Beruflich Dokumente
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Hollie Raynor, Ph.D., R.D., L.D.N. Associate Professor Department of Nutrition Obesity Research Center
Objectives
Define evidenceevidence-based treatment Describe the components of evidence evidencebased childhood obesity interventions Describe the components of evidenceevidencebased adult obesity interventions Id tif effective Identify ff ti dietary di t interventions i t ti used in adult behavioral weight control interventions
What is Evidence-based?
The focus on using evidence evidence-based i t interventions ti comes from f concerns that th t patients/clients receive treatment that is grounded in tradition and/or outdated training, rather than scientific evidence Research R h community it encouraged dt to scrutinize and evaluate interventions in order to ascertain their efficacy
What is Evidence-based?
How are interventions evaluated?
Accumulation of research
Quality of research
Experimental vs. Observational designs Methods Measures (self(self-report vs. objective) Randomized Controlled Trials
Meta Meta-analyses
What is Evidence-based?
Evidence Evidence-based medicine
Current best evidence for making clinical decisions about the care of patients/clients Incorporates best research evidence, clinical expertise, and patient values Currently y used to improve p the q quality y of care, and can provide objective criteria for decisions regarding the allocation of health care resources
What is Evidence-based?
Limitations
Understanding efficacy (emphasis on internal validity) vs. effectiveness (emphasis on external validity)
Type of population studied Geographic settings Health care setting
Overweight/Obese - definition
Definitions of overweight and obese are based upon body mass index (BMI): weight (kg)/height (m2) In children, BMI percentile for age and gender is the preferred measure for detecting overweight in children and adolescents Overweight (at risk for overweight): 85th to 94th percentile BMI Obese (overweight): >95th percentile BMI
Overweight/Obese - definition
In adults adults, overweight and obese are classified by BMI BMI > 25 = overweight BMI > 30 = obese BMI > 40 = extreme obesity
BMI = 25 Inches 60 61 62 63 64 65 66 67 68 69 70 71 129 133 137 142 146 151 155 160 165 170 175 180
BMI = 30 153 158 164 169 174 180 186 191 197 203 209 215
Behavioral Theory
Evidence-based childhood and adult obesity Evidenceinterventions are based on behavioral theory
Antecedents Behaviors Consequences
-2
-6
-8
Months
Franz MJ et al. Weight-loss outcomes: a systematic review and meta-analysis of weight loss clinical trials with a minimum 1-year follow-up. JADA 2007;107:1755-67.
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Behavioral Targets
Evidence Evidence-based interventions target behaviors that reduce energy intake and increase energy expenditure
Low Low-calorie diet (900(900-1200 kcals/day)
Most widely studied is the Traffic Light Diet (Epstein and colleagues) Categorizes food into Green, Yellow, Red (based upon energyenergy -density and nutrient quality) Reduce R d i intake t k of f fastfast f t-food, f d soda, d sweet t and d salty lt snack k foods Generally does not cause an increase in F&V and dairy products unless specifically targeted in treatment
Behavioral Targets
Leisure Leisure-time activities
Increase in physical activity (60 minutes/day), with focus on play and family activities Reduction in TV watching ( (< < 15 hours/week)
Increases physical activity May help with decreasing intake
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Family Family-based is not just including parents/caregivers in the treatment of their children's children s obesity it is:
Changing the context of the family (home) environment to help support the change a child is making:
Parenting Communication Support Environment
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Tie weight change to behavior change to demonstrate relationship between behaviors and weight Feedback on self self-monitoring is important
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Positive reinforcement
Treatment Structure
Family Family-based:
Group process Cognitive C Cognitivei i -behavioral b h i l Social learning (Interventionist serves as model of parenting behaviors)
Sessions:
Review of assigned homework (group process and social learning) Presentation and discussion of new topic (cognitive behavioral parenting behaviors/practices) Assignment of new homework
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Treatment Structure
6-months of treatment (Parent + child)
Weekly sessions for 12 to 16 weeks
Group session for parents Group session for children 15 minute individual parentparent-child meeting with an interventionist
For remaining 2 to 3 months of treatment, frequency of sessions drops to either one or two meetings/month
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Maternal and Child Health Bureau Recommendations for Treatment in a Primary Care Setting 1 Start treatment in children as young as 3 1. years of age 2. Apply a familyfamily-based model in treatment 3. Use behavior modification techniques 4. Help families make small changes 5. Target changing 2 or 3 eating and activity behaviors at a time
Childhood Interventions
Behaviors recommended to target in primary care settings
Fast Fast-food intake (limit) Sweetened drink intake (limit) Sweet and salty snack foods (limit) Low Low-fat dairy (2 servings per day) Fruits & vegetables (1.5 c fruits & 2.5 c vegetables/day) Physical activity (60 minutes per day) TV watching (< 2 hrs/day)
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Childhood Interventions
Will these recommendations be effective at treating young children who are overweight? AND What are the best behaviors to target?
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Anthropometric assessments conducted every 3 months (to 12 month followfollow-up) with feedback to families and pediatrician
Child HELP
Increase Fruits and Vegetables (2 servings fruit and 3 servings vegetables/day) Low Low-fat dairy (2 servings/day) energygy-dense foods Low Low-energy increase feelings of fullness and may displace consumption of low low- nutrient nutrientdense foods Decrease Sweet/salty snack foods (< 3 servings/week) Sweetened drinks (< 3 servings/week) Decrease intake of foods that are low in nutrientnutrientdensity and high in energyenergydensity
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2.8 2.6 2.4 2.2 2 1.8 1.6 1.4 1.2 1 0.8 0.6 0.4 0.2 0 0 6 Months 12
zBMI
Kids CAN
Traditional Physical Activity (60 min/day) Sweetened drinks (<3 servings/week) Traditional behaviors that target increasing energy expenditure and decreasing energy intake Substitution TV watching (<2 hours/day) Low Low-fat milk (2 servings/day) Focusing on substitute behaviors for targeted behaviors may enhance feelings of choice for engaging in targeted behavior
81 families randomized
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2.6 2.4 2.2 2 1.8 1.6 1.4 1.2 1 0.8 0.6 0.4 0.2 0 0 6 Months 12
Parenting focus
Children that do better have parents that are doing better
Self Self-monitoring Modeling Stimulus control Pre Pre-planning, problemproblem-solving
zBMI
Caloric prescription appears to be needed to produce clinically relevant weight status improvements
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Physical activity
200 minutes of moderatemoderate-intense activity/week 10,000 steps/day
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Behavior Modification
Strategies for Antecedents: - Change Ch the th home h environment i t (stimulus ( ti l control)
Eating Leisure Leisure-time behaviors
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24
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Behavior Modification
Strategies for behaviors:
Self Self-monitoring
Goals of program
Kcals, fat Physical Activity Weight
Tie weight change to behavior change to d demonstrate t t relationship l ti hi b between t behaviors and weight Feedback on self self-monitoring is important
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Behavior Modification
Strategies for consequences:
Positive reinforcement
Structure of Treatment
As longer duration of contact improves outcomes, standard length of intervention is 18 months
Weight loss interventions
Weekly for 6 months 60 minute group sessions 2 times/month for months 7 7-18 - 60 minute group sessions i
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29
30
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Dietary Structure
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Last L t 24 months: th
Both groups followed the same 12001200-1500 kcals/day diet and used meal replacements for 1 meal and 1 snack per day
2 4 6 8 10 12
Meal Replacement
0 2 4 6
10 12 14 16 18 20 22 24 26 28
Time (months)
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Dietary Variety
Increased dietary variety is associated with increased intake, weight, and body fat in animals (for a review Raynor & Epstein, 2001, Psychological Bulletin) c eased variety a e y within a meal ea is s Increased associated with increased consumption in humans
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FOS
70 60 50
70 60 50 Percent variety 40 30 20 10 0
LFM
40 30 20 10 0
LFV
70 60 Percent variety 50 40 30 20 10 0
50 40 30 20 10 0
Mean percent variety in 5 food groups for recent successful weight losers before and after a standard weight loss intervention (n= 96), and registry participants (n = 2237) (M + SEM). Raynor, H. A., Jeffery, R. W., Phelan, S., Hill, J. O., & Wing, R.R. (2005). Amount of food group variety consumed in the diet and long-term weight loss maintenance. Obesity Research, 13, 883890.
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200 participants
Research Team
Providence, RI Rena Wing, Ph.D. Chantelle Hart, Ph.D. Elissa Jelalian, Ph.D. Patrick Vivier, M.D. Kathrin Osterholt, M.S. Amanda Fine Allison Martir Patty Tellier Holly Manigan Knoxville, TN Betsy Anderson, M.S., R.D. L.D.N. Ashlee Schoch Lusi Martin Shannon Looney, M.P.H. Christen Mullane, M.A. Jess Bachman, M.S., R.D., L.D.N. Emily Van Walleghen, Ph.D. Andrew Carberry Adriana Coletta
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