Rebecca K. Golley

Twelve-Month Effectiveness of a Parent-led, Family-Focused Weight-Management Program for Prepubertal Children: A Randomized, Controlled Trial

BACKGROUND. Parenting-skills training may be an effective age-appropriate child behavior-modification strategy to assist parents in addressing childhood overweight. OBJECTIVE. Our goal was to evaluate the relative effectiveness of parenting-skills training as a key strategy for the treatment of overweight children. DESIGN. The design consisted of an assessor-blinded, randomized, controlled trial involving 111 (64% female) overweight, prepubertal children 6 to 9 years of age randomly assigned to parenting-skills training plus intensive lifestyle education, parenting-skills training alone, or a 12-month wait-listed control. Height, BMI, and waist-circumference z score and metabolic profile were assessed at baseline, 6 months, and 12 months (intention to treat). RESULTS. After 12 months, the BMI z score was reduced by ∼10% with parenting-skills training plus intensive lifestyle education versus ∼5% with parenting-skills training alone or wait-listing for intervention. Waist-circumference z score fell over 12 months in both intervention groups but not in the control group. There was a significant gender effect, with greater reduction in BMI and waist-circumference z scores in boys compared with girls. CONCLUSION. Parenting-skills training combined with promoting a healthy family lifestyle may be an effective approach to weight management in prepubertal children, particularly boys. Future studies should be powered to allow gender subanalysis.

Interventions that involve parents to improve children's weight-related nutrition intake and activity patterns - what nutrition and activity targets and behaviour change techniques are associated with intervention effectiveness?

Parent involvement is an important component of obesity prevention interventions. However, the best way to support parents remains unclear. This review identifies interventions targeting parents to improve childrens weight status, dietary and/or activity patterns, examines whether intervention content and behaviour change techniques employed are associated with effectiveness. Seventeen studies, in English, 1998–2008, were included. Studies were evaluated by two reviewers for study quality, nutrition/activity content and behaviour change techniques using a validated quality assessment tool and behaviour change technique taxonomy. Study findings favoured intervention effectiveness in 11 of 17 studies. Interventions that were considered effective had similar features: better study quality, parents responsible for participation and implementation, greater parental involvement and inclusion of prompt barrier identification, restructure the home environment, prompt self‐monitoring, prompt specific goal setting behaviour change techniques. Energy intake/density and food choices were more likely to be targeted in effective interventions. The number of lifestyle behaviours targeted did not appear to be associated with effectiveness. Intervention effectiveness was favoured when behaviour change techniques spanned the spectrum of behaviour change process. The review provides guidance for researchers to make informed decisions on how best to utilize resources in interventions to support and engage parents, and highlights a need for improvement in intervention content reporting practices.

Comparison of metabolic syndrome prevalence using six different definitions in overweight pre-pubertal children enrolled in a weight management study

Objectives:To assess the implications of variation in Metabolic Syndrome (MS) definition (biochemical and anthropometric indicators) on MS prevalence estimates in a population of overweight and mildly obese children.Design:Cross-sectional study.Subjects:Ninety-nine (64 girls) overweight or mildly obese, but otherwise healthy, pre-pubertal 6–9-year olds recruited for a randomized controlled trial of weight management.Measures:Height, weight and waist circumference were measured with BMI and waist z-scores calculated. Fasting cholesterol and fractions, glucose and insulin were measured, together with systolic and diastolic blood pressure (BP). Anthropometric and metabolic indicators were classified as normal or elevated using adult- or child-specific cut points with clustering of MS indicators also assessed using two adult and three child-specific definitions.Results:A total of 0–4% of subjects were classified with MS when adult definitions were applied. This increased to between 39 and 60% using child-specific definitions, varying according to whether hyperinsulinaemia was central to the MS classification. Systolic BP, triglycerides, total cholesterol, high-density lipoprotein cholesterol and waist z-score increased across insulin quartiles (P<0.05). The use of body mass index and waist circumference in the MS definition classified the same subjects.Conclusions:The classification of MS in children depends strongly on the definition chosen, with MS prevalence estimates higher if insulin is part of the definition and child-specific cut points for metabolic indicators are used. Hyperinsulinaemia and MS are common consequences of childhood obesity but they are not commonly part of the assessment or management plan for weight management in children. There is a need for the establishment of normal insulin ranges and consistent definition of MS in childhood and adolescence.

Assessing dietary intake in children and adolescents: Considerations and recommendations for obesity research

Abstract Dietary intake and food habits are important contributors to the obesity epidemic. They are highly modifiable components of energy balance and are usually targeted in both obesity prevention and treatment programs. However, measurement of total diet creates challenges and can convey a large burden in terms of cost, technical expertise, impact on respondents and time. It is not surprising therefore that comprehensive reports of dietary intake in children are uncommon and, when reported, have limitations. The aim of this paper is to guide researchers and practitioners in selecting the most appropriate dietary assessment method for situations involving children and adolescents. This paper presents a summary of the issues to consider when choosing a method, a description of some of the more commonly used dietary assessment methods for young people and a series of case-studies to illustrate the range of circumstances faced when measuring dietary intake. We recommend that researchers consider the specific components of dietary intake addressed in their research and practice, and whether diet should be reported comprehensively or as targeted components. Other considerations include age, cognitive ability, weight status, physical activity level, respondent burden, and reliability and validity in the context of program goals and research questions. A checklist for selecting the appropriate dietary methodology is provided. This guide aims to facilitate the reporting of dietary intake and food habits in the context of obesity using valid and reliable measures, thus contributing to the evidence-base for nutrition policies and programs relating to obesity.

Sleep duration or bedtime? Exploring the association between sleep timing behaviour, diet and BMI in children and adolescents.

Objective:To determine whether sleep timing behaviour is associated with energy intake and diet quality in children and adolescents.Design:Cross-sectional analysis of nationally representative survey data.Sample:A total of 2200 participants of the 2007 Australian National Children’s Nutrition and Physical Activity Survey aged 9–16 years with 2 days of food intake data, 4 days of use of time data and complete anthropometry. Participants were grouped into one of four sleep–wake behaviour categories: early bed–early rise (EE); early bed–late rise (EL); late bed–early rise (LE) and late bed–late rise (LL). The four categories were compared for body mass index (BMI) z-score, energy intake and diet quality assessed using the Dietary Guideline Index for Children and Adolescents. Analyses were adjusted for survey design, sociodemographic characteristics, sleep duration and physical activity level (PAL).Results:In adjusted multivariate regression models with sleep timing behaviour group as the independent variable, the ‘LL’ category compared with the ‘EE’ category had a higher BMI z-score (β=0.20, 95% confidence interval (CI) 0.06 to 0.34, P=0.007), and lower diet quality (β=−4.0, 95% CI −5.7 to −2.3, P<0.001). Children and adolescents who went to bed late also had a higher intake of extra foods (that is, energy-dense, nutrient-poor foods) while those whom went to bed early consumed more fruit and vegetables. Energy intake was associated with sleep duration (β=−4.5 kJ, 95% CI −6.7 to −2.4, P<0.001), but not sleep timing behaviour.Conclusion:Late bedtimes and late wake up times are associated with poorer diet quality, independent of sleep duration, PAL and child and sociodemographic characteristics.

Scores on the Dietary Guideline Index for Children and Adolescents Are Associated with Nutrient Intake and Socio-Economic Position but Not Adiposity

Diet quality indices reflect overall dietary patterns better than single nutrients or food groups. The study aims were to develop a measure of adherence with dietary guidelines applicable to child and adolescent populations in Australia and determine the association between index scores and food and nutrient intake, socio-demographic characteristics, and measures of adiposity. Data were analyzed from 4- to 16-y-old participants of the 2007 Australian Childrens Nutrition and Physical Activity Survey (n = 3416). The Dietary Guideline Index for Children and Adolescents (DGI-CA) comprises 11 components: 5 core food groups, wholegrain bread, reduced-fat dairy foods, extra foods (nutrient poor and high in fat, salt, and added sugar), healthy fats/oils, water, and diet variety (possible score of 100). The index criteria were age specific. The mean DGI-CA score was low (53.6 ± 0.4), similar between boys and girls, and differed by age; the youngest children scored higher than the oldest children (P < 0.0001). Higher DGI-CA scores were associated with lower energy intake, energy density, total and saturated fat, and sugar intake; higher protein, carbohydrate, fiber, calcium, iron, vitamin C, vitamin A, folate, phosphorous, magnesium, zinc, and iodine intakes; and a higher polyunsaturated:saturated fat ratio (P < 0.0001). DGI-CA scores were associated with socio-economic characteristics and measures of family circumstance. Weak positive associations were observed between DGI-CA score and BMI or waist circumference Z-scores in the 4- to 10-y and 12- to 16-y age groups only. This index is the first validated index in Australia and one of the few international indices to describe the diet quality of children and adolescents.

Reliability and validity of the Children's Dietary Questionnaire; A new tool to measure children's dietary patterns

OBJECTIVE To assess the reliability and validity of a new parent report measure of childrens dietary patterns, allowing assessment against national guidelines. METHODS The 28-item Childrens Dietary Questionnaire (CDQ) was developed based on Australian healthy eating guidelines and knowledge of current dietary intake of Australian children. It assesses intake patterns in either the previous week or 24 hours of foods for which intake is recommended (positive indicators - fruit, vegetables, water, reduced fat products) and foods for which intake is discouraged (negative indicators - high fat/sugar foods [non-core foods], sweetened beverages and full fat dairy products). Four food group subscales are generated: fruit and vegetable, fat from dairy, sweetened beverages and non-core foods. Test-retest reliability, internal consistency, relative validity and the ability to detect change were tested in five separate study samples of children, totalling 706 children aged 4 to 16 years. RESULTS The fruit and vegetable and non-core foods subscales demonstrated good internal consistency (alpha 0.76 and 0.62, respectively) and item:total correlations greater than 0.2. The fat from dairy and the sweetened beverages subscales consistently performed poorly. All subscales demonstrated satisfactory test-retest reliability (intraclass correlation coefficient 0.51 to 0.90) and ability to detect change in the expected direction following a weight management intervention. Relative validity suggests ability to distinguish positive or negative dietary risk based on CDQ scores at the group but not individual level. CONCLUSION The CDQ shows acceptable reliability and relative validity for assessing group level child dietary patterns with key aspects of healthy eating guidelines.

Characterizing whole diets of young children from developed countries and the association between diet and health: a systematic review

Early childhood is an important nutritional period that involves the transition from a milk-based diet to ordinary foods. A systematic review was conducted of studies that applied whole-of-diet analysis of children aged 1-5 years to examine associations between diet and nutrition, health, and development. Literature searches identified 40 articles using dietary indices, principal component analysis, or cluster analysis. Reports that applied indices (n = 23, 18 indices) were cross-sectional, and most measured diet quality or variety. Articles reporting principal component or cluster analyses (n =17) described between two and six dietary patterns, and most identified healthy, unhealthy, and traditional patterns. In cross-sectional analyses, mixed associations were found between index or pattern scores and nutrient intake (n = 10), nutritional biomarkers (n = 1), and anthropometry (n = 10). Five reports from two birth cohorts showed healthier dietary patterns were associated with better lean mass, cognition, and behavior, but not with bone mass or body mass index at later ages. Few studies have characterized the diets of children under 5 years of age and linked diet with health. Given the limited evidence, research establishing the predictive validity of whole-of-diet methods in childhood is needed.

Randomised controlled trials in overweight children: Practicalities and realities

AIM To highlight and discuss the practical aspects of conducting high quality, randomised controlled trials (RCTs) with overweight and obese children and their families. CONTENT Realistic considerations and suggestions for researchers arising from the experiences of three Australian interventions in overweight/obese children are highlighted. The practical implications of key issues arising during this type of RCT include study design, obtaining ethical approval, choice of outcome measures, recruitment, working with families, impact and process evaluation, retention strategies, managing multi-site trials and data management. CONCLUSION Interventions for overweight children and their families are challenging. Although there were some differences in the design and outcome measures among the three studies, there were many similarities. Multi-site trials, although more expensive than single-site trials, are advantageous in increasing sample size and external validity. Collectively we have developed strategies to address key problems in conducting RCTs, including the common challenges of recruitment, retention and working with families.

Combined Home and School Obesity Prevention Interventions for Children What Behavior Change Strategies and Intervention Characteristics Are Associated With Effectiveness

This review identifies studies describing interventions delivered across both the home and school/community setting, which target obesity and weight-related nutrition and physical activity behaviors in children. Fifteen studies, published between 1998 and 2010, were included and evaluated for effectiveness, study quality, nutrition/activity content, behavior change techniques, and theoretical basis, using validated assessment tools/taxonomies. Seven studies were rated as effective. Behavior change techniques used to engage families, and techniques associated with intervention effectiveness were coded. Effective studies used about 10 behavior change techniques, compared with 6.5 in ineffective studies. Effective interventions used techniques including providing general information on behavior–health links, prompting practice of behavior, and planning for social support/social changes. Different behavior change techniques were applied in the home and school setting. The findings of this review provide novel insights into the techniques associated with intervention effectiveness that can inform the development of public health obesity prevention strategies.