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Practitioner Review: Bridging the gap betweenresearch and clinical practice in pediatric obesity

Elissa Jelalian,1 Yana Markov Wember,1 Heidi Bungeroth,2 and Vered Birmaher21Department of Psychiatry, Rhode Island Hospital, Brown Medical School, Providence, RI, USA; 2The Miriam

Hospital, Providence, RI, USA

Background: Pediatric obesity is a significant public health concern, with rising prevalence rates inboth developed and developing countries. This is of particular significance given that overweight chil-dren and adolescents are at increased risk for multiple medical comorbidities, as well as psychosocialand behavioral difficulties. The current review highlights findings from the empirical pediatric obesitytreatment literature, with particular attention to diet, physical activity, and behavior interventions.Evaluation and treatment considerations relevant to working with overweight children and adolescentswith psychiatric comorbidities are reviewed. Methods: Review of the relevant treatment literature, witha focus on randomized clinical trials, was conducted. Recommendations regarding treatment of childrenand adolescents with psychiatric comorbidities are based on relevant prospective studies of the rela-tionship between weight status and psychological variables and studies with adult popula-tions. Results: Well-established pediatric weight control interventions have been conducted inresearch settings. These studies provide a starting point, but are limited by homogeneous samples thatmay exclude participants with psychiatric comorbidities. Practitioners treating obese children andadolescents with psychiatric disorders are encouraged to assess individual, familial, and contextualvariables specific to weight (e.g., motivation and existing support to change current eating and physicalactivity patterns, extent of weight-related conflict within family, impact of weight on current functioning)in order to prioritize treatment objectives. Conclusions: The review concludes with a discussion ofcurrent empirical and practical challenges, including explicitly targeting obese children and adolescentswith psychiatric concerns and determining appropriateness of pursuing weight control interventions inthis population. Keywords: Obesity, pediatrics, review, clinical practice, overweight.

The last three decades have seen a dramatic increasein pediatric obesity in both developed and developingcountries. While considerable attention has beengiven recently to identifying and intervening withobesity in a pediatric setting, there has been minimalfocus on considerations related to working withoverweight children and adolescents in a mentalhealth setting. The goals of the current review aretwofold: 1) to familiarize mental health clinicianswith current research regarding prevalence, medicaland psychosocial correlates, and treatment inter-ventions for pediatric obesity, and 2) to consider howawareness of these issues can be incorporated intoclinical work with overweight children and adoles-cents with psychiatric comorbidities.

Definition and prevalence

The increasing prevalence of pediatric obesity,highest for minority children and adolescents fromeconomically disadvantaged families, represents asignificant health concern and challenge. For chil-dren between the ages of 2 and 19 years, overweightstatus is defined with reference to sex and age spe-cific growth charts from the United States Centersfor Disease Control and Prevention (Kuczmarskiet al., 2002). At risk of overweight is defined as bodymass index (BMI; kg/m2) greater than or equal to the85th percentile but less than the 95th percentile and

overweight is defined as BMI greater than the 95thpercentile with reference to sex and age specificgrowth charts (Himes & Dietz, 1994). Body massindex also serves as a proxy measure of adiposity inchildren and adolescents (Yanovski, 2001b); conse-quently, the terms overweight and obese are at timesused interchangeably in pediatric samples.

The most recent data available for the UnitedStates indicate that 31% of all children between 6and 19 years of age are either at risk for overweightor overweight, with 16% of this sample at or abovethe 95th% BMI for sex and age (Hedley, Ogden,Johnson, Carroll, Curtin, & Flegal, 2004). This rep-resents approximately a 10% increase for childrenand adolescents over the last 25 years. Similarincreases in prevalence have been observed globally,with rising incidence of childhood and adolescentobesity in several European countries, as well asdeveloping countries (Chu, 2001; Lissau et al., 2004;Lobstein, James, & Cole, 2003; World HealthOrganization, 2003). Given the scope of this epi-demic, empirically-grounded practical recommen-dations are needed for mental health professionals inoffice-based practice.

Medical risks associated with pediatric obesity

There are well-known immediate and long-termmedical consequences associated with pediatric

Journal of Child Psychology and Psychiatry 48:2 (2007), pp 115–127 doi:10.1111/j.1469-7610.2006.01613.x

� 2006 The AuthorsJournal compilation � 2007 Association for Child and Adolescent Mental Health.Published by Blackwell Publishing, 9600 Garsington Road, Oxford OX4 2DQ, UK and 350 Main Street, Malden, MA 02148, USA

obesity, which include cardiovascular, endocrine,pulmonary, orthopedic, and metabolic diseases(Must & Strauss, 1999; Yanovski, 2001a). Theseproblematic medical sequelae are compounded by agreater risk of pediatric obesity persisting intoadulthood, as well as increased vulnerability toobesity-related morbidity and mortality in adulthood(Guo, Roche, Chumlea, Gardner, & Siervogel, 1994).Children and adolescents whose obesity status ismore severe have a greater propensity to becomeobese adults. Clearly, these immediate and long-termmedical consequences as well as the intractablenature of adult obesity underscore the critical needto target weight management in the pediatric popu-lation.

Predisposing factors

There are numerous speculations regarding the ba-sis for increased prevalence of pediatric obesity, ofwhich a comprehensive review is beyond the scope ofthe current paper. It is well accepted that whilegenetic makeup can predispose an individual to be-come obese (Price, 2002), interaction with environ-mental factors is critical in the development of sometypes of obesity. Contextual variables such as foodselection within the home, familial eating and feed-ing patterns and practices, and level of food mon-itoring can negatively impact children’s dietarybehaviors and contribute to weight gain (Birch &Fisher, 1998). Socioeconomic and cultural barrierssuch as limited availability of nutritious food alter-natives (Fitzgibbon & Stolley, 2004), unsafe neigh-borhoods that preclude exercise, and culturalperceptions about a child’s weight status can alsoimpede healthy eating and physical activity (Sherryet al., 2004). At a community level, national surveydata indicate an increase in sedentary behavior (e.g.,television viewing, playing computer and video-games) for children and adolescents coupled with areduction in frequency and intensity of physicalactivity (Dowda, Ainsworth, Addy, Saunders, & Ri-ner, 2001; Myers, Strikmiller, Webber, & Berenson,1996). These lifestyle changes further exacerbate therisk for pediatric obesity. Youngsters who do notregularly exercise and spend more time viewing tel-evision daily are more likely to be overweight (An-dersen, Crespo, & Bartlett, 1998; Dowda et al., 2001;Grund, Krause, Siewers, Rieckert, & Muller, 2001;Trost, Kerr, Ward, & Pate, 2001). Along with de-creased participation in physical activity are in-creased opportunities for consumption of energydense foods. The last two decades have seen a sig-nificant increase in consumption of sugar-sweetenedbeverages, particularly soda (Tippett & Cleveland,1999), with an association to obesity in some pro-spective studies (Berkey, Rockett, Field, Gillman, &Colditz, 2004; Ludwig, Peterson, & Gortmaker,2001). There has also been a significant increasein the percentage of children and adolescents

consuming snacks, the number of meals consumedaway from home, and the percentage of food budgetsdevoted to the purchase of fast foods (Nicklas,Baranowski, Cullen, & Berenson, 2001), all ofwhich may contribute to increased rates of pediatricobesity.

Pediatric obesity treatment/highlights fromthe empirical literature

Given the increased prevalence of pediatric obesity,there has been considerable focus on identifyinginterventions. Several comprehensive reviews ofpediatric weight control interventions have beenconducted over the last five years. An earlier reviewconcludes that there are ‘well-established’ weightcontrol interventions for school age children withoutcomorbid psychiatric or medical concerns and‘promising’ interventions for overweight adolescents,with documentation of long-term weight loss (i.e.,10 years) for some portion of school age children(Jelalian & Saelens, 1999). A review by Epstein pro-vides an overview of the well-researched family-basedbehavioral intervention for overweight school agechildren and their parents (Epstein, 2003). Otherreviews provide conceptual models for familyinvolvement in weight control trials for pediatricsamples (St. Jeor, Perumean-Chaney, Sigman-Grant,Williams,&Foreyt, 2002) and suggest the importanceof parent involvement in weight loss programs forchildren (McLean, Griffin, Toney, & Hardeman,2003). We provide a brief review of selected random-ized clinical trials to illustrate key components ofexisting weight control interventions and identifylimitations and areas for further research.

Comprehensive pediatric weight managementinterventions typically involve a number of commonelements. These include dietary prescription andeducation, physical activity program and/or pre-scription, and behavioral intervention. Behavioralstrategies, including self-monitoring of diet andphysical activity, implementation of stimulus controltechniques, goal setting, and contingency manage-ment (i.e., reinforcement for increasing or reducing atargeted behavior) are used to support prescribedchanges in diet and physical activity. Self-monitor-ing is commonly accomplished through completionof diet and physical activity records, and may besupported by use of physical activity monitors suchas pedometers. Stimulus control strategies refer tothe category of interventions that change environ-mental cues to support healthier eating and physicalactivity patterns. Common stimulus control strat-egies include removing high calorie foods, increasingaccess to healthy foods, and increasing visibility ofcues related to physical activity. Goal setting in thecontext of a pediatric weight control program typic-ally focuses on specific behaviors, such as increasedphysical activity, and calorie reduction.

116 Elissa Jelalian et al.

� 2006 The AuthorsJournal compilation � 2007 Association for Child and Adolescent Mental Health.

Table 1 includes a selected summary of empiricaltrials addressing manipulations of diet, physicalactivity, and parental involvement in pediatricweight control programs. The table is intended toreflect some of the key findings in these three areas.The dietary intervention that has received mostempirical support is the Traffic Light Diet (Epstein,2003), wherein foods are assigned to colors of thetraffic light. Assignments are made based on nutri-tional value and fat content of food choices, withgreen indicating ‘go,’ yellow indicating ‘caution,’ andred denoting ‘stop.’ In studies involving the TrafficLight Diet with school age children, the accom-panying calorie guideline is 900 to 1200 calories/day. While the Traffic Light diet incorporates rec-ommendations for reduced dietary fat, more recentlypublicized approaches have focused on diets that arelow in carbohydrates. Although the topic has re-ceived considerable publicity, there is relatively littleavailable data, particularly with children. We iden-tified only two published studies (Spieth et al.,2000), one of which is a randomized trial with ado-lescents (Sondike, Copperman, & Jacobson, 2003).The results from this study are favorable; however,given questions regarding long-term efficacy andsustainability, implementation of low carbohydrateor low glycemic index diets with pediatric popula-tions should be considered cautiously.

A second component of comprehensive weightcontrol interventions is prescription of physicalactivity. Physical activity interventions may includestructured activity (i.e., specific time designated foraerobic exercise, such as going to the gym) or life-style activity (i.e., increasing energy expenditurethrough lifestyle changes, such as taking the stairsrather than the elevator). Review of studies outlinedin Table 1 indicates support for lifestyle as well asaerobic exercise. An early study compared aerobicand lifestyle activity with and without diet in a groupof overweight children between the ages of 8 and12 years (Epstein, Wing, Koeske, Ossip, & Beck,1982). Initially, all of the groups demonstrated acomparable decrease in percent overweight. How-ever, at follow-up, lifestyle activity with and withoutdiet was superior to aerobic activity with and withoutdiet. A second study evaluated the efficacy of aerobicexercise, calisthenics, or lifestyle activity combinedwith dietary intervention in a group of school agechildren. Children randomized to diet combined withlifestyle activity intervention demonstrated greaterreduction in percent overweight than those assignedto diet and aerobic exercise or diet and calisthenicsat one year (Epstein, Wing, Koeske, & Valoski, 1985).At 10-year follow-up, both lifestyle and aerobicactivity were superior to calisthenics (Epstein, Valo-ski, Wing, & McCurley, 1994).

Recent research focuses on decreasing sedentarybehaviors rather than increasing physical activity. Inthe first study to evaluate this concept with children,Epstein and colleagues (1995) found that reinforcing

children for decreasing sedentary behavior led togreater reduction in percent overweight than rein-forcing for increasing physical activity. These find-ings were not replicated in a subsequent study(Epstein, Paluch, Gordy, & Dorn, 2000) in whichchildren reinforced for decreasing sedentary behav-ior demonstrated a comparable decrease in percentoverweight as those reinforced for increasing phys-ical activity. Findings from a recent study suggestthat reduction in sedentary behavior may be mosteffective in producing weight loss for children whosubstitute physical activity, typically boys (Epstein,Paluch, Kilanowski, & Raynor, 2004). In a recentreview of physical activity interventions, Miller andDunstan (2004) conclude that interventions toreduce sedentary behaviors and increase lifestylephysical activity may be the most promising fortreating overweight children.

Parental involvement

A frequently evaluated dimension related to pediatricweight management interventions is parent involve-ment. Several approaches have been adopted withparents, including targeting parents for weight loss,enlisting parents as supporters of child weight con-trol efforts, and providing parents with training ingeneral behavioral child management skills. Whileone study found no difference in child weight lossassociated with parent role (Israel, Stolmaker,Sharp, Silverman, & Simon, 1984), another in-vestigation established that targeting and reinforcingboth child and parent for weight loss was moreeffective than not having a specific target for weightloss (Epstein, Wing, Koeske, Andrasik, & Ossip,1981). This same intervention led to better main-tenance of weight loss than not having a specificweight loss target at 5 and 10-year follow-up (Ep-stein, McCurley, Wing, & Valoski, 1990; Epsteinet al., 1994). Targeting parents alone compared tochildren alone led to better child weight loss at theend of treatment (Golan, Weizman, Apter, & Fainaru,1998) and at 2-year follow-up, with a 15% reductionin overweight in the parent-only group and a 3%increase in the child-only group (Golan & Crow,2004). In combination, these findings suggest thattargeting parents for weight control efforts is aneffective strategy.

Other dimensions that have been evaluated withregard to parent involvement include additionalparent training interventions as well as focus onparent versus child control for regulation of weightcontrol behaviors. Greater benefit was observed inan intervention that included a problem-solving in-tervention for children and parents compared tostandard behavior modification (Graves, Meyers, &Clark, 1988). However, a subsequent study showedno benefit to problem-solving relative to a standardfamily-based weight control intervention (Esptein,Paluch, Gordy, Saelens, & Ernst, 2000). There was

Practitioner Review in pediatric obesity 117


Table

1

Reference

Sample

Experimental

design

Intervention

Outcome

Follow-u

p

Diet

Epstein,Wing,Stera

ncheck,

Dickson,&

Michelson,

1980

6–1

2years

and>20%

overw

eight

RCT

Tra

fficlightdietexercise

instruction,behavior

modification

Tra

fficlightdiet,

exercise,&

behaviorsuperiorto

education

Differencesmaintainedat

3month

spost-tx

Epstein,Wing,Koeske,&

Valoski,1984

8–1

2years

and20–8

0%

overw

eight

RCT

Tra

fficlightdietaloneor

combinedwithlifestyle

exercise

Dietaloneaswellas

combinedwithlifestyle

exercisesuperiorto

waitlistcontrol

Differencesmaintainedat

6month

spost-tx,5,and

10yearfollow-u

p

Sondike,Copperm

an,&

Jacobson,2003

12–1

8years

and

BMI>95th

%forage

RCT

Low

carb

ohydra

te(40gra

ms

daily)vs.low

fat(<40gra

ms

daily)

Low

carb

ohydra

tesuperior

tolow

fatover12weeks

None

Spieth

etal.,2000

Meanageof10years

Pre-p

ost

Low

glycemic

index

Low

glycemic

index

superiorto

low

fat

None

Physicalactivity

Epstein,Wing,Koeske,

Ossip,&

Beck,1982

8–1

2years

20–8

0%

overw

eight

RCT

Tra

fficlightdiet&

behavior

modificationcombinedwith

lifestyle

exerciseor

progra

mmedexercise

Compara

ble

weightlosses

foralltx

conditions

Lifestyle

activitywithor

withoutdietsuperiorto

aerobic

activity


Valoski,1985

8–1

2years

20–8

0%

overw

eight

RCT

Tra

fficlightdietcombinedwith

progra

mmedaerobic,

lifestyle,orcallisth

enic

exercises

Immediate

outcomes

compara

ble.1yearafter

tx:lifestyle

superiorto

aerobic

andcalisth

enics

10years

aftertx:lifestyle

andaerobic

superiorto

calisth

enics

Epstein

etal.,1995

8–1

2years

20–1

00%

overw

eight

RCT

Comprehensivebehaviora

lprogra

mcomparing

reinforcingdecreasing

sedentary

behaviorvs.

increasingphysicalactivity

Reinforcingdecreased

sedentary

behavior

superiorto

increasing

physicalactivity

1yearafterra

ndomization,

superioroutcomefor

decreasedsedentary

behavior

Epstein,Paluch,Gord

y,&

Dorn

,2000

8–1

2years

20–1

00%

overw

eight

RCT

Comprehensivebehavior

weightcontrolprogra

mwith

decreasedsedentary

behaviors

vs.increased

physicalactivity

Compara

ble

decreasesin

%overw

eightforboth

conditions

2years

after

randomization,

compara

ble

outcomes

Epstein,Paluch,

Kilanowski,&

Raynor,

2004

8–1

2years

>85%

BMI

RCT


lweightcontrolprogra

mwith

reinforcementofreducedsed

entary

behaviororstimulus

controlto

support

reduced

sedentary

behavior

Compara

ble

decreasesin

weightforboth

conditions

1yearafterra

ndomization,

compara

ble

decreases

Parentinvolvement

Parents

asweightlosstargets

Epstein,Wing,Koeske,

Andra

sik,&

Ossip,1981

Childrenage6–1

2years

Childandparent

15–8

0%

overw

eight

RCT

Behaviora

lweightcontrol

comparingparentandchild

target,

childtarget,

and

non-specifictargets

Significantreductionin

%overw

eightforallgroups

5years

from

pre-tx:parent

&childtargetedsuperiorto

non-specifictarget.

10yea

rsfrom

pre-tx:parent

&ch

ildtargeted

superior

tonon-spec

ifictarget



Table

1Continued

Reference

Sample

Experimental

design

Intervention

Outcome

Follow-u

p

Isra

el,Stolm

aker,

Sharp

,Silverm

an,&

Sim

on,1984

8–1

2years

20–9

9%

overw

eight

RCTto

txorwaitlist,

Parentself-selectto

weightlossorcontrol

Behaviora

lweightcontrol–

parents

targetedforweight

lossorin

helperrole

Both

txconditionssuperior

towaitlistcontrol

Nodifferencebetw

een

groups1yearfrom

pre-treatm

ent

Parentvs.childcontrol


Valoski,1986

8–1

2years

20–8

0%

overw

eight

RCT


lweightcontrol.Parentcontrol

trainingcomparedto

child

self-controltrainingand

crossedwithparentover

weightstatu

s

Nodifferencein

childvs.

parentcontrol.Sim

ilar

outcomefornon-over

weightparents

3years

from

pre-tx:no

differencein

childvs.

parentcontrol

Isra

el,Guile,Baker,

&Silverm

an,1994

8–1

2years

Child>20%

overw

eight

RCT

Behaviora

lweightcontrol.

Comparedparentcontrolvs.

childself-controlemphasis

Significantdecreasesin

both

groups;nodifference

betw

eengroups

3years

from

pre-tx:no

significantdifferences

betw

eengroups

Parents

assole

targets

Golan,Weizman,Apter,

&Fainaru

,1998

Parents

ofchildrenages

6–1

1years

and>20%

overw

eight

RCT

Parentalonevs.childalone

Betterchildweightloss

associatedwithtargeting

parents

2yearfollow-u

p:

significantlygreater

reductionin

%overw

eight

inparentonly

condition

Golan&

Crow,2004

7yearfollow-u

p:superior

outcomeforparentonly

condition

Parents

inadolescent

weightcontroltrials

Brownel,Kelm

an,&

Stu

nkard

,1983

12–1

6years

ofageand

20%

overw

eight

RCT


lweightcontrolcomparing

adolescentalone,in

group

withmoth

ers,andsepara

tegroups

Superioroutcomefor

adolescentandmoth

er

attendingsepara

tegroups

1yearfrom

pre-tx:superior

outcomemaintainedfor

adolescentandmoth

er

attendingsepara

tegroups

Coates,Killen,&

Slinkard

,1982

13–1

7years

and>10%

overw

eight

RCT

Behaviora

lweightcontrol

comparingparentparticipa-

tionin

separa

tegroupvs.

noparentinvolvement

Compara

ble

decreasein

percentoverw

eightfor

both

groups

9month

sfrom

pre-tx:

compara

ble

decreasesin

both

groups

Waddenetal.,1990

12–1

6-year-old

black

females>10kg

overw

eight

RCT


lweightcontrolcomparing

adolescentalone,in

group

withmoth

ers,andsepara

tegroups

Compara

ble

decreasesin

percentoverw

eightforall

groups

Adaptedfrom

Jelalian&

Saelens,1999.



no short-term advantage to addition of parenttraining to a standard behavioral weight controlprogram; however, there appeared to be someadvantage at one-year follow-up (Israel, Stolmaker,& Andrian, 1985). Finally, there has been no dem-onstrated advantage for either child or parent controlover weight regulatory behaviors (Epstein, Wing,Koeske, & Valoski, 1986; Israel, Guile, Baker, &Silverman, 1994), although findings from the latterstudy provide some promising clinical implicationsfor enhanced child self-regulation. There is need forcontinued focus on the most effective role for par-ents, particularly in light of issues related to costeffectiveness, which would favor an equally effectiveand less costly intervention.

The normative adolescent striving for in-dependence makes the question of parent involve-ment in adolescent weight control interventions animportant one. Three studies have explicitly ad-dressed this question, with varying outcomes. All ofthese studies engaged parents as supporters toadolescent weight control efforts. In a study ofadolescents between 12 and 16 years of age, ado-lescents who attended treatment sessions sepa-rately from their mothers demonstratedsignificantly greater decrease in percent overweightthan adolescents who attended treatment alone orattended groups together with their mothers(Brownell, Kelman, & Stunkard, 1983). A secondinvestigation with African American girls did notresult in a significant advantage for the treatmentcondition that included adolescent and parent inseparate groups (Wadden et al., 1990). Finally,when adolescent participation alone was comparedto parent participation in a separate group, therewas no observable benefit related to weight lossassociated with parent involvement (Coates, Killen,& Slinkard, 1982).

The discrepant findings related to parental in-volvement in adolescent weight control effortshighlight the importance of developmental con-siderations in weight management interventions.One area for further study in overweight adoles-cents is the potential utility of involving peers aspart of weight control interventions. The role ofpeers in influencing health behaviors, includingdiet (Adams, 1997) and physical activity (Reynoldset al., 1998; Smith, 2003), has been well docu-mented. Peers have been incorporated in someadolescent weight control programs (Sothern,Schumacher, von Almen, Carlisle, & Udall, 2002).Additionally, a preliminary randomized trial de-monstrates some advantage to a peer-enhancedintervention that encourages increasing self-con-fidence and teamwork through a series of groupchallenges (Jelalian, Mehlenbeck, Lloyd-Richard-son, Birmaher, & Wing, in press). Developingweight management interventions tailored towardadolescents is an area that would benefit fromadditional research efforts.

Maintenance of weight loss

At least some pediatric weight management inter-ventions have led to long-term weight loss for a sig-nificant percentage of participants. After ten years,30% of children treated in four different family-basedintervention studies achieved non-obese status(Epstein et al., 1994). The specific interventions thatled to better long-term outcomes for children weretargeting both parent and child for weight loss andprescribing diet with either lifestyle changes oraerobic exercise. Approximately 60% of childrenwhose parents were targeted for weight control ef-forts achieved non-obese status at seven years fol-lowing intervention (Golan & Crow, 2004).

Less is known regarding long-term maintenance ofweight loss for adolescents. The majority of treat-ment studies targeting adolescents provide data onfairly brief follow-up periods. Outcomes with regardto maintenance of weight loss vary considerably,with findings that range from a decrease of ap-proximately 20% overweight maintained at one yearfrom pre-treatment (Brownell et al., 1983) to a returnto baseline level of overweight at 12 months followingpost-treatment (Ikeda, Fujii, Fong, & Hanson, 1982)to a weight increase from baseline (Wadden et al.,1990). Factors that were associated with weight gainin the year following a residential treatment programfor overweight adolescents included decreasedinvolvement in physical activity, modest increases incalorie intake, decreased proportion of calories frombreakfast, and increased amount of time watchingtelevision (Rolland-Cachera et al., 2004). Additionalresearch identifying factors that facilitate weightmaintenance through adolescence is a priority.

Intensive weight control interventions

Intensive weight control interventions, includingvery low calorie diets (VLCDs) or protein sparingmodified fasts, behavioral treatment offered in aresidential or camp setting, pharmacotherapy, andbariatric surgery, have been implemented primarilywith adolescents with morbid obesity. Early studies,conducted in inpatient settings, are informative indemonstrating the potential utility of VLCDs in pro-ducing substantial weight decreases in adolescentsamples (Stallings, Archibald, Pencharz, Harrison, &Bell, 1988). Treatment of adolescents in residentialsettings has also produced very significant weightlosses, with an average weight loss of 5.7 kg duringapproximately one month at a residential camp(Barton, Walker, Lambert, Gately, & Hill, 2004) andBMI decreases ranging from nine to ten units over a9- to 10-month period (Braet, Tanghe, Decaluwe,Moens, & Rosseel, 2004; Dao et al., 2004) in resi-dential treatment programs. At least one residentialprogram has reported maintenance of a significantdecrease in BMI at 14-month follow-up (Braet et al.,



2004). Pharmacotherapy, including use of sibut-ramine and orlistat, as well as caffeine (Molnar,Torok, Erhardt, & Jeges, 2000), has been used aloneor as adjuncts to behavioral interventions withpediatric populations. A decrease of approximately4% weight was observed for a brief course of orlistatcombined with education and behavioral interven-tion in a sample of overweight adolescents (McDuffieet al., 2002). Two recent studies demonstrate signi-ficant weight reductions for adolescents receivingbehavioral treatment with sibutramine compared tobehavioral treatment combined with placebo(Berkowitz, Wadden, Tershakovec, & Cronquist,2003) or placebo alone (Godoy-Matos et al., 2005).

With the increasing prevalence of morbid obesityin adolescents, surgery has become an option forpatients who are extremely overweight and areexperiencing immediate health consequences. Anobvious consideration in recommendation of anyintensive intervention is the relative risk associatedwith obesity compared to the potential risks oftreatment. It has been recommended that anyintensive intervention be accompanied by behavioraltreatment targeting changes in diet, physical activ-ity, and sedentary behavior (Yanovski, 2001b). Thereader is referred to a review by Yanovski (2001a) fora comprehensive discussion of intensive interven-tions.

Limitations of existing pediatric weight controlinterventions

Our review of the empirical literature suggests thatcomprehensive behavioral interventions that includedietary prescription, physical activity and/or de-creased sedentary behavior, and behavior modifica-tion targeted at both children and parents or parentsalone can be effective treatments for pediatricobesity. Similar components have been identified asuseful with adolescents, with the potential consid-eration of medication, particularly with obesity-related comorbidities.

One limitation of the empirical literature is that themajority of studies were conducted in the 1980s and1990s. Given the change in the prevalence of pedi-atric overweight, the differences in environmentalfactors, and the greater number of children who aremorbidly obese, findings from some of these earlierstudies may not generalize to current samples ofoverweight children. Additionally, many interven-tions were conducted by one investigative team andhave not been replicated by others.

A second limitation of the existing empiricaltreatment literature is that the majority of pediatricweight control trials include homogeneous popula-tions, without specific attention to tailoring inter-ventions for particular ethnic groups. To the extentthat particular populations are at increased risk foroverweight, it makes sense to tailor interventions tobe attractive to these groups (Baskin, Ahluwalia, &

Resnicow, 2001). Furthermore, there are data tosuggest the importance of cultural influences onvarious components of weight management, includ-ing perception of overweight (Flynn & Fitzgibbon,1996; Winkleby, Gardner, & Taylor, 1996), dietarypractices (Sherry et al., 2004; Xie, Gilliland, Li, &Rockett, 2003), and perceptions of and access tophysical activity (Fitzgibbon & Stolley, 2004). Forexample, what is defined as overweight with refer-ence to external criteria such as BMI percentile maybe perceived as healthy, strong, or desirable within aparticular culture. Consequently, consideration ofcultural variables, including race and ethnicity, is animportant aspect of designing weight control pro-grams. There are very few published examples ofweight control interventions conducted with AfricanAmerican adolescents. These include a study con-ducted with African American girls in a publichousing development (Resnicow et al., 2000) and aninternet-based behavioral weight control program foradolescent girls (White et al., 2004). Development ofculturally sensitive weight control interventions is animportant area for future research.

A further limitation is that treatment studies typ-ically exclude children with comorbid psychiatricconcerns. With the exception of the recent review byZametkin and colleagues (2004), there has beenminimal focus on considerations related to workingwith overweight children and adolescents with psy-chiatric comorbidities. Consequently, there is not anestablished treatment literature guiding interventionwith this population.

Convergence of overweight and psychologicalconcerns

There are a number of vantage points from which tounderstand the relationship between obesity andpsychological concerns. In their review of psychiatricissues related to obesity, Zametkin and colleagues(2004) raise the question of whether obesity shouldbe considered a psychiatric or behavioral disorder.Their conclusion is that while obesity does not ap-pear to result from a psychiatric disorder, there areconditions related to obesity, such as depressivesymptoms and eating disorder symptomatology, thatare commonly related to overweight and should beevaluated in this population. This recommendationmay be based on findings from a number of studies,documenting the occurrence of psychological andemotional concerns in overweight pediatric popula-tions.

Childhood obesity may be associated withincreased peer difficulties, diminished body image,social competence, and self-esteem, as well as higherrates of depressive symptomatology (Erickson,Robin-son, Haydel, & Killen, 2000; Israel & Ivanova, 2002;Neumark-Sztainer et al, 2002; Strauss, 2000). Stud-ies evaluating global as well as specific dimensions of



self-esteem demonstrate some significant differencesbetween overweight and normal-weight school agechildren, particularly as related to a more negativebody image (Trost et al., 2001; Vander & Thelen,2000). Overweight girls appear to be at greater riskthan boys, as the magnitude of the relationship be-tween body esteem and weight status appears to bestronger for girls than for boys; however, this impactmay be attenuated in cultures where there is lessstigmatization of obesity (Manus & Killeen, 1995;Strauss, 2000; Young-Hyman, Schlundt, Herman-Wenderoth, & Bozylinski, 2003). Given the socialstigma associated with obesity, it is not surprisingthat obesity impacts adolescents’ relationships due toincreased vulnerability to weight-related teasing andsocial isolation. Overweight adolescents may be soci-ally marginalized among their peers and experiencemore weight-related stigmatization by peers andfamily members (Strauss & Pollack, 2003; Neumark-Sztainer et al., 2002).

Although not uniformly the case, some studieshave found increased rates of depressive symptomsin overweight populations. A sample of clinicallyobese adolescents had higher scores on anxiety anddepression than did a non-clinical obese sample(Erermis et al., 2004). Maternal reports of depres-sion, somatization, and internalizing problems werein the ‘at risk’ range for children presenting to a pe-diatric weight management program (Zeller, Saelens,Roehrig, Krik, & Daniels, 2004b). Other investigatorsfound high rates of depressive symptomatology inoverweight adolescents seeking treatment, as well asan association between binge eating and depressivesymptoms (Isnard et al., 2003). Overweight childrenhave also been found to have higher rates of eatingdisordered cognitions and behaviors than their non-overweight peers (Tanofsky-Kraff et al., 2004). Aneating disorder symptom of particular interest inoverweight children and adolescents is that of bingeeating (Marcus & Kalarchian, 2003). It is difficult toestimate the number of overweight children andadolescents with clinical or subclinical binge eatingdisorder, as the few studies conducted have em-ployed varying instruments to assess children atdifferent age groups. However, approximately 5% of asample of overweight children between the ages of 6and 10 were described as meeting criteria for BED(Morgan et al., 2002), while nearly one-third of asample of overweight adolescents were reported toengage in ‘binge eating’ (Berkowitz, Stunkard, &Stallings, 1993).

A second vantage point from which to understandthe link between obesity and psychiatric sympto-matology is offered by prospective studies docu-menting a relationship between obesity anddepression. Depressed mood in adolescents atbaseline has been found to be an independent pre-dictor of obesity in later adolescence (Goodman &Whitaker, 2002) and depressed adolescent girls wereat greater risk for obesity in adulthood compared to

their non-depressed peers (Richardson et al., 2003).McElroy and colleagues (2004) have noted thatadolescent depression is a risk factor for adultobesity and suggest that depressive syndromes mayhave symptoms that contribute to weight gain, suchas increased appetite and reduced physical activity.Some support is provided by a large-scale surveystudy of middle school students in which an inverserelationship was observed between change in phys-ical activity and change in depressive symptoms(Motl, Birnbaum, Kubik, & Dishman, 2004). Anotherpotential link between depression and obesity is viathe treatment of depression with medications thatimpact weight regulation. As noted by Zametkin andcolleagues (2004), a number of psychotropic medi-cations are associated with weight gain and requirethat practitioners inform patients of this potentialside effect.

While the mechanisms for the relationship ob-served between depression and obesity are not fullyunderstood, there are a number of practical impli-cations that follow. The first is the potential utility ofattending to healthy nutrition and physical activityas part of an overall treatment plan for patientspresenting with depression (Fitzgibbon, 2004). Tothe extent that exercise is associated with significantmental health benefits (Penedo & Dahn, 2005), focuson physical activity may be of particular significance.Secondly, it is critical to attend to mood as well as toweight in overweight populations (Fabricatore &Wadden, 2004).

Treatment recommendations: overweightchildren and adolescents with comorbidities

Mental health professionals are most likely toevaluate and treat overweight children and ado-lescents presenting for a psychiatric or behavioraldisorder (Fitzgibbon, 2004). Because major psy-chiatric diagnosis is commonly noted as an exclu-sion criterion in randomized trials targetingoverweight children and adolescents, there is noexisting treatment literature directly addressingtreatment of overweight children with psychiatriccomorbidities. Consequently, our discussion andrecommendations for mental health providers arebased on relevant related literatures and practicalconsiderations and should be considered prelim-inary.

Addressing weight management within a mentalhealth setting is often complicated by the fact thatweight does not constitute the primary referralquestion or even an area of concern (Fitzgibbon,2004) and may be accompanied by disagreementswithin the family about the need to incorporateweight status in the child’s overall treatment goals. Itmay be more appropriate to broach weight manage-ment later in the treatment process, once theclinician is able to address potential treatment-



interfering issues such as lack of motivation toinitiate weight loss treatment. Empathic commun-ication with a patient or family about weight man-agement can be an important intervention point(Fitzgibbon, 2004). Similarly, obesity may arise as anexplicit concern within the course of treatment,necessitating a thorough evaluation of precipitatingand perpetuating factors at that point. Practitionerguidelines regarding screening and treatmentobjectives (Barlow & Dietz, 1998) may be used toinform decisions regarding priority accorded toweight concerns. In cases where immediate medicalconcern associated with obesity has been identified,weight management should be considered as an areafor intervention. However, even in such a circum-stance, it is critical to proceed only with the interestand motivation of child and parent (Barlow & Dietz,1998).

Prior to initiating weight management re-commendations, practitioners should assess therelationship between a child’s weight and psychi-atric symptoms as well as familial variables(Fitzgibbon, 2004). Specifically, the provider shouldexplore the family’s attitudes regarding the child’sor adolescent’s weight and the extent to which thepatient’s weight is a source of conflict within thefamily. Both at the initiation and throughouttreatment, the clinician should provide psycho-education regarding the relationship betweenobesity and psychiatric symptomatology, help thepatient anticipate personal benefits of weight loss,and diffuse potential family conflict around weight.In initiating these family discussions, it is import-ant to recognize that obesity and psychiatricsymptoms exist within a familial context that im-pacts each family member’s beliefs and feelingsabout cause, treatment, and need for intervention(Whitaker, 2004), creating potential challenges toweight management efforts. Furthermore, it isimportant to assess the patient’s and family’sreadiness to change current weight-related behav-iors to maximize treatment effectiveness and avoidexacerbating a patient’s psychiatric symptoms(Zametkin et al., 2004).

One perspective to consider in addition to readi-ness to change (Zametkin et al., 2004) is the childand family’s ability to adhere to complex diet andexercise prescriptions. Findings from adult studiessuggest that depression impacts adherence tomedical treatment, including dietary guidelines(DiMatteo, Lepper, & Croghan, 2000). Furthermore,one characteristic of non-completers of a 16-weekpediatric weight management program was higherself-reported depressive symptomatology and lowerself-concept scores than completers (Zeller et al.,2004a). While these studies were not conducted withpsychiatric samples, they suggest the importancethat psychiatric symptoms, particularly depression,may play in adherence to recommendations from aweight control program.

Within the context of mental health treatment,providers are encouraged to monitor potentialpsychosocial correlates, such as low self-esteem,negative body image, peer difficulties, and depres-sion. For children presenting with primary psychi-atric symptoms, it may be appropriate to focus onthese issues because successful treatment (e.g.,alleviation of depressive symptoms) may place thechild in a better place to target their weight. Par-ticipation in a weight control treatment has beenfound to reduce depressive symptoms in over-weight adult populations (Stunkard, Faith, & Alli-son, 2003). In addition, to the extent that physicalactivity has been associated with improvement inmood, attending to physical activity patterns in anoverweight or at risk of overweight depressed childmay serve to enhance mood as well as supportweight control.

Considerations in addressing weight

There are a number of key considerations in deter-mining to pursue weight control treatment inpatients presenting with primary psychiatric dis-orders. Of critical importance is whether psychiatricsymptomatology may be exacerbated by participa-tion in a weight control program. Careful evaluationof both child and parental factors, including currentstressors and parental psychopathology, with par-ticular attention to history of eating disorders infamily members, is requisite, and there may becontraindications to pursuing treatment. This eval-uation should include attention to the extent a psy-chiatric disorder is likely to impact adherence to dietand exercise prescription. Treatment may be con-traindicated if there is limited likelihood of adher-ence to a complex regimen, as this may contribute toa perceived sense of failure and exacerbate depres-sive symptoms. Another key consideration is thelevel of instrumental and emotional support forundergoing significant changes to diet and physicalactivity within a family. These issues need to beconsidered prior to enrollment in any weight man-agement program and have increased importance inevaluating a child with psychiatric comorbidity. Alsoimportant is determining an appropriate goal withregard to weight regulation. For children who havedemonstrated a trajectory of continuing increase inoverweight status, intervention to stabilize weightmay be appropriate and more feasible than weightloss (Israel et al., 1994).

Finally, careful consideration must be given to therole of mental health practitioners in providingweight management treatment. There are two criticalquestions for consideration. The first relates to therequisite expertise for providing weight managementinterventions. Knowledge of nutritional require-ments of children, appropriate physical activityguidelines, and behavioral principles related to



weight management is critical. This range ofexpertise may best be accomplished in the context ofa multidisciplinary treatment setting, involving inputfrom a medical provider, nutritionist, exercise phy-siologist, and mental health professional. Psycho-social providers may have a role to play in supportingfamily changes in eating and activity patterns, aswell as assisting with parenting skills and family-based interventions (Barlow & Dietz, 1998). Alter-natively, it may be appropriate for the mental healthpractitioner to focus on the primary mental healthconcern and provide a referral for eating and activity-related issues (Fitzgibbon, 2004). The secondquestion that should be addressed relates to theappropriateness of the same treatment provider ad-dressing both psychiatric and weight concerns. Thismay be contraindicated to the extent that a patient’srelative success or lack thereof with weight man-agement goals is likely to impact the therapeuticrelationship.

Conclusions and future directions

There are well-developed pediatric weight controlinterventions that include dietary and exercise pre-scription combined with behavior modification(Jelalian & Saelens, 1999). These trials have beenconducted in controlled settings and focus nearlyexclusively on children without significant psychi-atric comorbidity. Potential questions include whe-ther it is useful to address concerns of self-worth,social functioning, and depressed mood in the con-text of group-based weight control interventions.Research with adult samples has evaluated the effi-cacy of behavioral weight control relative to eatingdisorder interventions for overweight adults withbinge eating disorder (Wilson & Fairburn, 2002;Yanovski, 2003). Similar studies with adolescentswould be of benefit. Finally, continued longitudinalwork on the evolution of eating disorders followingweight control treatment, particularly with adoles-cents, is an important area. Given the increasingprevalence of obesity and the documented associ-ation to psychosocial concerns, studies that expli-citly target overweight children and adolescents withcomorbid psychiatric issues is an important area forfuture research. Additionally, deciding whether toexplicitly include weight management as a treatmentobjective is an important clinical consideration.Practitioners are also encouraged to expand theevaluation process to incorporate individual andcontextual variables specific to eating, physicalactivity, as well as familial attitudes and supportsregarding change.

Acknowledgements

The authors would like to thank Chantelle Hart forreading a previous version of this manuscript.

Correspondence to

Elissa Jelalian, The CORO Center, Suite 204, OneHoppin Street, Providence, RI 02903, USA; Tel: 401444-8945; Fax 401 444-8742; Email [email protected]

References

Adams, L.L. (1997). An overview of adolescent eatingbehavior barriers to implementing dietary guidelines.Annual New York Academy of Science, 817, 36–48.

Andersen, R.E., Crespo, C.J., & Bartlett, S.J. (1998).Relationship of physical activity and television watch-ing with body weight and level of fatness amongchildren: Results from the third national health andnutrition examination survey. The Journal of theAmerican Medical Association, 279, 938–942.

Barlow, S.E., & Dietz, W.H. (1998). Obesity evaluationand treatment: Expert committee recommendations.Pediatrics, 102, e29.

Barton, S.B., Walker, L.L., Lambert, G., Gately, P.J., &Hill, A.J. (2004). Cognitive change in obese adoles-cents losing weight. Obesity Research, 12, 313–319.

Baskin, M.L., Ahluwalia, H.K., & Resnicow, K. (2001).Childhood and adolescent obesity: Obesity interven-tion among African-American children andadolescents. Pediatric Clinics of North America, 48,1027–1039.

Berkey, C.S., Rockett, H.R.H., Field, A.E., Gillman,M.W., & Colditz, G.A. (2004). Sugar-added beveragesand adolescent weight change. Obesity Research, 12,778–788.

Berkowitz, R., Stunkard, A.J., & Stallings, V.A. (1993).Binge-eating disorder in obese adolescent girls.Annals of the New York Academy of Sciences, 699,200–206.

Berkowitz, R.I., Wadden, T.A., Tershakovec, A.M., &Cronquist, J.L. (2003). Behavior therapy and sibut-ramine for the treatment of adolescent obesity: Arandomized controlled trial. The Journal of the Amer-ican Medical Association, 289, 1805–1812.

Birch, L.L., & Fisher, J.O. (1998). Development ofeating behaviors among children and adolescents.Pediatrics, 101, 539–549.

Braet, C., Tanghe, A., Decaluwe, V., Moens, E., &Rosseel, Y. (2004). Inpatient treatment for childrenwith obesity: Weight loss, psychological well-being,and eating behavior. Journal of Pediatric Psychology,29, 519–529.

Brownell, K.D., Kelman, J.H., & Stunkard, A.J. (1983).Treatment of obese children with and without theirmothers: Changes in weight and blood pressure.Pediatrics, 71, 515–523.

Chu, N.F. (2001). Prevalence and trends of obesityamong school children in Taiwan: The Taipei ChildrenHeart Study. International Journal of Obesity, 25,170–176.

Coates, T.J., Killen, J.D., & Slinkard, L.A. (1982).Parent participation in a treatment program foroverweight adolescents. International Journal of Eat-ing Disorders, 1, 37–48.

Dao, H.H., Frelut, M.L., Oberlin, F., Peres, G., Bour-geois, P., & Navarro, J. (2004). Effects of a multi-



disciplinary weight loss intervention on body compo-sition in obese adolescents. International Journal ofObesity, 28, 290–299.

DiMatteo, M.R., Lepper, H.S., & Croghan, T.W. (2000).Depression is a risk factor for noncompliance withmedical treatment: Meta-analysis of the effects ofanxiety and depression on patient adherence.Archives of Internal Medicine, 160, 2101–2107.

Dowda, M., Ainsworth, B.E., Addy, C.L., Saunders, R.,& Riner, W. (2001). Environmental influences, phy-sical activity, and weight status in 8- to 16-year-olds.Pediatrics and Adolescent Medicine, 155, 711–717.

Epstein, L.H. (2003). Development of evidence-basedtreatments for pediatric obesity. In A.E. Kazdin & J.R.Weisz (Eds.), Evidence-based psychotherapies forchildren and adolescents (pp. 374–388). New York:The Guilford Press.

Epstein, L.H., McCurley, J., Wing, R.R., & Valoski, A.(1990). Five-year follow-up of family-based behavioraltreatments for childhood obesity. Journal of Consult-ing and Clinical Psychology, 58, 661–664.

Epstein, L.H., Paluch, R.A., Gordy, C.C., & Dorn, J.(2000). Decreasing sedentary behaviors in treatingpediatric obesity. Archives of Pediatrics and Adoles-cent Medicine, 154, 220–226.

Epstein, L.H., Paluch, R.A., Gordy, C.C., Saelens, B.E.,& Ernst, M.M. (2000). Problem solving in the treat-ment of childhood obesity. Journal of Consulting andClinical Psychology, 68, 717–721.

Epstein, L.H., Paluch, R.A., Kilanowski, C.K., & Raynor,H.A. (2004). The effect of reinforcement or stimuluscontrol to reduce sedentary behavior in the treatmentof pediatric obesity. Health Psychology, 23, 371–380.

Epstein, L.H., Valoski, A.M., Vara, L.S., McCurley, J.,Wisniewski, L., Kalarchian, M.A., Klein, K.R., &Shrager, L.R et al. (1995). Effects of decreasingsedentary behavior and increasing activity on weightchange in obese children. Health Psychology, 14,109–115.

Epstein, L.H., Valoski, A., Wing, R.R., & McCurley, J.(1994). Ten-year outcomes of behavioral family-basedtreatment for childhood obesity. Health Psychology,13, 373–383.

Epstein, L.H., Wing, R.R., Koeske, R., Andrasik, F., &Ossip, D.J. (1981). Child and parent weight loss infamily-based behavior modification programs. Jour-nal of Consulting and Clinical Psychology, 49, 674–685.

Epstein, L.H., Wing, R.R., Koeske, R., Ossip, D.J., &Beck, S. (1982). A comparison of lifestyle change andprogrammed aerobic exercise on weight and fitnesschanges in obese children. Behavior Therapy, 13,651–665.

Epstein, L.H., Wing, R.R., Koeske, R., & Valoski, A.(1984). Effects of diet plus exercise on weight changein parents and children. Journal of Consulting andClinical Psychology, 52, 429–437.

Epstein, L.H., Wing, R.R., Koeske, R., & Valoski, A.(1985). A comparison of lifestyle exercise, aerobicexercise, and calisthenics on weight loss in obesechildren. Behavior Therapy, 16, 345–356.

Epstein, L.H., Wing, R.R., Koeske, R., & Valoski, A.(1986). Effect of parent weight on weight loss in obesechildren. Journal of Consulting and Clinical Psycho-logy, 54, 400–401.

Epstein, L.H., Wing, R.R., Steranchak, L., Dickson, B.,& Michelson, J. (1980). Comparison of family-basedbehavior modification and nutrition education forchildhood obesity. Journal of Pediatric Psychology, 5,25–36.

Erermis, S., Cetin, N., Tamar, M., Bukusoglu, N.,Akdeniz, F., & Goksen, D. (2004). Is obesity a riskfactor for a psychopathology among adolescents?Pediatrics International, 46, 296–301.

Erickson, S.J., Robinson, T.N., Haydel, K.F., & Killen,J.D. (2000). Are overweight children unhappy?: Bodymass index, depressive symptoms, and overweightconcerns in elementary school children. Archives ofPediatrics and Adolescent Medicine, 154, 931–935.

Fabricatore, A.N., & Wadden, T.A. (2004). Psychologicalaspects of obesity. Clinics in Dermatology, 22, 332–337.

Fitzgibbon, M.L. (2004). Commentary on ‘Psychiatricaspects of child and adolescent obesity: A review ofthe past 10 years’. Journal of the American Academyof Child and Adolescent Psychiatry, 43, 151–153.

Fitzgibbon, M.L., & Stolley, M.R. (2004). Environmentalchanges may be needed for prevention of overweightin minority children. Pediatric Annals, 33, 45–49.

Flynn, K., & Fitzgibbon, M. (1996). Body image ideals oflow-income African American mothers and theirpreadolescent daughters. Journal of Youth andAdolescence, 25, 615–630.

Godoy-Matos, A., Carraro, L., Vieira, A., Oliveira, J.,Guedes, E., Mattos, L., et al. (2005). Treatment ofobese adolescents with sibutramine: A randomized,double-blind, controlled study. The Journal of ClinicalEndocrinology and Metabolism, 90, 1460–1465.

Golan, M., & Crow, S. (2004). Targeting parentsexclusively in the treatment of childhood obesity:Long-term results. Obesity Research, 12, 357–361.

Golan, M., Weizman, A., Apter, A., & Fainaru, M.(1998). Parents as the exclusive agents of change inthe treatment of childhood obesity. American Journalof Clinical Nutrition, 67, 1130–1135.

Goodman, E., & Whitaker, R.C. (2002). A prospectivestudy of the role of depression in the development andpersistence of adolescent obesity. Pediatrics, 109,497–504.

Graves, T., Meyers, A.W., & Clark, L. (1988). Anevaluation of parental problem-solving training inthe behavioral treatment of childhood obesity. Jour-nal of Consulting and Clinical Psychology, 56, 246–250.

Grund, A., Krause, H., Siewers, M., Rieckert, H., &Muller, M.J. (2001). Is TV viewing an index of physicalactivity and fitness in overweight and normal weightchildren? Public Health Nutrition, 4, 1245–1251.

Guo, S.S., Roche, A.F., Chumlea, W.C., Gardner, J.D.,& Siervogel, R.M. (1994). The predictive value ofchildhood body mass index values for overweight atage 35 years. American Journal of Clinical Nutrition,59, 810–819.

Hedley, A.A., Ogden, C.L., Johnson, C.L., Carroll, M.D.,Curtin, L.R., & Flegal, K.M, (2004). Prevalence ofoverweight and obesity among US children, adoles-cents, and adults, 1999–2002. Journal of the Amer-ican Medical Association, 288, 1728–1732.

Himes, J.H., & Dietz, W.H. (1994). Guidelines foroverweight in adolescent preventive services: Recom-



mendation from an expert committee. AmericanJournal of Clinical Nutrition, 59, 307–316.

Ikeda, J.P., Fujii, M., Fong, K.A., & Hanson, M. (1982).Two approaches to adolescent weight loss. Journal ofNutritional Education, 14, 90–92.

Isnard, P., Michel, G., Frelut, M.L., Vila, G., Falissard,B., Naja, W., et al. (2003). Binge eating and psycho-pathology in severely obese adolescents. InternationalJournal of Eating Disorders, 34, 235–243.

Israel, A.C., Guile, C.A., Baker, J.E., & Silverman, W.K.(1994). An evaluation of enhanced self-regulationtraining in the treatment of childhood obesity.Journal of Pediatric Psychology, 19, 737–749.

Israel, A.C., & Ivanova, M.Y. (2002). Global anddimensional self-esteem in preadolescent and earlyadolescent children who are overweight: Age andgender differences. International Journal of EatingDisorders, 31, 424–429.

Israel, A.C., Stolmaker, L.A., & Andrian, C.A. (1985). Theeffects of trainingparents ingeneral childmanagementskills on a behavioral weight loss program for children.Behavior Therapy, 16, 169–180.

Israel, A.C., Stolmaker, L., Sharp, J.P., Silverman,W.K., & Simon, L.G. (1984). An evaluation of twomethods of parental involvement in treating obesechildren. Behavior Therapy, 15, 424–429.

Jelalian, E., Mehlenbeck, R., Lloyd-Richardson, E.E.,Birmaher, V., & Wing, R.R. (In press). ‘Adventuretherapy’ combined with cognitive behavioral treat-ment for overweight adolescents. International Jour-nal of Obesity.

Jelalian, E., & Saelens, B.E. (1999). Empirically sup-ported treatments in pediatric psychology: Pediatricobesity. Journal of Pediatric Psychology, 24, 223–248.

Kuczmarski, R.J., Ogden, C.L., Guo, S.S., Grummer-Strawn, L.M., Flegal, K.M., Mei, Z., et al. (2002). 2000CDC growth charts for the United States: Methods anddevelopment. Vital Health Statistics 11, 246, 1–190.

Lissau, I.,Overpeck,M.D.,Ruan,W.J.,Due, P.,Holstein,B.E., Hediger, M.L., & The Health and Behavior inSchool-Aged Children Obesity Working Group (2004).Body mass index and overweight in adolescents in 13European countries, Israel, and the United States.Pediatric and Adolescent Medicine, 158, 27–33.

Lobstein, T.J., James,W.P., &Cole, T.J. (2003). Increas-ing levels of excess weight among children in England.International Journal of Obesity, 27, 1136–1138.

Ludwig, D.S., Peterson, K.E., & Gortmaker, S.L. (2001).Relation between consumption of sugar-sweeteneddrinks and childhood obesity: A prospective, observa-tional analysis. The Lancet, 357, 505–508.

Manus, H.E., & Killeen, M.R. (1995). Maintenance ofself-esteem by obese children. Journal of Child andAdolescent Psychiatric Nursing, 8, 17–27.

Marcus, M.D., & Kalarchian, M.A. (2003). Binge eatingin children and adolescents. International Journal ofEating Disorders, 34, S47–S57.

McDuffie, J.R., Calis, K.A., Uwaifo, G.I., Sebring, N.G.,Fallon, E.M., Hubbard, V., & Yanovski, J.A. (2002).Three-month tolerability of orlistat in adolescentswith obesity-related comorbid conditions. ObesityResearch, 10, 642–650.

McElroy, S.L., Kotwal, R., Malhotra, S., Nelson, E.B.,Keck, P.E., & Nemeroff, C.B. (2004). Are mooddisorders and obesity related? A review for the mental

health professional. Journal of Clinical Psychiatry, 65,634–651.

McLean, N., Griffin, S., Toney, K., & Hardeman, W.(2003). Family involvement in weight control, weightmaintenance and weight loss interventions: A sys-tematic review of randomized trials. InternationalJournal of Obesity, 27, 987–1005.

Miller, Y.D., & Dunstan, D.W. (2004). The effective-ness of physical activity interventions for thetreatment of overweight and obesity and type 2diabetes. Journal of Science and Medicine in Sports,7(Suppl. 1), 52–59.

Molnar, D., Torok, K., Erhardt, E., & Jeges, S. (2000).Safety and efficacy of treatment with an ephedrine/caffeine mixture. The first double-blind placebo-controlled pilot study in adolescents. InternationalJournal of Obesity and Related Metabolic Disorders,24, 1573–2578.

Morgan, C.M., Yanovski, S.Z., Nguyen, T.T., McDuffie,J., Sebring, N.G., Jorge, M.R., Keil, M., & Yanovski,J.A. (2002). Loss of control over eating, adiposity, andpsychopathology in overweight children. InternationalJournal of Eating Disorders, 31, 430–441.

Motl, R.W., Birnbaum, A.S., Kubik, M.Y., & Dishman,R.K. (2004). Naturally occurring changes in physicalactivity are inversely related to depressive symptomsduring early adolescence. Psychosomatic Medicine,66, 336–42.

Must, A., & Strauss, R.S. (1999). Risks and conse-quences of childhood and adolescent obesity. Inter-national Journal of Obesity, 23, S2–S11.

Myers, L., Strikmiller, P.K., Webber, L.S., & Berenson,G.S. (1996). Physical and sedentary activity in schoolchildren grades 5–8: The Bogalusa Heart Study.Medi-cine and Science in Sports and Exercise, 28, 852–859.

Neumark-Sztainer, D., Falkner, N., Story, M., Perry, C.,Hannan, P.J., & Mulert, S. (2002). Weight-teasingamong adolescents: Correlations with weight statusand disordered eating behaviors. International Jour-nal of Obesity, 26, 123–131.

Nicklas, T.A., Baranowski, T., Cullen, K.W., & Beren-son, G. (2001). Eating patterns, dietary quality andobesity. Journal of the American College of Nutrition,20, 599–608.

Penedo, F.J., & Dahn, J.R. (2005). Exercise and well-being: A review of mental and physical health benefitsassociated with physical activity. Current Opinion inPsychiatry, 18, 189–93.

Price, R.A. (2002). Genetics and common obesities:Background, current status, strategies and futureprospects. In T.A. Wadden & A.J. Stunkard (Eds.),Handbook of obesity treatment (pp. 73–94). New York:The Guilford Press.

Resnicow, K., Yarock, A.L., Davis, A., Wang, D.T.,Carter, S., Slaughter, L., et al. (2000). Go Girls!:Results from a nutritional and physical activityprogram for low-income, overweight African Americanadolescent females. Health Education and Behavior,27, 616–631.

Reynolds, K.D., Killen, J.D., Bryson, S.W., Maron, D.J.,Taylor, C.B., Maccoby, N., & Farquhar, J.W. (1998).Psychosocial predictors of physical activity in adoles-cents. Preventive Medicine, 19, 541–551.

Richardson, L.P., Davis, R., Poulton, R., McCauley, E.,Moffit, T.E., Caspi, A., et al. (2003). A longitudinal



evaluation of adolescent depression and adult obes-ity. Archives of Pediatrics and Adolescent Medicine,157, 739–745.

Rolland-Cachera, M.F., Thibault, H., Souberbielle, J.C.,Soulie, D., Carbonel, P., Deheeger, M., Roinsol, D.,Longueville, E.,Bellisle,G.,&Serog, P. (2004).Massiveobesity in adolescents: Dietary interventions andbehaviors associated with weight regain at 2-yearfollow-up. International Journal of Obesity, 28, 514–519.

St. Jeor, S.T., Perumean-Chaney, S., Sigman-Grant,M., Williams, D., & Foreyt, J. (2002). Family-basedinterventions for the treatment of childhood obesity.Journal of the American Dietetic Association, 102,640–644.

Sherry, B., McDivitt, J., Birch, L.L., Cook, F.H., Sand-ers, S., Prish, J.L., Francis, L.A., & Scanlon, K.S.(2004). Attitudes, practices, and concerns about childfeeding and child weight status among socioecono-mically diverse white, Hispanic, and African-Amer-ican mothers. Journal of the American DieteticAssociation, 104, 215–221.

Smith, A.L. (2003). Peer relationships in physicalactivity contexts: A road less traveled in youth sportand exercise psychology research. Psychology of Sportand Exercise, 4, 25–39.

Sondike, S.B., Copperman, N., & Jacobson, M.S. (2003).Effects of a low-carbohydrate diet on weight loss andcardiovascular risk factor in overweight adolescents.The Journal of Pediatrics, 142, 253–258.

Sothern, M.S., Schumacher, H., von Almen, T.K.,Carlisle, L.K., & Udall, J.N. (2002). Committed tokids: An integrated, 4-level team approach to weightmanagement in adolescents. Journal of the AmericanDietetic Association, 102, S81–S85.

Spieth, L.E., Harnish, J.D., Lenders, C.M., Raezer, L.B.,Pereira, M.A., Hangen, S.J., & Ludwig, D.S. (2000). Alow-glycemic index diet in the treatment of pediatricobesity. Archives of Pediatrics and Adolescent Medi-cine, 154, 947–951.

Stallings, V.A., Archibald, E.H., Pencharz, P.B., Harri-son, J.E., & Bell, L.E. (1988). One-year follow-up ofweight, total body potassium, and total body nitrogenin obese adolescents treated with the protein-sparingmodified fast. American Journal of Clinical Nutrition,48, 91–94.

Strauss, R.S. (2000). Childhood obesity and self-esteem. Pediatrics, 105, 1–5.

Strauss, R.S., & Pollack, H.A. (2003). Social margin-alization of overweight children. Pediatric and Ado-lescent Medicine, 157, 746–752.

Stunkard, A.J., Faith, M.S., & Allison, K.C. (2003).Depression and obesity. Society of Biological Psychi-atry, 54, 330–337.

Tanofsky-Kraff, M., Yanovski, S.Z., Wilfley, D.E., Mar-marosh, C., Morgan, C.M., & Yanovski, J.A. (2004).Eating-disordered behaviors, body fat, and psycho-pathology in overweight and normal-weight children.Journal of Consulting and Clinical Psychology, 72, 53–61.

Tippett, K.S., & Cleveland, L.E. (1999). How currentdiets stack up: Comparison with dietary guidelines.In E. Frazao (Ed.), America’s eating patterns: Changesand consequences (pp. 51–71). Washington, DC:United States Department of Agriculture.

Trost, S.G., Kerr, L.M., Ward, D.S., & Pate, R.R. (2001).Physical activity and determinants of physical activityin obese and non-obese children. International Jour-nal of Obesity, 25, 822–829.

VanderWal,J.S.,&Thelen,M.H. (2000).Eatingandbodyimage concerns among obese and average-weightchildren. Addictive Behavior, 25, 775–778.

Wadden, T.A., Stunkard, A.J., Rich, L., Rubin, C.J.,Sweidel, G., & McKinney, S. (1990). Obesity in blackadolescent girls: A controlled clinical trial of treat-ment by diet, behavior modification, and parentalsupport. Pediatrics, 85, 345–352.

Whitaker, R.C. (2004). Mental health and obesity inpediatric primary care. Archives of Pediatric andAdolescent Medicine, 158, 826–828.

White, M.A., Martin, P.D., Newton, R.L., Walden, H.M.,York-Crowe, E.E., Gordon, S.T., et al. (2004). Medi-ators of weight loss in a family-based interventionpresented over the internet. Obesity Research, 12,1050–1059.

Wilson, G.T., & Fairburn, C.G. (2002). Treatments foreating disorders. In P.E. Nathan & J.M. Gorman(Eds.), A guide to treatments that work (2nd edn,pp. 559–592). New York: Oxford University Press.

Winkleby, M.A., Gardner, C.D., & Taylor, B. (1996). Theinfluence of gender and socioeconomic factors onHispanic/White differences in body mass index.Preventative Medicine, 25, 203–211.

World Health Organization (2003). Global strategy ondiet, physical activity and health. Retrieved September14, 2004, from: http://www.who.int/dietphysical-activity/publications/facts/obesity/en/.

Xie, B., Gilliland, F.D., Li, Y.F., Rockett, H.R.H. (2003).Effects of ethnicity, family income, and education ofdietary intake among adolescents. Preventative Medi-cine, 36, 30–40.

Yanovski, J.A. (2001a). Intensive therapies for pediatricobesity. Pediatric Clinics of North America, 48, 1041–1053.

Yanovski, J.A. (2001b). Pediatric obesity. Endocrine andMetabolic Disorders, 2, 371–383.

Yanovski, S.Z. (2003). Binge eating disorder and obesityin 2003: Could treating an eating disorder have apositive effect on the obesity epidemic? InternationalJournal of Eating Disorders, 34, S117–S120.

Young-Hyman, D., Schlundt, D.G., Herman-Wenderoth,L.H., & Bozylinski, K. (2003). Obesity, appearance,and psychosocial adaptation in young African Amer-icanchildren.Journal of Pediatric Psychology,28, 463–472.

Zametkin, A.J., Zoon, C.K., Klein, H.W., & Munson, S.(2004). Psychiatric aspects of child and adolescentobesity: A review of the past 10 years. Journal of theAmerican Academy of child and Adolescent Psychi-atry, 43, 134–150.

Zeller, M.H., Kirk, S., Claytor, R., Khoury, P., Grieme,J., Santangelo, M. et al. (2004a). Predictors of attri-tion from a pediatric weight management program.Journal of Pediatrics, 144, 466–470.

Zeller, M.H., Sealens, B.E., Roehrig, H., Kirk, S., &Daniels, S.R. (2004b). Psychological adjustment ofobese youth presenting for weight managementtreatment. Obesity Research, 12, 1576–1586.

Manuscript accepted 9 November 2005

