Chapter 22: Overweight and Obesity

Anna Vannucci

Marian Tanofsky-Kraff

Overview

Overall prevalence of pediatric obesity appears to have stabilized in recent years, although it remains high

One third of children and adolescents in the United States are overweight or obeseOverweight: BMI ≥ 85th percentile for age and sexObese: BMI ≥ 95th percentile

Rates of extreme obesity (BMI ≥ 99th percentile) are increasing disproportionately faster than the rates of moderate levels of obesity

Obesity

Linked to numerous medical conditions in youths: Cardiovascular disease (e.g., hypertension)Coronary artery diseaseEarly death during adulthoodOrthopedic problemsAsthmaAllergiesPoor health-related quality of life

Detrimental effects on psychosocial functioning. Obese children are more likely to report: Depression, anxiety, disordered eating, ADHD, social

discrimination/exclusion, teasing, and bullying

Early Intervention

Pediatric obesity-related consequences can be prevented or potentially reversed

Being overweight in childhood is a robust predictor of obesity during adolescence and young adulthood (Nader et al., 2006)Obesity track across the life span can start as early as 6

months of age

Childhood ideal point to interveneEating and behaviors more amenable to changeNatural increases in height create circumstances where even

small weight reductions are enough to satisfy criteria for normal weight (Goldschmidt et al., 2013)

Expert Treatment Guidelines

U.S. Preventive Services Task Force

American Academy of Pediatrics

Both have published guidelines for the screening, prevention, and treatment of pediatric obesity

Recommendations include:Primary care physicians track BMI, and assess children’s medical

and behavioral risk factorsOverweight and obese children receive specialty treatment of

moderate to high intensity that incorporate behavioral counseling targeting diet and physical activity

Pharmacotherapy or surgical options are recommended for older children/adolescents

Family-Based Behavioral Interventions

First line of treatment

Demonstrated efficacy in reducing adiposity (Wilfley et al., 2010)

Most efficacious family-based interventions incorporate: Dietary modificationsChanges in energy expenditureBehavior change techniques Parental involvement across all levels of change

Dietary Modification

Goal: dietary strategies that induce an overall negative energy balance Obese children normally consume greater overall calories

and have a higher fat intake than nonobese youths

Traffic Light Diet (Epstein & Squires, 1998)Classifies food into three categories:

• Red: low in nutrients, high in calories• Yellow: high in nutrients and calories• Green: high in nutrients, low in calories

Shown to be effective at reducing energy intake

Energy Expenditure Modification

Children are encouraged to work toward 60 minutes of moderate to vigorous physical activity every day

Parents are encouraged to find activities that children enjoy, are age appropriate, and offer a variety

Decrease the time that children/adolescents stay sedentary Has been associated with less overall energy intake (Coon et

al., 2001)

Behavior Change Techniques

Incorporating behavior change strategies is more effective at achieving weight loss when compared to approaches that offer only psychoeducation (Wilfley at al., 2007)

Goals determined collaboratively between family and providers

Components: self-monitoring, family-based reward system, stimulus control

Parent Involvement

Greater degree of parental involvement in behavioral weight loss treatment leads to greater child weight loss and maintenance outcomes (Heinberg et al., 2010)

Parent’s role is conceptualized as the “facilitator”

Parents play an important role in: Controlling the availability of healthy foodsAccess to unhealthy foodsAmount of physical activityAmount of screen time

Adaptations of Family-Based Lifestyle Interventions

Parent-only interventions: provide more flexibility for families; more cost-effective for providers; comprise the same components as family-based interventions except all information is provided to the parent

Family-based behavioral social facilitation treatment: expands the sustained behavior change beyond the individual and home; extends treatment duration and practicing new skills across contexts

Novel Targeted Interventions

Approximately 50% of youths either do not lose weight during treatment or regain weight soon after treatment stops (Wilfley et al., 2010)

Aberrant eating patterns: Loss of control eatingEating in the absence of hungerEmotional eating

Large proportion of obese youths report these aberrant eating patterns (~30–45%)

Interpersonal Psychotherapy

Interpersonal model of loss of control eating: Social problems (e.g., high-conflict relationships) lead to the experience of negative affect, which precipitates loss of control eating episodes (Tanofsky-Kraff et al., 2007)Particularly appealing for use in adolescents at high risk for

obesity, as overweight teens often report poor social functioning (Strauss & Pollack, 2003)

Interpersonal psychotherapy for the prevention of excess weight gain: targets reductions in loss of control eating by improving interpersonal functioning

Regulation of Cues Intervention

Eating in the absence of hunger: eating in response to the presence of palatable foods despite an absence of physiological hungerMay reflect poor responsivity to internal satiety cues (Birch & Fisher,

1998)

Externality theory of obesity: Individuals who eat in the absence of hunger are more responsive to environment and external cues (e.g., smell, taste, sight of food)

Regulation of cues intervention: time-limited program that targets eating in the absence of hunger in overweight children and their parents by teaching families to be more sensitive to internal hunger and fullness cues and to learn to resist eating in the absence of hunger when exposed to external food cues

Group Parent Training

Emotional eating: consuming food in attempt to cope with transient or enduring negative emotions (Heatherton & Baumeister, 1991); positive relationship between emotional eating and being overweight

Affective theories: Emotional eating is based on an ineffective attempt to regulate (i.e., alleviate, escape) negative emotions Warm and responsive, yet directive, approach to

parenting leads children to develop adaptive means of regulating emotions and behavior

Group Parent Training

Eight-session programAdministered solely to parents or guardians of

overweight preschool-age children in three stages:1) Provides parents with parenting tools to decrease

parental stress2) Aims to improve household structure through

modification of mealtimes and bedtimes3) Emphasizes the importance of parental role modeling

of healthy lifestyle behaviors and provides skills to help parents teach their children effective ways to identify and respond appropriately to hunger vs. emotional cues

Measuring Treatment Effects

BMI: calculated from person’s weight (kg) and height (m); examining changes in only BMI has disadvantages in pediatric samples because BMI does not take into account youth’s normative changes in BMI over time

Percent overweight: most often calculated as the percent over a child’s ideal BMI the child’s gender and ageChange in percent overweight has often been used to

report children’s relative body weight change throughout the course of a pediatric obesity intervention

Clinical Case: Sean

12-year-old boy

Overweight

Both parents and brother are overweight

Weight has slowly increased since he was a toddler

Treatment: family-based behavioral intervention; logging his eating and activity behaviors daily, reducing afternoon snacking behaviors, and replacing some of his time spent playing video games with an outdoor activity with friends

Clinical Case: Becky

16-year-old female

Recurrent loss of control eating, concerns about her weight

First loss of control eating episode at 11 years old and started gaining a lot of weight

Treatment: interpersonal psychotherapy for the prevention of excess weight gain

Clinical Case: Dillon

8-year-old male

Frequently ate in the absence of hunger

Dillon wants to lose weight, but becomes frustrated because he has so much difficulty resisting his cravings

Treatment: Regulation of Cues intervention where both he and his dad set goals of improving their awareness of and response to internal hunger and fullness cues

Clinical Case: Katrina

4-year-old female

High risk for obesity by virtue of being at the 87th BMI percentile

Has severe temper tantrums nearly every day at preschool and homeMother says that the only thing that calms Katrina down is

giving her cookies

Treatment: group parent training program targeting parental tress; Katrina’s mother’s goal was to improve the way she deals with stress in her life