Christopher Bolling

a Pilot Randomized Controlled Trial of a Clinic and Home-Based Behavioral Intervention to Decrease Obesity in Preschoolers

We evaluated the efficacy of a 6‐month clinic and home‐based behavioral intervention (Learning about Activity and Understanding Nutrition for Child Health; LAUNCH) to reduce obesity in preschool children ≥95th BMI percentile compared to enhanced standard of care (Pediatrician Counseling; PC). LAUNCH was a family‐based behavioral intervention that taught parents to use child behavior management strategies to increase healthy eating and activity for their children and themselves. PC presented the same diet and activity recommendations, but was delivered in a one‐time PC session. Eighteen children aged 2–5 years (mean 4.71 ± 1.01) with an average BMI percentile of 98 (±1.60) and an overweight parent were randomized to LAUNCH or PC. Assessments were conducted at baseline, 6 months (end of LAUNCH treatment) and 12 months (6 months following LAUNCH treatment). LAUNCH showed a significantly greater decrease on the primary outcomes of child at month 6 (post‐treatment) BMI z (−0.59 ± 0.17), BMI percentile (−2.4 ± 1.0), and weight gain (−2.7 kg ± 1.2) than PC and this difference was maintained at follow‐up (month 12). LAUNCH parents also had a significantly greater weight loss (−5.5 kg ± 0.9) at month 6 and 12 (−8.0 kg ± 3.5) than PC parents. Based on the data from this small sample, an intensive intervention that includes child behavior management strategies to improve healthy eating and activity appears more promising in reducing preschool obesity than a low intensity intervention that is typical of treatment that could be delivered in primary care.

How Pediatricians Can Improve Diet and Activity for Overweight Preschoolers: A Qualitative Study of Parental Attitudes

OBJECTIVE This study sought feedback from parents of overweight preschoolers on terms for overweight and treatment strategies pediatricians could use to help parents improve diet and activity for their children. METHODS Twenty-three parents of 21 children aged 2 to 6 years and between the 85th and 94th percentile body mass index participated in focus groups conducted by a pediatrician to assess 1) terms and health risks that motivate parents, 2) barriers that prevent adoption of recommended behaviors, and 3) recommendations for pediatricians on strategies to help parents improve child diet and activity. RESULTS With regard to weight status, parents preferred the terms overweight and obese as long as pediatricians provided rationale for the classification. Parents recommended that pediatricians avoid colloquial terms to describe weight status. With regard to American Academy of Pediatrics recommendations for weight management in overweight preschoolers, parents were reluctant to restrict 100% fruit juice, needed specific strategies to increase vegetable consumption, and said limiting screen time would be difficult, especially when busy or during inclement weather. Despite identification of barriers, parents reported confidence in adopting all recommended behaviors except vegetable intake if given the rationale for the recommendation and strategies for implementation. CONCLUSION Parents recommended that pediatricians speak clearly about weight status, explain rationale for concern, relate that concern to family history, and provide specific advice and treatment recommendations.

Role of Carbohydrate Modification in Weight Management among Obese Children: A Randomized Clinical Trial

OBJECTIVE To compare the effectiveness and safety of carbohydrate (CHO)-modified diets with a standard portion-controlled (PC) diet in obese children. STUDY DESIGN Obese children (n=102) aged 7-12 years were randomly assigned to a 3-month intervention of a low-CHO (LC), reduced glycemic load (RGL), or standard PC diet, along with weekly dietary counseling and biweekly group exercise. Anthropometry, dietary adherence, and clinical measures were evaluated at baseline and 3, 6, and 12 months. Analyses applied intention-to-treat longitudinal mixed models. RESULTS Eighty-five children (83%) completed the 12-month assessment. Daily caloric intake decreased from baseline to all time points for all diet groups (P<.0001), although LC diet adherence was persistently lower (P<.0002). At 3 months, body mass index z score was lower in all diet groups (LC, -0.27 ± 0.04; RGL, -0.20 ± 0.04; PC, -0.21 ± 0.04; P<.0001) and was maintained at 6 months, with similar results for waist circumference and percent body fat. At 12 months, participants in all diet groups had lower body mass index z scores than at baseline (LC, -0.21 ± 0.04; RGL, -0.28 ± 0.04; PC, -0.31 ± 0.04; P<.0001), and lower percent body fat, but no reductions in waist circumference were maintained. All diets demonstrated some improved clinical measures. CONCLUSION Diets with modified CHO intake were as effective as a PC diet for weight management in obese children. However, the lower adherence to the LC diet suggests that this regimen is more difficult for children to follow, particularly in the long term.

A Pilot Randomized Controlled Trial of a Behavioral Family-Based Intervention With and Without Home Visits to Decrease Obesity in Preschoolers

OBJECTIVE Tested two family-based behavioral treatments for obesity in preschool children, one meeting the Expert Committee guidelines for Stage 3 obesity intervention criteria (LAUNCH-clinic) and one exceeding Stage 3 (LAUNCH with home visit [LAUNCH-HV]), compared with a Stage 1 intervention, pediatrician counseling (PC). METHODS In all, 42 children aged 2-5 years with a body mass index (BMI) percentile of ≥95th were randomized. A total of 33 met intent-to-treat criteria. Assessments were conducted at baseline, Month 6 (posttreatment), and Month 12 (6-month follow-up).  RESULTS  LAUNCH-HV demonstrated a significantly greater decrease on the primary outcome of change in BMI z-score (BMIz) pre- to posttreatment compared with PC (p = .007), whereas LAUNCH-clinic was not significantly different from PC (p = .08). Similar results were found for secondary outcomes.  CONCLUSIONS  LAUNCH-HV, but not LAUNCH-clinic, significantly reduced BMIz compared with PC by posttreatment, indicating the need for intensive behavioral intervention, including home visitation, to address weight management in obese preschool children.

High Body Mass Index in Infancy May Predict Severe Obesity in Early Childhood

Objective To characterize growth trajectories of children who develop severe obesity by age 6 years and identify clinical thresholds for detection of high‐risk children before the onset of obesity. Study design Two lean (body mass index [BMI] 5th to ≤75th percentile) and 2 severely obese (BMI ≥99th percentile) groups were selected from populations treated at pediatric referral and primary care clinics. A population‐based cohort was used to validate the utility of identified risk thresholds. Repeated‐measures mixed modeling and logistic regression were used for analysis. Results A total of 783 participants of normal weight and 480 participants with severe obesity were included in the initial study. BMI differed significantly between the severely obese and normal‐weight cohorts by age 4 months (P < .001), at 1 year before the median age at onset of obesity. A cutoff of the World Health Organization (WHO) 85th percentile for BMI at 6, 12, and 18 months was a strong predictor of severe obesity by age 6 years (sensitivity, 51%‐95%; specificity, 95%). This BMI threshold was validated in a second independent cohort (n = 2649), with a sensitivity of 33%‐77% and a specificity of 74%‐87%. A BMI ≥85th percentile in infancy increases the risk of severe obesity by age 6 years by 2.5‐fold and the risk of clinical obesity by age 6 years by 3‐fold. Conclusions BMI trajectories in children who develop severe obesity by age 6 years differ from those in children who remain at normal weight by age 4‐6 months, before the onset of obesity. Infants with a WHO BMI ≥85th percentile are at increased risk for developing severe obesity by age 6 years.

Learning about Activity and Understanding Nutrition for Child Health (LAUNCH): Rationale, design, and implementation of a randomized clinical trial of a family-based pediatric weight management program for preschoolers

Obesity affects nearly 2 million preschool age children in the United States and is not abating. However, research on interventions for already obese preschoolers is limited. To address this significant gap in the literature, we developed an intervention targeting obesity reduction in 2 to 5year olds, Learning about Activity and Understanding Nutrition for Child Health (LAUNCH). This paper describes the rationale, design, participant enrollment, and implementation of a 3-arm randomized, parallel-group clinical trial comparing LAUNCH to a motivational-interviewing intervention (MI) and standard care (STC), respectively. Whereas LAUNCH was designed as a skills based intervention, MI focused on addressing the guardians motivation to make changes in diet and activity and providing tools to do so at the guardians level of readiness to implement changes. Child body mass index z-score was the primary outcome, assessed at pretreatment, posttreatment (Month 6), and 6 and 12month follow-ups (Months 12 and 18). Mechanisms of weight change (e.g., dietary intake, physical activity) and environmental factors associated with weight (e.g., foods available in the home, caregiver diet) were also assessed. This study is unique because it is one of the few randomized controlled trials to examine a developmentally informed, clinic and home skills based behavioral family intervention for preschoolers who are already obese. Being obese during the preschool years increases the likelihood of remaining obese as an adult and is associated with serious health conditions; if this intervention is successful, it has the potential to change the health trajectories for young children with obesity.

Barriers to Recruitment in Pediatric Obesity Trials: Comparing Opt-in and Opt-out Recruitment Approaches

Objective To compare the efficacy of opt‐in versus opt‐out recruitment methods in pediatric weight management clinical trials. Methods Recruitment of preschoolers and school‐age children across two obesity randomized controlled trials (RCTs) were compared using the same opt‐in recruitment approach (parents contact researchers in response to mailings). Opt‐in and opt‐out strategies (parents send decline postcard in response to mailings if they do not want to participate) were then compared across two preschool obesity RCTs. Results Opt‐in strategies yielded a significantly lower overall recruitment rate among preschoolers compared with school‐age children. Among preschoolers, an opt‐out strategy demonstrated a significantly higher overall recruitment rate compared with an opt‐in strategy with the main advantage in the number of families initially contacted. Conclusions Opt‐out recruitment strategies may be more effective in overcoming the barriers of recruitment in the preschool age‐group because it does not rely on parent recognition of obesity.

Clinic and Home-Based Behavioral Intervention for Obesity in Preschoolers: A Randomized Trial

Objective To test the hypotheses that an innovative skills‐based behavioral family clinic and home‐based intervention (LAUNCH) would reduce body mass index z score (BMIz) compared with motivational interviewing and to standard care in preschool‐aged children with obesity. Study design Randomized controlled trial with children between the ages of 2 and 5 years above the 95th percentile for body mass index for age and sex recruited from 27 pediatrician offices across 10 recruitment cycles between March 12, 2012 and June 8, 2015. Children were randomized to LAUNCH (an 18‐session clinic and home‐based behavioral intervention), motivational interviewing (delivered at the same frequency as LAUNCH), or standard care (no formal intervention). Weight and height were measured by assessors blinded to participant assignment. The primary outcome, BMIz at month 6 after adjusting for baseline BMIz, was tested separately comparing LAUNCH with motivational interviewing and LAUNCH with standard care using regression‐based analysis of covariance models. Results A total of 151 of the 167 children randomized met intent‐to‐treat criteria and 92% completed the study. Children were 76% White and 57% female, with an average age of 55 months and BMI percentile of 98.57, with no demographic differences between the groups. LAUNCH participants demonstrated a significantly greater decrease in BMIz (mean = −0.32, SD = ±0.33) compared with motivational interviewing (mean = −0.05, SD = ±0.27), P < .001, ω2 = 0.74 and compared with standard care (mean = −0.13, SD = ±0.31), P < .004, ω2 = 0.75. Conclusions In preschool‐age children, an intensive 6‐month behavioral skills‐based intervention is necessary to reduce obesity. Trial Registration Clinicaltrials.gov NCT01546727.

Are Preschoolers Meeting the Mark? Comparing the Dietary, Activity, and Sleep Behaviors of Preschoolers With Obesity to National Recommendations

Objective National health organizations and expert committees have issued recommendations for health behaviors related to obesity risk. Behavioral and family-based weight management interventions for preschoolers often target improving adherence to these recommendations, but it is unknown how the health behaviors of preschoolers with obesity enrolled in weight control treatments (WCTs) compare with these guidelines. In this study, the dietary intake, activity, and sleep behaviors of preschoolers with obesity enrolled in a family-based behavioral WCT are described and compared with national health behavior recommendations. Methods Health behaviors of 151 preschoolers with obesity (M age = 4.60, SD = 0.93) enrolled in a clinical trial of a weight management program were measured at baseline through caregiver-report questionnaires, three 24-hr dietary recalls, and accelerometers. Results In total, 70% of the sample exceeded daily caloric recommendations, only 10 and 5% met recommendations for fruit and vegetable intake, respectively, and only 30% met the recommendation of consuming no sugar-sweetened beverages. The majority of the sample met the daily recommendations for 60 min of moderate-to-vigorous activity (80%), < 2 hr of screen time (68%), and sleep duration (70%). Conclusions Behavioral weight management interventions for preschoolers with obesity should target the health behaviors where children are not meeting recommendations.

50 years ago in the Journal of Pediatrics: the influence of tonsillectomy on growth and caloric intake.

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