Family-based Counseling to Reduce Childhood Overweight (2006)
Nuutinen O. Long-term effects of dietary counseling on nutrient intake and weight loss in obese children. Eur J Clin Nutr. 1991 Jun;45(6):287-97.PubMed ID: 1915202
- To determine whether dietary counseling in an intensive program for weight control affects food consumption, nutrient intake, and weight loss in obese children.
- To determine whether there is a relationship between changes in nutrient intake and changes in relative weight and fat mass.
Obese children: >120% ideal body weight
Normal weight children: <120% ideal body weight
Subjects were not randomized to treatment groups (because of the long duration of the study, the author considered it unethical to leave the obese subjects untreated).
Four treatment groups:
Group 1a: Obese children (n=16), given individual counseling
Group 1b: Obese children (n=16), treated in clinical group setting (behavioral treatment)
Group 2: Obese children (n=16), treated in school setting
Group 3: Normal weight children (n=32) in same school as Group 2
In final analysis, groups 1a and 1b were combined since there were no significant differences during study. Combined groups were defined as Intensive Treatment group.
Group 1a: Individual Treatment
Children met with physician once a month in the first year and twice during the second year. They met with a dietitian five times. Parents attended individual sessions with the child.
The emphasis in the dietary counseling was on reducing fat and sugar intake and increasing fruit and vegetable intake. Food records were kept by the children/parents. Individual diet prescribed by the dietitian consisting of energy intake between 1400-2200 kcal, 25% from protein, 35% from fat, 45% from carbohydrates.
Topics discussed with parents included food purchasing and preparation and family dietary habits.
Group 1b: Behavioral Treatment
In addition to meetings with physician (as with Group 1a) the children and parents in the behavioral treatment group met in small groups (parents and children together for two sessions and separate for the other sessions) seven times the first year for behavioral training. As with Group 1a, diet records were kept.
The nutritionist met with the groups in every other session and the focus of the dietary counseling was similar to that in Group 1a. Additionally, discussions in the behavioral treatment group were aimed at identifying behaviors group members were motivated to change and identifying which behaviors would be put into practice before the next meeting.
Group 2: School-based Treatment
Students met with the school nurse once a month in the first year, and twice during the second year of treatment. Parents were not present.
The objective of the meeting with the school nurse was to encourage the student to "find their own solutions" to dietary problems.
Only half the students were willing to keep food records, and only one quarter of the students received a meal plan (energy intake between 1200-1500 kcal).
Group 3: Controls, no treatment.
Student's T test used to identify differences between groups 1a and 1b, and for comparing anthropometric data between groups 1 and 2. MANOVA used to assess changes in food and nutrient intake. ANOVA used to test for food and nutrient intake differences among groups. Differences between two groups was assessed using least-significant difference with Bonferroni correction. Nonhomogeneous variables assessed using non-parametric analyses.
Timing of Measurements
Anthropomentric measurements for groups 1 and 2 taken once a month (in Group 1 by the same physician, and in Group 2 by the school nurse). In control group (normal weight children) anthropometric measurements were taken by the same physician at baseline, one year and two years.
- Relative weight: measured by dividing the child's weight by the expected weight for height and multiplied by 100.
- Nutrient intake: four day food records were kept by child (with parent help) at baseline, one year, and two years (except in Group 1 where food records were recorded four times). Food record included two weekdays and two weekend days. School lunch was recorded by the child or adult attendant.
- Relative energy intake: calculated by dividing the energy intake by expected weight for height.
- Treatment format
- Growth: using Tanner's rating of pubertal development
Initial N: 48 treatment and 32 controls.
Attrition (final N):
- 4 dropped from the behavioral treatment group
- 3 controls were discovered to be obese at beginning of the study and were excluded.
Ethnicity: Not given.
Other relevant demographics: None described.
Children in Group 1 (intensive treatment) were different from Group 2 (school-based treatment) on the following measures:
- higher relative weight
- more fat tissue
Location: Not reported.
- Consumption of fat and milk products decreased in Group 1 and continued throughout the observation period (p<.001)
- Consumption of fat and milk products did not change for Groups 2 and 3 (though, there was no statistical difference in fat or milk product consumption among the three groups).
- Group 1 consumed less beverages, sugar, and "other foods" than Group 3 (p<.05).
- Groups 1 and 2 consumed less cereal products than Group 3 (p<.01).
Energy and Nutrient Intake
- Group 1 had lower sucrose consumption compared to Groups 2 (p<.05) and 3 (p<.001).
- Group 1 showed a decreased relative intake of energy, fat, protein, and carbohydrates across the observation period (all decreases statistically signfiicant). All decreases were significantly greater than controls (Group 3).
- Group 2 had a lower relative energy and protein intake after the second year (both statistically significant).
- Group 3 relative intake was not significantly different than baseline.
Group 1: Relative weight
Baseline: 160.9% (SD: 20.1)
Year 1: -16.2% (p<.001)
Year 2: -12.8% lower than baseline (p<.001)
Baseline: 142.1% (SD: 12.8)
Year 1: no significant decrease
Year 2: -7.3% from baseline (ns)
- For all obese children (Groups 1 and 2) changes in relative weight and fat mass were not associated with energy intake.
- In children going through their pubertal growth spurt decreased energy intake was related to lower fat mass in the first year (p<.05).
- For children who had already passed their pubertal growth spurt, decreased energy intake was associated with decrease in relative weight in the first year (p<.05) and in fat mass in the second year (p<.05).
Intensive dietary counseling of obese children produced lasting dietary changes over the course of the study.
Conventionally treated children (i.e., children in the school-based treatment group) did not show any significant changes in nutrient intake or relative weight.
The decreases in relative weight of intensively treated obese children (Groups 1a and 1b), were greater than the average decreases shown by other studies.
- Excellent discussion of study limitations and potential problems.
- Multi-year study
- Control group (although controls were normal weight and not obese, so comparable only on dietary and nutrient intake)
- Growth phases taken into account
- School intervention was not well described (or, perhaps it was just not well structured so that there was not much to describe).
- Physical activity either not described or not used in the intervention. No control for this variable.
- Behavioral intervention not well described
- Subject characteristics (besides weight and age) were not given, so generalizability is questionable.
Quality Criteria Checklist: Primary Research
|1.||Would implementing the studied intervention or procedure (if found successful) result in improved outcomes for the patients/clients/population group? (Not Applicable for some epidemiological studies)||Yes|
|2.||Did the authors study an outcome (dependent variable) or topic that the patients/clients/population group would care about?||Yes|
|3.||Is the focus of the intervention or procedure (independent variable) or topic of study a common issue of concern to dieteticspractice?||Yes|
|4.||Is the intervention or procedure feasible? (NA for some epidemiological studies)||Yes|
|1.||Was the research question clearly stated?||Yes|
|1.1.||Was (were) the specific intervention(s) or procedure(s) [independent variable(s)] identified?||Yes|
|1.2.||Was (were) the outcome(s) [dependent variable(s)] clearly indicated?||Yes|
|1.3.||Were the target population and setting specified?||No|
|2.||Was the selection of study subjects/patients free from bias?||No|
|2.1.||Were inclusion/exclusion criteria specified (e.g., risk, point in disease progression, diagnostic or prognosis criteria), and with sufficient detail and without omitting criteria critical to the study?||No|
|2.2.||Were criteria applied equally to all study groups?||No|
|2.3.||Were health, demographics, and other characteristics of subjects described?||No|
|2.4.||Were the subjects/patients a representative sample of the relevant population?||No|
|3.||Were study groups comparable?||No|
|3.1.||Was the method of assigning subjects/patients to groups described and unbiased? (Method of randomization identified if RCT)||No|
|3.2.||Were distribution of disease status, prognostic factors, and other factors (e.g., demographics) similar across study groups at baseline?||No|
|3.3.||Were concurrent controls or comparisons used? (Concurrent preferred over historical control or comparison groups.)||Yes|
|3.4.||If cohort study or cross-sectional study, were groups comparable on important confounding factors and/or were preexisting differences accounted for by using appropriate adjustments in statistical analysis?||N/A|
|3.5.||If case control study, were potential confounding factors comparable for cases and controls? (If case series or trial with subjects serving as own control, this criterion is not applicable.)||N/A|
|3.6.||If diagnostic test, was there an independent blind comparison with an appropriate reference standard (e.g., "gold standard")?||N/A|
|4.||Was method of handling withdrawals described?||No|
|4.1.||Were follow-up methods described and the same for all groups?||Yes|
|4.2.||Was the number, characteristics of withdrawals (i.e., dropouts, lost to follow up, attrition rate) and/or response rate (cross-sectional studies) described for each group? (Follow up goal for a strong study is 80%.)||No|
|4.3.||Were all enrolled subjects/patients (in the original sample) accounted for?||Yes|
|4.4.||Were reasons for withdrawals similar across groups?||No|
|4.5.||If diagnostic test, was decision to perform reference test not dependent on results of test under study?||N/A|
|5.||Was blinding used to prevent introduction of bias?||No|
|5.1.||In intervention study, were subjects, clinicians/practitioners, and investigators blinded to treatment group, as appropriate?||No|
|5.2.||Were data collectors blinded for outcomes assessment? (If outcome is measured using an objective test, such as a lab value, this criterion is assumed to be met.)||No|
|5.3.||In cohort study or cross-sectional study, were measurements of outcomes and risk factors blinded?||N/A|
|5.4.||In case control study, was case definition explicit and case ascertainment not influenced by exposure status?||N/A|
|5.5.||In diagnostic study, were test results blinded to patient history and other test results?||N/A|
|6.||Were intervention/therapeutic regimens/exposure factor or procedure and any comparison(s) described in detail? Were interveningfactors described?||No|
|6.1.||In RCT or other intervention trial, were protocols described for all regimens studied?||Yes|
|6.2.||In observational study, were interventions, study settings, and clinicians/provider described?||N/A|
|6.3.||Was the intensity and duration of the intervention or exposure factor sufficient to produce a meaningful effect?||Yes|
|6.4.||Was the amount of exposure and, if relevant, subject/patient compliance measured?||Yes|
|6.5.||Were co-interventions (e.g., ancillary treatments, other therapies) described?||No|
|6.6.||Were extra or unplanned treatments described?||No|
|6.7.||Was the information for 6.4, 6.5, and 6.6 assessed the same way for all groups?||No|
|6.8.||In diagnostic study, were details of test administration and replication sufficient?||N/A|
|7.||Were outcomes clearly defined and the measurements valid and reliable?||Yes|
|7.1.||Were primary and secondary endpoints described and relevant to the question?||Yes|
|7.2.||Were nutrition measures appropriate to question and outcomes of concern?||Yes|
|7.3.||Was the period of follow-up long enough for important outcome(s) to occur?||Yes|
|7.4.||Were the observations and measurements based on standard, valid, and reliable data collection instruments/tests/procedures?||Yes|
|7.5.||Was the measurement of effect at an appropriate level of precision?||Yes|
|7.6.||Were other factors accounted for (measured) that could affect outcomes?||No|
|7.7.||Were the measurements conducted consistently across groups?||Yes|
|8.||Was the statistical analysis appropriate for the study design and type of outcome indicators?||Yes|
|8.1.||Were statistical analyses adequately described and the results reported appropriately?||Yes|
|8.2.||Were correct statistical tests used and assumptions of test not violated?||Yes|
|8.3.||Were statistics reported with levels of significance and/or confidence intervals?||Yes|
|8.4.||Was "intent to treat" analysis of outcomes done (and as appropriate, was there an analysis of outcomes for those maximally exposed or a dose-response analysis)?||No|
|8.5.||Were adequate adjustments made for effects of confounding factors that might have affected the outcomes (e.g., multivariate analyses)?||No|
|8.6.||Was clinical significance as well as statistical significance reported?||Yes|
|8.7.||If negative findings, was a power calculation reported to address type 2 error?||N/A|
|9.||Are conclusions supported by results with biases and limitations taken into consideration?||Yes|
|9.1.||Is there a discussion of findings?||Yes|
|9.2.||Are biases and study limitations identified and discussed?||Yes|
|10.||Is bias due to study's funding or sponsorship unlikely?||Yes|
|10.1.||Were sources of funding and investigators' affiliations described?||No|
|10.2.||Was the study free from apparent conflict of interest?||Yes|