health. Obes Rev 2004;5 Suppl 1:1-104.

2. Vaska VL, Volkmar R. Increasing prevalence of obesity in South Australian 4-year-olds. J Paediatr Child Health 2004;40:353-5.

3. Magarey AM, Daniels LA, Boulton TJC, Cockington RA. Predicting obesity in early adulthood from childhood and parental obesity. Int J Obes 2003;27:505-13.

4. Summerbell CD, Ashton V, Campbell KJ, Edmunds L, Kelly S, Waters E. Interventions for treating obesity in children (Cochrane Review). In: The Cochrane Library, Issue 4, 2003. Chichester, UK: John Wiley & Sons Ltd.

5. Braet C, Van Winckel M, Van Leeuwen K. Follow-up results of different treatment programs for obese children. Acta Paediatr 1997;86:397-402.

6. Golan M, Weizman A, Apter A, Fainaru M. Parents as the exclusive agents of change in the treatment of childhood obesity. Am J Clin Nutr 1998;67:1130-5.

7. Golan M, Crow S. Targeting parents exclusively in the treatment of childhood obesity: long-term results. Obes Res 2004;12:357-61.

8. Smith A, Kellett E, Schmerlaib Y. The Australian Guide to Healthy Eating. Canberra: Commonwealth Department of Health and Family Services; 1998.

9. National Health and Medical Research Council. Dietary Guidelines for Children and Adolescents in Australia. Canberra: NHMRC; 2003.

Anthea Magarey, Research Fellow

Rebecca Gehling, PhD Candidate

Rebecca Haigh, PhD Candidate

Lynne Daniels, Associate Professor

Department of Nutrition and Dietetics

School of Medicine

Flinders University, Adelaide