Many experts agree that the most effective route to curbing the epidemic of obesity in this country involves tackling the issue among children—before unhealthy habits and lifestyles become entrenched. However, as with weight management programming geared toward adults, it is hard to find scientific evidence that a particular strategy or program designed for children actually works over the long term. And the challenge of finding a solution to this problem is even greater when you consider that pediatric obesity is most prevalent among minority and disadvantaged populations.
Still, enough people are working on this issue that viable approaches to the problem are beginning to emerge. One such methodology is a program developed at Yale University in New Haven, CT, that utilizes an educational process to gradually produce positive lifestyle changes in youngsters and their families.
In a one-year, randomized controlled trial that compared the effect of this program, called Bright Bodies, with a more traditional, clinic-based approach to weight management, the Bright Bodies program produced a range of clinical improvements regarding key metrics including body mass index (BMI), whereas such values among control group participants actually worsened.
Although the results of this groundbreaking trial were just published in the Journal of the American Medical Association (JAMA), the lead author of the study, Mary Savoye, RD, CD-N, CDE, recently provided a more in-depth discussion of what the critical components of the Bright Bodies program are, what costs are involved, and how the approach might be successfully duplicated elsewhere.
Obesity: A major pediatric challenge
Savoye spoke at a news conference scheduled to coincide with publication of JAMA’s June 27 issue, which was devoted entirely to issues related to chronic disease in children. Although it is not entirely clear how many children suffer from chronic disease, Catherine DeAngelis, MD, MPH, a coeditor of the issue, noted that the best estimate is that 15%–18% of children have at least one chronic condition. “It is a very substantial problem,” said DeAngelis. “A chronic condition in a child will become a chronic condition in an adult. You just know that. And what you are talking about for adults is maybe 10 or 20 years of suffering. With a child, you are talking about 50 and maybe even 60 years of suffering.”
A large number of these cases are directly linked to the dramatic increases in childhood obesity that have occurred during the past four decades. Citing statistics from the National Health and Nutrition Examination survey and the Centers for Disease Control and Prevention (CDC), Savoye noted that in 1963, only 4% of six- to 11-year-olds and 5% of 12- to 19-year-olds were considered overweight or obese. “Today we are at 19% and 17%, [respectively]. And if we were to isolate this group and look at minorities, this percentage would be as high as 26%,” said Savoye, indicating that the problem represents a major pediatric health challenge.
The effect of childhood obesity is particularly apparent in the increasing prevalence of Type 2 diabetes among youngsters. “Years ago, Type 2 diabetes was diagnosed at age 40. Now children are being diagnosed at 15 to 16 years of age,” said Savoye.
Family involvement is critical
Noting that it is clear that the traditional approach, involving infrequent visits to a clinic for counseling and education, has not proven effective in addressing the problem, Savoye and colleagues set out to investigate whether a higher-intensity program—including supervised physical activity, nutrition counseling, and psychosocial support—would deliver clinically significant returns in an inner-city population of children in New Haven, CT.
Participants in the study had to be eight to 16 years of age, and they had to meet the CDC’s definition of overweight, which involves having a BMI greater than the 95th percentile. In addition, there had to be a caregiver willing to participate in the program with the child. Children who met the study criteria were then randomized on a two-to-one basis, either to the Bright Bodies weight management group or the control group, which would receive traditional care. Ultimately, 105 children were randomized to the intervention group, and 69 were randomized to receive traditional care.1
Interestingly, investigators also initially intended to further randomize the intervention participants toward two different nutritional approaches: one that involved a dieting group and one that focused on educating families about healthy food choices. However, Savoye noted that it quickly became clear that the dieting approach was not working at all. “Most of the kids [in the dieting group] dropped out. At the six-month mark, we only had five or six participants,” she said, noting that at this point, investigators abandoned the dieting approach altogether, and siphoned all of the intervention participants toward the healthy food choices intervention.
The overall goal of the healthy food approach was to encourage entire families to make better food choices. Consequently, both caregivers and children in the intervention group were required to attend a 40-minute nutrition class, facilitated by a registered dietitian, once per week. “You would be surprised how many families feel that everybody in the family should be eating differently than the overweight child,” noted Savoye. “So, we really worked on the concept of getting everyone in the family to eat healthy together.”
Intervention includes fitness & emotional support
In addition to the nutrition component, the children in the Bright Bodies group also attended supervised exercise classes twice per week for 50 minutes. Participants were grouped according to age, and Savoye emphasized that program developers tried to incorporate games, relay races, and other activities that would be enjoyable. “The goal . . . was to instill a sense that exercise can be fun for these kids, and that it is critical to the weight-management equation,” she said, noting that the kids were also encouraged to exercise for three additional days on their own. All the kids wore heart rate monitors during these sessions so that staff members could ensure that they were working at 65%–85% of their maximum heart rate.
A third component of the Bright Bodies program involved 40-minute sessions, once per week, that focused on behavior modification. The sessions were facilitated by either a registered dietitian or a social worker, and Savoye explained that there were separate classes for parents and children.
At the end of six months, the Bright Bodies group shifted to a maintenance phase, where the various classes decreased from biweekly to bimonthly for the final six months of the study. Alternatively, there was no change in the care provided to the control group. “They came in and received a medical assessment, diet and exercise counseling, and brief psychosocial counseling by our social worker,” said Savoye, noting that the families were asked to increase their physical activity and decrease their sedentary activity.
Intervention delivers positive outcomes
A significant number of participants in the intervention program dropped out before the end of the one-year study period. Of 105 participants, only 75 completed the program. From follow-up discussions with some of these individuals, Savoye indicated that transportation was a big problem for many of the families. “Also, we found that a lot of people just didn’t realize what kind of commitment we were talking about. It sounded good to them at the beginning, but to come in twice a week I think was very hard for them,” she said. However, there was also a high dropout rate in the control group, even though the commitment was far less in that arm of the study. Of 69 participants, only 44 completed the study.
Despite the problem with dropouts, investigators found that the Bright Bodies group significantly outperformed the control group on a range of indicators. For example, while the Bright Bodies participants were able to, on average, maintain their baseline weight at 12 months, control group participants gained an average of 7.7 kg. This correlated to reductions in BMI for the Bright Bodies group and increases in BMI in the control group.
Similarly, there was a 20-lb difference in body fat, on average, between participants in the two groups, with intervention group participants decreasing the percentage of body fat in their bodies whereas that percentage was increasing in control group participants.
There was not much difference between the two groups with respect to cardiovascular outcomes, such as lipid levels and blood pressure, but investigators found significant differences in insulin resistance, as measured by the homeostasis assessment model for insulin resistance, or HOMA-IR. Using this measure, Savoye found that 57% of the participants in the intervention group and 59% of the participants in the control group had insulin resistance at baseline. “Out of that percentage, half of [the participants] in the treatment group had their insulin resistance resolved within the 12-month study period,” said Savoye, but she noted that none of the control group members experienced similar improvement. In fact, she points out that 25 control group participants who did not exhibit signs of insulin resistance at the beginning of the study had developed insulin resistance by the end of the study.
Future focus on cost, dissemination
The randomized trial lasted for only 12 months, but Savoye indicated that she has good reason to believe that the positive results achieved in the Bright Bodies group will have lasting effect, noting that earlier pilot studies of the approach showed continuing benefits at two years. “My sense is that these kids will continue to do very well and that the secret is that it is an educational process,” she said. “They can now make informed decisions about better food choices.”
Investigators are now working on calculating the cost-effectiveness of the approach for a separate study, but considering that program developers received free use of a school facility to carry out the study and that they received some funding, Savoye calculated that program expenses amounted to about $800 per child, per year to decrease BMI by 1.7 units. “With rent, the program will cost more, but I think this is a very economical way to treat a child, and to make really good changes in health outcomes. It is affordable,” she said.
1Savoye M., Shaw M., Dziura J., et al. “Effects of a Weight Management Program on Body Composition and Metabolic Parameters in Overweight Children.” JAMA 2007; 297:2697–2704.