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Recommendations Summary

Pediatric Weight Management (PWM) Nutrition Counseling and Behavior Therapy Strategies in the Treatment of Obesity in Children and Adolescents

Click here to see the explanation of recommendation ratings (Strong, Fair, Weak, Consensus, Insufficient Evidence) and labels (Imperative or Conditional). To see more detail on the evidence from which the following recommendations were drawn, use the hyperlinks in the Supporting Evidence Section below.


  • Recommendation(s)

    PWM: Nutrition Counseling

    Nutrition counseling, delivered by an RD (which is inclusive of goal-setting, self-monitoring, stimulus control, problem-solving, contingency management, cognitive restructuring, use of incentives and rewards and social supports), should be a part of the behavior therapy component of a multi-component pediatric weight-management program.

    Rating: Consensus
    Imperative

    PWM: Behavioral Therapy

    Behavior therapy strategies should be included as part of a multi-component pediatric weight-management program. Research shows that when behavior therapy strategies are included within the context of a multi-disciplinary team, weight status and body composition improve.

    Rating: Strong
    Imperative

    PWM: Family-Based Counseling

    Family-based counseling that includes parent training or modeling should be included as part of a multi-component weight-management program that targets children ages six to 12 years. During the development of a multi-component treatment program for children ages 12 years and younger, the registered dietitian should advise the health-care team on the advantages of incorporating parent training or modeling as part of the treatment program. Research studies that including parent training or modeling as part of a multi-component weight-management program for children 12 years and younger showed positive changes in a child’s weight status and adiposity.

    Rating: Strong
    Imperative

    • Risks/Harms of Implementing This Recommendation

      None.

    • Conditions of Application

      Additional training may be required for some dietitians to implement some behavior strategies.

      Adequate screening for eating disorders, depression and family risk factors (see the topics under Parent/Child Relationship or Emotional Climate) may fall outside the scope of expertise of individual dietitians and may require consultation with a behavioral therapy specialist member of the health-care team.

    • Potential Costs Associated with Application

      Behavioral interventions targeting children may require resources that some programs do not have available. Program budgets may need to be increased in order to incorporate a behavioral component with a qualified professional.

      If program costs are passed directly to patients and families, this may limit access to the program for less affluent patients and their families.

      Absence of health insurance coverage for weight management could limit program access.

    • Recommendation Narrative

      Recommendation: Nutritional Counseling by a Registered Dietitian

      Nutrition counseling is defined as "a supportive process, characterized by a collaborative counselor-patient/client relationship, to set priorities, establish goals, and create individualized action plans that acknowledge and foster responsibility for self-care to treat an existing condition and promote health."

      Recommendation: Behavioral Strategies

      Inclusion of behavioral therapy strategies was a well-developed and well-described part of the majority of the studies that show successful results. 50 of the studies reviewed contained a behavioral counseling component. Of these studies, eight compared a treatment group with a behavioral counseling component to a treatment group without behavioral training.

      Seven of the randomized controlled trials received a positive quality rating, while one (Golan, Weizman, et al 1998) received a neutral quality rating.

      The six studies that compared an intervention with a behavioral component to an intervention without a behavioral component all found that the treatment group that included a behavioral training intervention had greater improvement in adiposity than the comparison groups (DISC, 1995; Flodmark CE, Ohlsson T et al, 1993; Graves T, Meyers AW et al, 1988; Saelens B, Sallis J et al, 2002; Obarzanek, Kimm et al, 2001; Golan, Weizman et al, 1998).

      In addition, intervention studies that included parent training or modeling showed positive changes in the child’s weight status and adiposity for children 12 years old and younger. The results of studies in youth over 12 years of age were more limited or inconsistent, thus the evidence to recommend parent training or modeling in obese adolescents needs further investigation.

      Recommendation: Family-Based Counseling

      There is a strong association between the inclusion of family-based counseling as part of the childhood obesity treatment program and reductions in weight status or adiposity in children ages six to 12. See What is the effectiveness of family-based counseling as a part of an intervention program to treat obesity in children (ages 6-12)? (Grade I).

      Inclusion of family counseling as part of a multi-component adolescent weight-management program may provide beneficial effects. However, definite conclusions are hampered by the fact that evidence is limited to a small number of older studies, studies of weak design and inconsistent results. See What is the effectiveness of family-based counseling as a part of an intervention program to treat obesity in adolescents (ages 13-18)? (Grade III).

    • Recommendation Strength Rationale

      Recommendation: Nutritional Counseling by a Registered Dietitian

      Nutrition Counseling has been defined as an integral part of the Nutrition Care Process by the American Dietetic Association. Since the recommendation is policy-based, rather than research-based, the strength of the recommendation is consensus.

      Recommendation: Behavioral Strategies

      Strong – The six studies that compared an intervention with a behavioral component to an intervention without a behavioral component all found that the treatment group that included a behavioral training intervention had greater improvement in adiposity than the comparison groups. (Grade I)

      The evidence for an association between improvement in adiposity and including a behavioral treatment component as part of a multicomponent pediatric weight management program was strong (Grade I).

      Recommendation: Family-Based counseling

      In relation to incorporating parent training or modeling with children 12 years and under, the bulk of the studies show that incorporating these to the intervention produces positive changes in the children’s weight and adiposity. (Grade I)

    • Minority Opinions

      None.