Pediatric Weight Management

Parent Training or Modeling to Reduce Childhood Overweight (2006)

Citation:

de Mello ED, Luft VC, Meyer F. Individual outpatient care versus group education programs. Which leads to greater change in dietary and physical activity habits for obese children? J Pediatr (Rio J). 2004 Nov-Dec;80(6):468-74.

PubMed ID: 15622423
 
Study Design:
Randomized controlled trial
Class:
A - Click here for explanation of classification scheme.
Quality Rating:
Neutral NEUTRAL: See Quality Criteria Checklist below.
Research Purpose:
To compare the results of a childhood obesity education programs using two types of treatment: individual outpatient treatment and childhood obesity education program in groups.
Inclusion Criteria:
  • body mass index (BMI) indicative of obesity
  • ability to attend eight times monthly in the company of parents and/or guardians residing in the same house
Exclusion Criteria:
  • Children suffering from chronic disease (defined as those children requiring continuous therapy)
  • Patients with mental or psychological disease that would interfere with understanding
  • Any whose guardians refused to sign the Informed Consent Form
Description of Study Protocol:

Recruitment

Subjects recruited through advertisements in high-circulation newspapers

Design

Six month program with meetings once a month.

Individual Treatment: took place at the pediatric nutritional support clinic that already existed at the Hospital de Clínicas de Porto Alegre under the supervision of the head researcher. Subjects met once a month with one of the three research assistants previously trained in the treatment. They were weighed and measured and received guidance on nutritional intake management and on increasing physical activity. Each subject received a manual which described the main features of the treatment and provided directions.

Group Treatment: subjects attended a group class once a month. The 45 minute educational session was taught by one of the trained program research assistants. After the class, subjects were divided according to age and sex into four groups for activities which included:

  • a review of the lesson and of the commitments made at the previous meeting
  • a task related to the subject-matter of the lesson
  • planning the objectives for the coming month
  • free activity

Parent Participation: Parents met in separate groups to discuss discuss problems and techniques for changing feeding habits.

Blinding used

Subjects were not informed of comparison groups (individual versus group), but were randomly assigned to one group or the other.

Intervention

The meeting sessions covered the following topics:

  • understanding obesity and its complications
  • food and the food guide pyramid
  • food substitutes and food preparation
  • how to be more active
  • behavioral, postural and self-esteem related issues
  • how to maintain healthy habits aquired during the program

Statistical Analysis

Base variables: Student's t test or Mann-Whitney and Wilcoxon non-parametric tests (when parametric test was not appropriate). Outcomes were assessed via covariate analysis. Interventions were compared using a relative risk analysis.

Positive outcomes were defined as: reduction in BMI, OI, total cholesterol, triglycerides, HDL-cholesterol fraction, caloric intake and increase in sporting activity.

Statistical significance was set at p<.05.

Data Collection Summary:

Timing of Measurements

Initial screening visit and six months later at post-treatment

Dependent Variables

  • weight
  • BMI
  • obesity index (OI, current weight/expected weight for the 50th percentile/current height/expected height for the 50th percentile x 100)
  • physical activity (measured via questionnaire)
  • child's food intake (over 24 hours) on the day before the consultation (including foods, type of preparation and quantities ingested)
  • child's general dietary habits
  • calorie intake (estimated from food records)

Independent Variables

 group versus individual intervention

Control Variables

 sexual maturity

Description of Actual Data Sample:

Initial N: 66

Attrition (final N): 28 (14 per group; 57.9% (22) male). Reasons for dropout included:

  • problems preventing parents and/or guardians from attending,
  • children and adolescents' lack of commitment
  • misunderstanding that the proposal would be something that was more "magical"
  • parents were unwilling to change their habits

No significant differences between program completers and dropouts on base variables. Dropout rate: 58%.

Age: 9.9±1.5 years (7.6-12.5)

Ethnicity: not specified

Other relevant demographics:

  • 28.9% (11) had no siblings,
  • 57.9% came from families with a family income of up to six times the national minimum wage
  • 50% (19) had already tried dieting to slim
  • 71.1% (27) had at least one obese family member
  • 39.5% (15) of the parents were obese

Anthropometrics

Location: Rio Grande do Sul, Brazil

Summary of Results:

Comparison Groups and Base Variables

Intervention groups were not significantly different on the following base variables: age, sex, family obesity, previous dieting, BMI, OI, cholesterol, triglycerides, regular soccer playing, watching television and playing video games, feeling like a sedentary person, considering their own nutrition unhealthy and eating between meals (p > 0.05).

The individual treatment group had greater frequency of:

  • general sporting activity (p = 0.027)
  • sport at the weekend (p = 0.022)
  • going for walks (p = 0.004)

Food Intake Outcomes

In terms of improved measures for food intake, the two treatment groups showed improvement on different intake measures.

Individual intervention group significantly improved on the following measures:

  • consumption of fruit (p = 0.033)
  • consumption of vegetables (p = 0.002)
  • eating less beans (p = 0.010)
  • eating less crisps + fried potatoes (0.024).

The group intervention treatment participants improved on the following measures:

  • consumption of soda was reduced (p = 0.022)
  • eating less sandwiches + burgers (p = 0.022)
  • eating less sandwiches + burgers + pizza (p = 0.025),
  • eating less sandwiches + burgers + pizza + fast food (p = 0.006)

Changes for all other intake variables was not statistically significant.

Physical Activity Outcomes

For all but one physical activity outcomes, only the group intervention showed statistically significant improvements.

Individual intervention group showed statistically significant change only on a measure of whether the child was "feeling sedentary: (p=.008).

Group intervention treatment:

  • increased their sporting activity (p = 0.004)
  • increased frequency of going for walks (p = 0.019)
  • increased weekend activities (p = 0.033)
  • decreased "feeling sedentary" (p=.046)

Adiposity Outcomes

For the individual treatment intervention there were no statistically significant changes in adiposity measures (BMI or OI) from baseline to post-treatment.

For the group treatment intervention authors report:

  • reductions in obesity index (OI) (p = 0.038) (note: the outcome reported in the text conflicts with the outcome reported in Table 1 which shows no statistically significant change in OI for either group)
  • total cholesterol (p = 0.003).

For both groups BMI remained stable over the 6 month period (no statistically significant change from baseline).

Author Conclusion:

"The current study shows that an educational program, which can be applied by any health professional at any location did not reveal to be less effective than traditional individualized childhood obesity treatment, and even exhibited certain advantages."

"The group education program resulted in greater increases in global physical activity, including at the weekends, with a tendency towards percentage reductions in the number of children who felt sedentary."

Funding Source:
University/Hospital: Universidade Federal do Rio Grande do Sul (Brazil), FIPE-HCPA-Fund of Incentive to Research at Hospital de ClĂ­nicas de Porto Alegre (Brazil)
Reviewer Comments:

Strengths:

  • randomized design

Weaknesses:

  • very high dropout rate (58%)
  • self report of measures
Quality Criteria Checklist: Primary Research
Relevance Questions
  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
 
Validity Questions
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? Yes
2. Was the selection of study subjects/patients free from bias? Yes
  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? Yes
  2.2. Were criteria applied equally to all study groups? Yes
  2.3. Were health, demographics, and other characteristics of subjects described? Yes
  2.4. Were the subjects/patients a representative sample of the relevant population? No
3. Were study groups comparable? Yes
  3.1. Was the method of assigning subjects/patients to groups described and unbiased? (Method of randomization identified if RCT) Yes
  3.2. Were distribution of disease status, prognostic factors, and other factors (e.g., demographics) similar across study groups at baseline? Yes
  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? Yes
  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%.) Yes
  4.3. Were all enrolled subjects/patients (in the original sample) accounted for? Yes
  4.4. Were reasons for withdrawals similar across groups? Yes
  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? Yes
  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? No
  6.4. Was the amount of exposure and, if relevant, subject/patient compliance measured? No
  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? N/A
  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? N/A
  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? No
  8.1. Were statistical analyses adequately described and the results reported appropriately? No
  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? No
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