Lifestyle interventions in the treatment of childhood overweight: a meta-analytic review of randomized controlled trials.

CONTEXT: Evaluating the efficacy of pediatric weight loss treatments is critical. OBJECTIVE: This is the first meta-analysis of the efficacy of RCTs comparing pediatric lifestyle interventions to no-treatment or information/education-only controls. DATA SOURCES: Medline, PsycINFO, and Cochrane Controlled Trials Register. STUDY SELECTION: Fourteen RCTs targetting change in weight status were eligible, yielding 19 effect sizes. DATA EXTRACTION: Standardized coding was used to extract information on design, participant characteristics, interventions, and results. DATA SYNTHESIS: For trials with no-treatment controls, the mean effect size was 0.75 (k = 9, 95% confidence interval [CI] = 0.52-0.98) at end of treatment and 0.60 (k = 4, CI = 0.27-0.94) at follow-up. For trials with information/education-only controls, the mean ES was 0.48 (k = 4, CI = 0.13-0.82) at end of treatment and 0.91 (k = 2, CI = 0.32-1.50) at follow-up. No moderator effects were identified. CONCLUSIONS: Lifestyle interventions for pediatric overweight are efficacious in the short term with some evidence for extended persistence. Future research is required to identify moderators and mediators and to determine the optimal length and intensity of treatment required to produce enduring changes in weight status.     

Theoretical underpinnings of a need-supportive intervention to address sustained healthy lifestyle changes in overweight and obese adolescents

ObjectivesRecent figures indicate that nearly a quarter of Australian adolescents are overweight or obese. Despite the well-established role of physical activity and healthy eating in reducing prevalence of obesity, there remains a lack of effective interventions that promote sustained behavior engagement. This paper aims to describe the theory-based integration and implementation of self-determination theory and goal setting theory in a family-based lifestyle intervention. Although these theories have been shown to independently predict motivation for behavior, a limited number of studies have described behavior-change techniques at a level to allow for effective evaluation and replication, and no studies have combined the theories in a healthy lifestyle behavior intervention.MethodsBehavior change techniques and the associated change mediators are described in relation to need-supportive environments provided by instructors and extended to parents in the home environment. Methods for motivating and promoting sustained engagement in adolescent physical activity and healthy eating and parent behaviors to support these lifestyle changes are discussed within the context of need-satisfaction and goal setting.ConclusionsThis study will contribute to understanding processes for developing and implementing behavior-change techniques based on the integration of two theories of motivation. Future interventions aimed at promoting maintenance of physical activity and healthy eating behaviors in overweight and obese adolescents will benefit by being informed of which techniques are effective at enhancing motivation within the intervention context and home environment.     

Effectiveness and safety of epilepsy surgery: what is the evidence?

Evidence from a recent randomized controlled trial of surgical versus medical therapy of temporal lobe epilepsy proves that antero-mesial resection is safe and more effective than medical therapy. The number of patients needed to treat for one patient to become free of disabling seizures is two, which is superior to most interventions in neurology. A meta-analysis of non-randomized trials gives almost identical results; about two-thirds of patients become seizure-free, compared with only 8% with medical therapy. The results are remarkably similar among studies from different parts of the world. Quality of life improves early after epilepsy surgery, the improvements are both statistically and clinically significant, and they are sustained. Surgical morbidity with clinically important permanent sequelae is 2%. Epilepsy surgery remains underutilized in developed countries and it does not exist in all but a few developing countries. Current randomized trials are underway to explore the effect of early surgery versus optimum medical therapy on the prevention of disability in patients with mesial temporal lobe epilepsy, and to examine the effectiveness of novel interventions, such as minimally invasive surgery and brain stimulation.     

Should medicare reimburse providers for weight loss interventions?

This issue of the American Psychologist (April 2007) includes two reviews of the literature on the effects of behavioral programs to reduce body weight. One review (T. Mann et al., 2007) concentrates on dietary interventions and finds little evidence that diets are of benefit. The second review (L. H. Powell, J. E. Calvin III, & J. E. Calvin Jr., 2007) concentrates on multicomponent interventions and reports some significant achievements of behavioral interventions. Although the reviews come to different conclusions about the value of supporting weight loss interventions, there appears to be agreement that diet alone results in little or no long-term benefit. Evidence-based multicomponent behavioral interventions or interventions that combine behavioral with medical or surgical treatments may offer better chances of long-term weight control. Evidence-based studies are needed to inform policy on provider reimbursement for weight loss programs.     

Promoting Social Nurturance and Positive Social Environments to Reduce Obesity in High-Risk Youth

Nurturing environments within the context of families, schools, and communities all play an important role in enhancing youth’s behavioral choices and health outcomes. The increasing prevalence rates of obesity among youth, especially among low income and ethnic minorities, highlight the need to develop effective and innovative intervention approaches that promote positive supportive environments across different contexts for at-risk youth. We propose that the integration of Social Cognitive Theory, Family Systems Theory, and Self-Determination Theory offers a useful framework for understanding how individual, family, and social-environmental-level factors contribute to the development of nurturing environments. In this paper, we summarize evidence-based randomized controlled trials that integrate positive parenting, motivational, and behavioral skills strategies in different contexts, including primary care, home, community, and school-based settings. Taken together, these studies suggest that youth and parents are most likely to benefit when youth receive individual-level behavioral skills, family-level support and communication, and autonomous motivational support from the broader social environment. Future investigators and healthcare providers should consider integrating these evidence-based approaches that support the effects of positive social climate-based interventions on promoting healthy eating, physical activity, and weight management in youth.     

Testing a new cognitive behavioural treatment for obesity: A randomized controlled trial with three-year follow-up

It is remarkably difficult for people with obesity to maintain a new lower weight following weight loss. The aim of the present study was to examine the immediate and longer-term effects of a new cognitive behavioural treatment that was explicitly designed to minimise this post-treatment weight regain. One hundred and fifty female participants with obesity were randomized to the new treatment, behaviour therapy (the leading alternative psychological treatment) or guided self-help (a minimal intervention). Both of the main treatments resulted in an average weight loss of about ten percent of initial weight whereas weight loss was more modest with guided self-help. The participants were subsequently followed-up for three years post-treatment. The great majority regained almost all the weight that they had lost with the new treatment being no better than the behavioural treatment in preventing weight regain. These findings lend further support to the notion that obesity is resistant to psychological methods of treatment, if anything other than a short-term perspective is taken. It is suggested that it is ethically questionable to claim that psychological treatments for obesity “work” in the absence of data on their longer-term effects.     

An experimental test of the effect of weight-loss dieting on bulimic pathology: tipping the scales in a different direction

Although it is widely accepted that dieting increases the risk for bulimic pathology, this hypothesis has not been tested in a randomized experiment. Accordingly, the authors conducted an experimental test of the dietary restraint model by randomly assigning nonobese women (N = 82) to either a 6-week, low-calorie diet or a waitlist control condition. The diet intervention resulted in significant weight loss, confirming that dieting was successfully manipulated. Contrary to the restraint model, dieting resulted in significant decreases in bulimic symptoms relative to the control condition. Results converge with past findings from randomized obesity prevention and treatment trials and provide evidence that dieting does not promote bulimic pathology; rather, effective decreases in caloric intake appear to reduce bulimic symptoms.     

A randomized controlled trial of single versus multiple health behavior change: promoting physical activity and nutrition among adolescents.

Targeting multiple behaviors for change may provide significant health benefits. This study compared interventions targeting physical activity and nutrition (PAN) concurrently versus physical activity (PA) alone. Adolescents (N=138) were randomized to the PAN or PA intervention or control condition (n=46 per group). Primary outcomes were change in PA accelerometer and 3-day dietary recording from baseline to 3-month follow-up. The PAN and PA interventions were efficacious in supporting boys' (p<.001) but not girls' (p=.663) PA relative to the control condition. Dietary change was minimal. Although the findings do not reveal a decrement to PA promotion when a nutrition intervention was added, neither do they reveal any additional benefit. More studies comparing single versus multibehavioral interventions are needed.     

Prevention of eating disorders and obesity via the internet

Internet technology has been expanding rapidly and has had a dramatic impact on how people communicate, learn and share information. This article presents applications of internet technology to the psychological domain, particularly in the prevention and treatment of eating disorders and obesity. Information regarding advantages and disadvantages of computerized interventions are discussed and several examples of randomized controlled trials with this technology are presented. The studies presented are not meant to be comprehensive of psychological interventions in general, but are examples of computerized applications from the eating disorder and obesity literatures. Ethical considerations and areas for future direction are also discussed.     

The Efficacy and Acceptability of Third-Wave Behavioral and Cognitive eHealth Treatments: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

eHealth is an innovative method of delivering therapeutic content with the potential to improve access to third-wave behaviural and cognitive therapies. This systematic review and meta-analysis aimed to determine the efficacy and acceptability of third-wave eHealth treatments in improving mental health outcomes. A comprehensive search of electronic bibliographic databases including PubMed, PsycINFO, Web of Science, and CENTRAL was conducted to identify randomized controlled trials of third-wave treatments in which eHealth was the main component. Twenty-one studies were included in the review. Meta-analyses revealed that third-wave eHealth significantly outperformed inactive control conditions in improving anxiety, depression, and quality-of-life outcomes and active control conditions in alleviating anxiety and depression with small to medium effect sizes. No statistically significant differences were found relative to comparison interventions. Findings from a narrative synthesis of participant evaluation outcomes and meta-analysis of participant attrition rates provided preliminary support for the acceptability of third-wave eHealth.Third-wave eHealth treatments are efficacious in improving mental health outcomes including anxiety, depression, and quality of life, but not more so than comparison interventions. Preliminary evidence from indices of participant evaluation and attrition rates supports the acceptability of these treatments.     

Getting “SMART” about implementing multi-tiered systems of support to promote school mental health

With the growing adoption and implementation of multi-tiered systems of support (MTSS) in school settings, there is increasing need for rigorous evaluations of adaptive-sequential interventions. That is, MTSS specify universal, selected, and indicated interventions to be delivered at each tier of support, yet few investigations have empirically examined the continuum of supports that are provided to students both within and across tiers. This need is compounded by a variety of prevention approaches that have been developed with distinct theoretical foundations (e.g., Positive Behavioral Interventions and Supports, Social-Emotional Learning) that are available within and across tiers. As evidence-based interventions continue to flourish, school-based practitioners greatly need evaluations regarding optimal treatment sequencing. To this end, we describe adaptive treatment strategies as a natural fit within the MTSS framework. Specifically, sequential multiple assignment randomized trials (SMART) offer a promising empirical approach to rigorously develop and compare adaptive treatment regimens within this framework.     

Long-term effects from a randomized trial of two public health preventive interventions for parental depression.

This article presents long-term effects of a randomized trial evaluating 2 standardized, manual-based prevention strategies for families with parental mood disorder: informational lectures and a brief, clinician-based approach including child assessment and a family meeting. A sample of 105 families, in which at least 1 parent suffered from a mood disorder and at least 1 nondepressed child was within the 8- to 15-year age range, was recruited. Parents and children were assessed separately at baseline and every 9 to 12 months thereafter on behavioral functioning, psychopathology, and response to intervention. Both interventions produced sustained effects through the 6th assessment point, approximately 4.5 years after enrollment, with relatively small sample loss of families (<14%). Clinician-based families had significantly more gains in parental child-related behaviors and attitudes and in child-reported understanding of parental disorder. Child and parent family functioning increased for both groups and internalizing symptoms decreased for both groups, with no significant group differences. These findings demonstrate that brief, family-centered preventive interventions for parental depression may contribute to long-term, sustained improvements in family functioning.     

Medicare's search for effective obesity treatments: diets are not the answer

The prevalence of obesity and its associated health problems have increased sharply in the past 2 decades. New revisions to Medicare policy will allow funding for obesity treatments of proven efficacy. The authors review studies of the long-term outcomes of calorie-restricting diets to assess whether dieting is an effective treatment for obesity. These studies show that one third to two thirds of dieters regain more weight than they lost on their diets, and these studies likely underestimate the extent to which dieting is counterproductive because of several methodological problems, all of which bias the studies toward showing successful weight loss maintenance. In addition, the studies do not provide consistent evidence that dieting results in significant health improvements, regardless of weight change. In sum, there is little support for the notion that diets lead to lasting weight loss or health benefits.     

The efficacy of structural ecosystems therapy with drug-abusing/dependent African American and Hispanic American adolescents.

Many family therapies for adolescent drug use include ecological interventions. The purpose of this randomized clinical trial was to establish whether ecological interventions contribute to the impact of family therapy above and beyond the contributions of family process-only interventions. A family-based ecological approach, structural ecosystems therapy (SET), was compared with family process-only condition (FAM) and community services control (CS). One hundred ninety substance-abusing or dependent African American and Hispanic adolescents were randomized to SET, FAM, or CS. Follow-up assessments were conducted at 3, 6, 12, and 18 months postrandomization. SET was significantly more efficacious than FAM and CS in reducing adolescent drug use. However, these improvements were limited to Hispanic adolescents. The study demonstrates the importance of investigating changes in adolescent drug use as a result of treatment condition across more than 1 racial/ethnic group.     

Factors associated with self-efficacy in persons with chronic illness

Change of lifestyle may be necessary for persons with chronic illnesses in order to manage their health situation and reduce symptom distress. Success in changing lifestyle partly depends on a person's self-efficacy beliefs. This cross-sectional study explores social support, physical activity, and illness perceptions in relation to self-efficacy in a sample with morbid obesity and in a sample with chronic obstructive pulmonary disease (COPD). The linear regression analyses showed that higher physical activity and less emotional response to illness were directly associated with higher self-efficacy among persons with obesity, while more social support; fewer perceived consequences from illness; and more understanding of the illness were directly associated with higher self-efficacy among persons with COPD. The results indicate that obese persons are likely to benefit from increasing physical activity and from receiving emotional support. Persons with COPD may be empowered by being able to utilize cognitive coping strategies and by receiving social support.     

Technology Delivered Interventions for Depression and Anxiety in Children and Adolescents: A Systematic Review and Meta-analysis

Depression and anxiety are common during adolescence. Whilst effective interventions are available treatment services are limited resulting in many adolescents being unable to access effective help. Delivering mental health interventions via technology, such as computers or the internet, offers one potential way to increase access to psychological treatment. The aim of this systematic review and meta-analysis was to update previous work and investigate the current evidence for the effect of technology delivered interventions for children and adolescents (aged up to 18 years) with depression and anxiety. A systematic search of eight electronic databases identified 34 randomized controlled trials involving 3113 children and young people aged 6–18. The trials evaluated computerized and internet cognitive behavior therapy programs (CBT: n = 17), computer-delivered attention bias modification programs (ABM: n = 8) cognitive bias modification programs (CBM: n = 3) and other interventions (n = 6). Our results demonstrated a small effect in favor of technology delivered interventions compared to a waiting list control group: g = 0.45 [95% CI 0.29, 0.60] p < 0.001. CBT interventions yielded a medium effect size (n = 17, g = 0.66 [95% CI 0.42–0.90] p < 0.001). ABM interventions yielded a small effect size (n = 8, g = 0.41 [95%CI 0.08–0.73] p < 0.01). CBM and ‘other’ interventions failed to demonstrate a significant benefit over control groups. Type of control condition, problem severity, therapeutic support, parental support, and continuation of other ongoing treatment significantly influenced effect sizes. Our findings suggest there is a benefit in using CBT based technology delivered interventions where access to traditional psychotherapies is limited or delayed.

     

African American Adolescent-Caregiver Relationships in a Weight Loss Trial

Successful family-based weight loss interventions for African American adolescents are rare. Parent-adolescent interactions supporting adoption of healthier nutrition and physical activity practices are not well understood. African American caregivers' and adolescents' perspectives on how they worked together to achieve weight loss need further exploration. This study describes the relationships experienced by adolescents and caregivers during the 6-month, evidence-based FIT Families weight loss trial and explores differences between families whose adolescents were successful and unsuccessful with weight loss. Exit interviews conducted with 136 adolescents (age 12–16 years; BMI percentile ≥95) and their caregivers (primarily mothers) were taped and transcribed verbatim. Content and thematic analysis was conducted to explore differences between groups stratified by weight loss. Five adolescent-caregiver relationship patterns emerged which describe dyads working together, working alone, working against each other; caregiver support and caregiver working on self. When relationship patterns were compared between groups stratified by weight loss, three themes emerged: motivation, support, and persistence. Families that achieved the greatest weight loss referred more often to working together to reach weight loss goals, attributed their success to adolescent self-motivation, with engaged caregiver support which allowed families to persist in change efforts. Family relationships involving adolescent autonomy, engaged parental support, and persistence despite challenges, clustered differently among adolescents who were successful at weight loss compared to those who were not. Interventionists trained to reinforce effective adolescent-parent interactions will advance behavioral interventions for families who have typically benefited least in prior interventions.     

The Integration of a Family Systems Approach for Understanding Youth Obesity,Physical Activity,and Dietary Programs

Rates of overweight in youth have reached epidemic proportions and are associated with adverse health outcomes. Family-based programs have been widely used to treat overweight in youth. However, few programs incorporate a theoretical framework for studying a family systems approach in relation to youth health behavior change. Therefore, this review provides a family systems theory framework for evaluating family-level variables in weight loss, physical activity, and dietary approaches in youth. Studies were reviewed and effect sizes were calculated for interventions that manipulated the family system, including components that targeted parenting styles, parenting skills, or family functioning, or which had novel approaches for including the family. Twenty-one weight loss interventions were identified, and 25 interventions related to physical activity and/or diet were identified. Overall, family-based treatment programs that incorporated training for authoritative parenting styles, parenting skills, or child management, and family functioning had positive effects on youth weight loss. Programs to improve physical activity and dietary behaviors that targeted the family system also demonstrated improvements in youth health behaviors; however, direct effects of parent-targeted programming is not clear. Both treatment and prevention programs would benefit from evaluating family functioning and parenting styles as possible mediators of intervention outcomes. Recommendations are provided to guide the development of future family-based obesity prevention and treatment programs for youth.     

Increasing the prevalence of successful children: The case for community intervention research

This paper makes a case for research on community interventions on child rearing. Sufficient evidence has accumulated about the development of children's problem behavior to justify evaluating efforts to reduce the prevalence of these problems in whole communities. The contextual risk factors for diverse child behavior problems are well understood, and interventions to ameliorate individual risk factors have been developed and evaluated. Because interventions with individual children have proven to be efficacious, it is now appropriate to direct energy toward reducing the prevalence of children with behavior problems. At the same time, existing interventions have limitations. Community interventions may be needed to modify the larger social context for families. This paper enumerates possible components of a community intervention to improve child-rearing outcomes. Existing evidence indicates that communities would benefit from making parent training and family support programs available to parents. Validated methods of identifying and remediating academic and behavioral problems in schools are available, but influencing schools to adopt them remains a problem. Community organizing could mobilize communities to allocate the resources necessary to support such parenting and schooling programs as well as encourage their adoption. Media campaigns could foster community support and directly influence parenting practices. Efforts to modify peer influences to use illicit substances have received empirical support; similar efforts may be relevant to preventing other problems. The development of a science of community interventions on child rearing is hampered by overreliance on randomized control trials. For this reason, two examples of time-series experimental evaluations of community intervention components are described here.