Fitch. Effective Dietary Therapies for Pediatric Obesity Tre

7/29/2019 Fitch. Effective Dietary Therapies for Pediatric Obesity Tre

1/6

Effective dietary therapies for pediatric obesity treatment

Angela Fitch&

Jenny Bock

# Springer Science + Business Media, LLC 2009

Abstract Dietary changes combined with behavioral man-agement techniques, such as short term attainable goalsetting, is effective for treating pediatric obesity. Dietaryinterventions combined with increasing physical activityare essential for weight loss. We review the basic nutritionconcepts that should be employed to treat pediatric obesityand summarize the available literature on effective dietaryinterventions that have been studied to date.

Keywords Dietary interventions . Obesity .Pediatric weight management

1 Introduction

Obesity is a complex, multi-factorial, chronic medicalcondition that is on the rise in the pediatric population[1]. Obesity, whether it occurs in the adult or pediatric population, still amounts to an imbalance of caloric intakevs. expenditure for most individuals. Dietary changes areimportant but should not be separated from other lifestyle

interventions such as increasing exercise and decreasingscreen time [ 2]. Dietary changes should not be consideredas temporary but rather a component of a more permanent transition to a healthier lifestyle. The goal is to induceincremental dietary changes that can be successfullyincorporated into a global lifestyle change during childhoodand maintained into adulthood. Contrary to many popular plans and advertisements, there are no temporary solutionsor quick fixes.

Here, we review the current literature on dietarymanagement of pediatric obesity and discuss fundamental practical lifestyle interventions that are the basis for pediatric obesity treatment.

2 Key components to obesity treatment

There are several core principles to begin treating pediatricobesity effectively from a dietary standpoint (Table 1).

2.1 Individualization

Although the core principles remain the same for all patients,dietary interventions to treat pediatric obesity must beindividualized to meet each patient s social, ethnic andindividual needs [ 3, 4]. A single approach is unlikely to fit the needs for the population as a whole. Several basic andeffective lifestyle recommendations should be instituted at the beginning of therapy which should form the foundation onwhich to begin the individualization process for each patient.

2.2 Food journaling

A food journal is an important tool in obtaining further insight as to what the obese pediatric patient is potentially

A. FitchInternal Medicine and Pediatrics,Pediatric Weight Management Program, University of Minnesota,

Minneapolis, MN, USA

J. Bock Fairview/University of Minnesota Medical Center,Department of Nutrition, Pediatric Weight Management Program,University of Minnesota,Minneapolis, MN, USA

A. Fitch ( * )Fairview Eagan Clinic,1440 Duckwood Drive,Eagan, MN 55122, USAe-mail: [email protected]

Rev Endocr Metab DisordDOI 10.1007/s11154-009-9113-9


2/6

eating on a daily basis. In our practice, we strive to havechildren and/or their parents continue to journal what theyare eating each day.

This journal will help guide treatment and also serves tohold patients and parents accountable for what they areeating. In this regard, it can serve as a useful behavioraltherapy as a child or parent may be less likely to eat certainfoods if they are responsible for writing it down in a journal.

A limitation in journaling is under reporting caloricconsumption. Women taking part in the Women HealthInitiative underreported caloric intake by 25% in their food journaling [ 5]. Similar studies have not been performed inthe adolescent population but it can be assumed that similar misrepresentation may well occur in this population.

The food journal can be a fun process (kids can decoratetheir journal) and records can be kept online usingresources such as www.thedailyplate.com . Adolescent patients may be more likely to be compliant with a food journal if they text message their diets using a smart phonerather than traditional recording tools [ 6]. Thus, journalingis an example of a general principle that can be individu-alized for each patient s needs.

2.3 Family involvement

Multiple studies have shown that successful pediatricweight loss strategies require support and understandingfrom the child s family [ 1, 2, 7 10]. This can be difficult especially when not all the family members are obese andmay resist adoption of similar dietary changes. Thisincludes extended family members and caretakers who

might encourage poor eating habits if they are unaware of the need for the patient to lose weight. Many times theremay be family members who are thin and the concept of weight loss is something they have trouble comprehending.Family members may wish to have certain foods availablein the home that are not a part of the healthy weight loss plan making it more difficult for children to make healthyfood choices. Such situations can sabotage a treatment planand make long term success difficult.

2.4 Goal setting using dietary interventions

The evidenced based lifestyle interventions as recentlyreviewed by the American Academy of Pediatrics Expert Committee from 2007 are shown in Table 2 [2]. These are practical, relatively simple goals to strive towards in at-tempting to eliminate excess calories in the diet but should be tailored to particular problem areas for the individual patient. An example of a practical, general lifestylemodification diet is the Go, Slow and Whoa or Stoplight food concept for children and parents. In this plan, providers give families a chart of go or green light foodsthat they can consume freely, slow or yellow light foodsthat they can consume only in moderation, and whoa or red light foods that they should only be consuming onoccasion. Utilization of these plans has been shown to beeffective in controlling caloric consumption [ 11, 12].

Compelling evidence now strongly supports the elimi-nation of sugar sweetened beverages as a simple way toreduce calorie intake that is effective at decreasing BMI,especially for those with the highest BMI range [ 13, 14].General recommendations for encouraging children toreduce calorie consumption are listed in Table 3. Wefrequently recommend limiting snacks to a 100 calorie portion. Practical examples of the portion size for 100calories of a given food are listed in Table 4. Giving parentsthis table can aid in preparation of these snacks ahead of time and also encourage appropriate portion sizes for snacking. This also encourages snacking with healthier,

Table 1 Core principles of dietary treatment program

Individualization of treatment

Food journaling

Family involvement and support

Short term, attainable goal setting

Elimination of sugar sweetened beverages Increased intake of water or skim milk Eating a healthy breakfast daily Pack lunch for school as much as possible Strive for 5 total fruits and vegetables daily at a minimum.

The current recommendations for the US Department of Agriculture

(www.mypyramid.gov ) are for 9 servings a day. Setting short term attainable goals for incremental changes Eat family meals together as much as possible Limit eating out at restaurants, particularly fast food Choose appropriate portion sizes Encourage the switch to skim milk and increase consumption of calcium

Table 2 Evidenced based initiallifestyle interventions to treat pediatric obesity

Rev Endocr Metab Disord
http://www.thedailyplate.com/http://www.mypyramid.gov/http://www.mypyramid.gov/http://www.thedailyplate.com/


3/6

lower calorie foods instead of caloric dense, nutrient poor items that are frequently marketed to children.

3 Going beyond the basics: specialized dietary treatmentapproaches

The above initial interventions can work well as a weight maintenance guide for children who are still growing inheight, thereby still lowering their BMI, and for those whodo not have any underlying metabolic disorder that predis- poses them to excess weight gain such as Prader-Willi,Turner, or Down syndrome. For patients with these types of genetic disorders or for adolescents that have reached their adult heights or are morbidly obese (BMI >99th percentile),a more sophisticated approach is often required. Samplemeal plans that estimate the caloric intake needed for weight loss are a critical component of a more aggressive approach,once other basic lifestyle interventions have been discussed.Areas to incorporate should include food journaling,assessment of caloric intake, and a reduction in the caloricintake while maintaining a required nutrient intake. Aregistered dietician skilled in weight management is anecessary component of this specific dietary interventionand can guide specific goals to set for the individual patient.

The current recommendation is to create a meal plan that follows the recommendations from the United StatesDepartment of Agriculture ( www.mypyramid.gov ) for macronutrient composition but in a reduced calorie format.A low fat (< 30%), high carbohydrate (55%), high protein(25%), and high fiber (5 g plus year of age/day) energydeficient diet is the general recommendation until addition-al data becomes available in pediatrics, recommending onestrategy over another or a more restrictive diet can bemedically supervised [ 7]. Perhaps as important as themacronutrients in the diet are the behavioral changes that accompany a change in lifestyle. Recent studies in adultscompared the effectiveness of a number of popular dietswith various macronutrient compositions on short termweight loss. Each macronutrient strategy resulted in asimilar degree of weight loss [ 15, 16]. Although similar trials have not been performed in children, these twostudies highlight the importance of calorie reduction rather

than composition, adhering to one s plan, and the impor-tance of long term behavior change.Two recent meta-analyses evaluated a variety of dietary strategies for weight loss studies in pediatric patients (Table 5) [17 , 18 ].Organized, goal setting, comprehensive treatment programsthat focus on multiple facets of obesity (diet, exercise andreduced screen time) are most likely to be successful on along-term basis. No one dietary treatment can be recom-mended at this time though each approach used in thestudies included has some merit.

3.1 Estimating caloric needs for weight loss

In pediatric weight management, the emphasis is typically placed on guiding healthy food choices and appropriate portion sizes, and not focused on achieving a certain caloricgoal. However, calculating estimated needs for weight maintenance or mild weight loss can be beneficial in providing and planning appropriate meal and snack plansfor the patient/parents to use as a guiding reference. Onetool available to estimate pediatric needs is The HealthyEating Plan Calculator (found at http://www.bcm.edu/cnrc/ HealthyEating_calculator.htm ) designed by the Baylor College of Medicine s Children s Nutrition ResearchCenter. This on-line calculator will estimate needs for weight maintenance using the 2005 Dietary Guidelines for Americans and The Institute of Medicine s nutritionalrecommendations for ages 4 and above, based on a child sage, gender, height, weight, and general activity level.Another useful tool is the MyPyramid Plan feature of theUSDA s website ( www.mypyramid.gov ). Upon entering thesame information, it will, again, give a caloric goal basedon the 2005 Dietary Guidelines. However, it is important tonote that for ages 2 8 years old, height and weight calculations are based solely on 50th percentile for agespecific height and weight to calculate requirements. Thiscan prove a useful guideline to gingerly reduce calories in

Table 4 100 Calorie snack ideas

Apple ( 1 medium)

Banana ( 1 medium)

Blueberries ( 1 cup)

Carrots ( 6 baby) with 3 Tbsp hummus or 2 Tbsp cream cheese

Celery ( 1 stalk) with 1 Tbsp peanut butter

Cashews (11 whole)

Cherries, raw (20)

Frozen yogurt, light (1/2 cup)

Edamame, boiled (1/3 cup)

Granola bar

Popcorn low fat microwave (3 cups)

Strawberries (2 cups)

Table 3 Techniques to encourage less calorie consumption

- Drink several ounces of water before the meal

- Use smaller plates

- Wait 20 minutes prior to second helpings

- Use the child s size of their fist to estimate portion for most foods

- Fill the plate with fruits and vegetables

- Use fruit as a dessert

http://www.mypyramid.gov/http://www.bcm.edu/cnrc/HealthyEating_calculator.htmhttp://www.bcm.edu/cnrc/HealthyEating_calculator.htmhttp://www.mypyramid.gov/http://www.mypyramid.gov/http://www.bcm.edu/cnrc/HealthyEating_calculator.htmhttp://www.bcm.edu/cnrc/HealthyEating_calculator.htmhttp://www.mypyramid.gov/


4/6

the case of a very obese younger child where using their actualweight would result in caloric intake recommendations that would exceed their actual needs. The MyPyramid Plan willalso provide a picture representation of the appropriateservings from each food group that will add up to this caloricgoal. This can provide parents with a clearer picture of wherethese calories should be coming from in their daily intake.

If a caloric goal is used, it is very important to ensure the plan still remains nutritionally complete. The PediatricWeight Management Guidelines from the 2007 ADAEvidence Analysis Library state that if energy restrictionin pediatrics is used, it is only appropriate if it is: 1) basedoff the professional judgment of a medical professional; 2) balanced in macronutrient composition; 3) is no fewer than900 kcals in ages 6 12 and 1200 kcals in ages 13 18; and 4))is medically supervised. In every case, calculating estimatedneeds for an individual should be an ongoing process, and re-evaluated and adjusted each visit based on patient compli-ance, food records, and weight changes.

3.2 Protein sparing modified fast diet

A protein sparing modified fast diet is a low calorie diet that maintains protein balance and limits carbohydrates

to induce a relative state of ketogenesis. This is typical-ly performed under the guise of an experienced medical provider using specially formulated liquid meal replace-ments. This dietary intervention was studied most intensively in 1996 by Figueroa-Colon et al [ 9].Theystudied 12 children in the study group and 7 children inthe control group who were super obese (140 195%of ideal body weight) for 6 months in a school basedsetting. Initially the study group was placed on a proteinsparing modif ied fas t d ie t for 9 weeks (600 800calories) and then maintained on a structured hypo-caloric diet (1200 calories) for 12 weeks. Both groupswere followed for 6 months. The control group had nospecific intervention. At 6 months, there was a statisti-cally significant mean weight loss of 5.6 kg in theintervention group compared to a mean weight gain of 2.8 kg in the 7 control children.

There is not enough long-term data on the healthconsequences of this type of diet to recommend its use inroutine clinical practice at this time but it can be effectivein controlled settings. It may be an ongoing area of research to be utilized in specialized medically supervisedcircumstances or in conjunction with bariatric surgery programs.

Table 5 Summary of pediatric weight loss studies

Study Treatment program Mean weight change Length of treatment

Braet et al. 1997 [ 8] Group - 13.08 kg 13 weeks

Individual - 9.84 kg 13 weeks

Advice - 6.84 kg 1 day

Camp - 14.67 kg 10 days

Control + 2.52 kg

Figueroa-Colon et al. 1996 [ 9] Protein sparing modified fast - 8.3 kg 10 weeks

Control + 0.2 kg

Foster et al. 1985 [ 19] Peer counseling and lunch box monitoring - 0.15 kg 12 weeks

Control +1.3 kg

Hills and Parker 1988 [ 20] Exercise treatment only - 5.5 kg 12 weeks

Control + 2.6 kg

Israel et al. 1985 [ 21] Weight reduction treatment program - 5.42 kg 8 weeks

Weight reduction program plus parent program - 4.83 kg

Control + 2.56 kg

Kirschenbaum et al. 1984 [ 22] Parent/child treatment - 2.7 kg 9 weeks

Child only treatment - 2.1 kg

Control + 0.2 kg

Senediak and Spence 1985 [ 23] Rapid behavioral treatment - 1.69 kg 4 weeks

Gradual procedural treatment - 1.44 kg

Non specific control - 0.32 kg 15 weeks

Waiting list control + 0.77 kg



5/6

3.3 Low carbohydrate and low glycemic index diets

In 2003, Sondike et al [ 24] conducted a randomized,controlled 12-week trial of a low carbohydrate diet in obeseadolescents. The study group (n=16) was instructed toconsume


6/6

overweight and obesity: summary report. Pediatrics. 2007;120(Suppl 4):S164 92.

3. Grimes-Robison C, Evans RR. Benefits and barriers to medicallysupervised pediatric weight-management programs. J ChildHealth Care. 2008;12(4):329 43.

4. Stock S, et al. Healthy Buddies: a novel, peer-led health promotion program for the prevention of obesity and eatingdisorders in children in elementary school. Pediatrics. 2007;120(4):e1059 68.

5. Hebert JR, et al. Differences between estimated caloric require-ments and self-reported caloric intake in the women s healthinitiative. Ann Epidemiol. 2003;13(9):629 37.

6. Shapiro JR, et al. Use of text messaging for monitoring sugar-sweetened beverages, physical activity, and screen time inchildren: a pilot study. J Nutr Educ Behav. 2008;40(6):385 91.

7. Hainer V, Toplak H, Mitrakou A. Treatment modalities of obesity:what fits whom? Diabetes Care. 2008;31(Suppl 2):S269 77.

8. Braet C, Van Winckel M, Van Leeuwen K. Follow-up results of different treatment programs for obese children. Acta Paediatr.1997;86(4):397 402.

9. Figueroa-Colon R, et al. Feasibility of a clinic-based hypocaloricdietary intervention implemented in a school setting for obesechildren. Obes Res. 1996;4(5):419 29.

10. Wake M, et al. Preschooler obesity and parenting styles of mothers and fathers: Australian national population study.Pediatrics. 2007;120(6):e1520 7.

11. Epstein LH, et al. Ten-year follow-up of behavioral, family-basedtreatment for obese children. JAMA. 1990;264(19):2519 23.

12. Epstein LH, Wing RR. Behavioral treatment of childhood obesity.Psychol Bull. 1987;101(3):331 42.

13. Wang YC. Impact of change in sweetened caloric beverageconsumption on energy intake among children and adolescents.Arch Pediatr Adolesc Med. 2009;163(4):336 43.

14. Ludwig D. Effects of decreasing sugar sweetened beverageconsumption on body weight in adolescents: a randomizedcontrolled pilot study. Pediatrics. 2006;117(3):673 80.

15. Dansinger ML. Comparison of the Atkins, Ornish, weight watch-ers, and zone diets for weight loss and heart disease risk reduction.JAMA. 2005;293:43 53.

16. Sacks FM. Comparisons of weight loss diets with different compositions of fat, protein and carbohydrates. NEJM.2009;360:859 73.

17. Snethen JA, Broome ME, Cashin SE. Effective weight loss for overweight children: a meta-analysis of intervention studies. JPediatr Nurs. 2006;21(1):45 56.

18. McGovern L, et al. Clinical review: treatment of pediatric obesity:a systematic review and meta-analysis of randomized trials. J ClinEndocrinol Metab. 2008;93(12):4600 5.

19. Foster GD, Wadden TA, Brownell KD. Peer-led program for thetreatment and prevention of obesity in the schools. J Consult ClinPsychol. 1985;53(4):538 40.

20. Hills AP, Parker AW. Obesity management via diet and exerciseintervention. Child Care Health Dev. 1988;14(6):409 16.

21. Israel A, Stolmaker L, Andrain C. The effects of training parents in general child management skills on a behavioralweight loss program for children. Behav Ther. 1985;16:169

180.22. Kirschenbaum DM, Harris E, Tomarken AJ. Effects of parental

involvement in behavioral weight loss therapy for preadolescents.Behav Ther. 1984;15:485 500.

23. Senediak C, Spence S. Rapid verses gradual scheduling of therapeutic contact in a family based behavioral weight control program for children. Behavioral Psychotherapy. 1985;13:265

87.24. Sondike SB, Copperman N, Jacobson MS. Effects of a low-

carbohydrate diet on weight loss and cardiovascular risk factor inoverweight adolescents. J Pediatr. 2003;142(3):253 8.

25. Ebbeling CB, et al. A reduced-glycemic load diet in the treatment of adolescent obesity. Arch Pediatr Adolesc Med. 2003;157(8):773 9.

26. Ebbeling CB. Effects of low-glycemic load vs. low-fat diet inobese young adults: a randomized controlled trial. JAMA.2007;297(19):2092 2102.

27. Kirk S, Scott BJ, Daniels SR. Pediatric obesity epidemic:treatment options. J Am Diet Assoc. 2005;105(5 Suppl 1):S44

51.28. Ludwig DS. Clinical update: the low glycemic index diet. Lancet.

2007;369(9565):890 2.


Documents

Fitch. Effective Dietary Therapies for Pediatric Obesity Tre