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Recommendations Summary

PWM: Multicomponent Pediatric Weight Management Interventions 2015

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: RDN in Multicomponent Pediatric Weight Management Interventions

    The registered dietitian nutritionist (RDN) should be an integral part of multi-component pediatric weight management interventions. A strong body of research indicates that short-term (six-month) and long-term (two-year) decreases in body mass index (BMI) and BMI Z-scores for all age categories were more likely to be achieved when an RDN or psychologist/mental health provider were involved in multi-component weight management interventions that included diet and nutrition [including medical nutrition therapy (MNT)], physical activity and behavioral components.

    Rating: Strong
    Imperative

    PWM: Multicomponent Pediatric Weight Management Interventions

    When providing pediatric weight management, the registered dietitian nutritionist (RDN) should ensure the multi-component interventions include diet/nutrition [medical nutrition therapy (MNT)], physical activity and behavioral components. A strong body of research indicates that short-term (six-month) and long-term (two-year) decreases in body mass index (BMI) and BMI Z-scores for all age categories were more likely to be achieved when an RDN or mental health professional were involved in the multi-component pediatric weight management interventions that included the above three major components.
     

    Rating: Strong
    Imperative

    • Risks/Harms of Implementing This Recommendation

      The harm of delivering multi-component pediatric weight management interventions is small. Pediatric weight management interventions for overweight and obese youths may mildly increase injury risk with exercise. However, no evidence of other adverse effects resulting from pediatric weight management programs on growth, eating disorder pathology or mental health was found. Caution is suggested because these findings were tentative due to incomplete reporting. More robust harms assessment and reporting was recommended to confirm this (USPSTF, Barton 2010; Whitlock et al, 2010). An update of the USPSTF 2010 is underway at the time of this publication. 

    • Conditions of Application

      • Adequate staffing with expertise in pediatric weight management and the major component areas is required
      • Intervention format and training and educational materials should be developmentally appropriate and health literate, as well as culturally relevant for both the child and parent or care giver
      • Age, socioeconomic status, cultural issues and disease conditions should be taken into consideration
      • Organizational barriers include lack of space for groups, space for physical activity (indoor and outdoor) and trained staff to conduct components of the intervention program
      • Absenteeism and attrition may affect success rate
      • The RDN should be aware of and refer to community resources and programs to support pediatric weight management.

    • Potential Costs Associated with Application

      Costs to Organization or Program

      • Substantial infrastructure is required to implement a multi-component pediatric weight management program
      • The costs and resources required depend upon the level of professional and support staffing, the setting (clinical and non-clinical space), individual or group sessions, size of groups, frequency of visits and duration of intervention
      • Participant absenteeism and attrition may affect reimbursement and program sustainability.
      Costs to Patient and Family
      • Costs of nutrition, physical activity and behavioral components and reimbursement for these may vary
      • The absence of health insurance coverage for pediatric weight management could limit program access and participation.

    • Recommendation Narrative

      A total of 72 articles (73 studies) provide support for the recommendations

      Positive Quality Studies (36)

      • A total of 34 randomized controlled trials (RCTs): Budd et al, 2007; Chanoine and Richard, 2011; Collins et al, 2011; Demol et al, 2009; Díaz et al, 2010; Epstein et al, 2008; Epstein et al, 2005; Ford et al, 2010; Jelalian et al, 2010; Jiang et al, 2005; Jones et al, 2008; Kalavainen et al, 2007; Kalavainen et al, 2011; Klesges et al, 2010; Krebs et al, 2010; Munsch et al, 2008; Naar-King et al, 2009; Nemet et al, 2005; O'Brien et al, 2010; Okely et al, 2010; Rezvanian et al, 2010; Robinson et al, 2010; Rooney et al, 2005; Rosado et al, 2008; Sacher et al, 2010; Saelens et al, 2011; Sato et al, 2010; Savoye et al, 2011; Shalitin et al, 2009; Simon et al, 2008; Stice et al, 2008; Wafa et al, 2011; Wilfley et al 2007; Yu et al, 2005
      • Two randomized crossover trials: Coppins et al, 2011; Doyle-Baker et al, 2011.
      Neutral Quality Studies (37)
      • A total of 31 RCTs: Atabek and Pirgon, 2008; Berkowitz et al, 2006; Berkowitz et al, 2011; Bravender et al, 2010; Burgert et al, 2008; Clarson et al, 2009; Croker et al, 2012; Doyle et al, 2008; Garipagaoglu et al, 2009; Godoy-Matos et al, 2005; Golan et al, 2006; Goldschmidt et al, 2011; Hart et al, 2010; Hughes et al, 2008; Jelalian et al, 2008; Jelalian et al, 2006; Johnston et al, 2011; Kalarchian et al, 2009; Magarey et al, 2011; Nemet et al, 2008; Pedrosa et al, 2011; Ribeiro et al, 2005; Tjønna et al, 2009; Van Mil et al, 2007; Wake et al, 2009; Weigel et al, 2008; Williams et al, 2007; Williamson et al, 2005; Williamson et al, 2006; Wilson et al, 2010; Yackobovitch-Gavan et al, 2008
      • Four non-randomized controlled trials: Adam et al, 2009; Nowicka et al, 2009; Reinehr et al, 2006; Reinehr et al, 2009
      • One cluster randomized trial:  Eliakim et al, 2007
      • One before-after study: Epstein et al, 2005 (Study 2).
      Multi-component Weight Management Interventions
       
      • Multi-component weight management interventions that include diet and nutrition, physical activity and behavioral components and involve an RDN or psychologist or mental health provider are more likely to be effective in treating overweight in children and teens compared to interventions missing at least one of these major components
      • Multi-component interventions were associated with shorter-term (six-month) and longer-term (two-year) decreases in BMI Z-scores and BMI for all age categories. Conversely, the absence of one or more of these components was associated with in an increase in BMI measures in the longer term.  Shorter-term and longer-term BMI-Z scores were reduced with both types of interventions. However, significantly greater reduction was reported in the multi-component interventions. BMI percentile reductions at six months were also observed in the multi-component interventions, but were reported in fewer studies.  
      • A huge number of possible combinations of intervention components existed across studies. Multiple correspondence analysis and hierarchical cluster analysis was used and two very clear clusters (types of intervention mixes) were identified: 
        • Multi-component intensive type (MCI): Study arms characterized by interventions that tend to include all of the following major components:
          • Diet and nutrition
          • Physical activity
          • Behavior
          • Involvement of an RDN or psychologist or mental health provider.
        • Minimal intervention type (MI): Study arms characterized by interventions that are likely to be missing at least one of the above major intervention components. 
      • We then examined the associations between these intervention mix types (MCI vs. MI) and the presence or absence of a range of diet, exercise and behavior intervention components.

      BMI Z-Score Outcomes

      Fifty arms reported BMI Z-score changes from baseline in at least one of the five time periods. Data analysis of arm-level BMI Z-score means indicated that both intervention mix types had a net reduction in BMI Z-score across periods (mean BMI Z-score below zero). However, BMI Z-score increased from the initial decrease at less than six months and stabilized at -0.1 BMI-Z compared to baseline for MI. The pattern was different with MCI; where BMI Z-score increased from the initial time point, but then decreased from six months to one year. Both types maintained a decrease in BMI Z-scores below baseline at two years.  At the one-year time point, the difference in BMI-Z for MCI was significantly lower (P<0.05) than for MI.  

      BMI Outcomes

      Forty-five arms reported BMI changes from baseline in at least one of the time periods. Data analysis indicated that the two intervention types showed similar patterns with respect to BMI change from baseline. In both MCI and MI, there were greater BMI declines in the first period (less than six months) with a BMI regain at the second year. The initial decreases in baseline BMI were offset by increases in BMI in later time periods, with both groups demonstrating a net BMI increase over baseline at two years. MCI remained very close to baseline BMI measure, even at the two-year time period. The BMI decrease in MCI was significantly higher at less than six months, six months and one year (P<0.05) compared to MI. 

      BMI Change Sub-analysis by Age Group
      • Because child growth affects BMI values, data were also analyzed to see whether there were differences in BMI changes at each time point by age categories. The sample was divided into three categories:
        • Child: Six to 11 years
        • Middle school: Twelve years to 14 years
        • Teen: Thirteen to 18 years.
      • For all three age categories, the BMI change from baseline showed significant short-term reductions for MCI compared to MI and remained very close to baseline BMI measures even at the two-year time period. 
      BMI Percentile Outcomes

      Fewer studies reported changes in BMI percentile (N=10). At less than six months, mean BMI percentile changes were significantly (P=0.005) different between the two intervention types, with MCI reporting the greatest decrease. The small number of arms reporting this outcome decreases our confidence in the effect of the two intervention types on BMI percentiles. 

    • Recommendation Strength Rationale

      • Conclusion statement is Grade I.
      • Study arms (groups in the study, for example, intervention group or control) varied widely in terms of the mix of intervention components used
      • Because of the extreme heterogeneity, differences between type were interpreted at the treatment arm, not at the individual child level. No attempt was made to estimate individual level effects of intervention.

    • Minority Opinions

      None.