Home and neighbourhood built environment features in family-based treatment for childhood obesity.

BACKGROUND: Family-based behavioural weight loss treatment (FBT) for childhood obesity helps families develop strategies to facilitate healthy choices in their home and other environments (e.g. home neighbourhood). The current study examines how the home food environment, both pre-FBT and post-FBT, and the neighbourhoods in which families live are associated with child weight and weight-related outcomes in FBT. METHODS: Parent-child dyads (n = 181) completed a 16-session FBT programme and completed home environment, anthropometric and child dietary/activity assessments at pre-FBT and post-FBT. Parents reported on availability of food, electronics and physical activity equipment in the home. The neighbourhood food and recreation environments around each dyad's residence was characterized using existing data within a geographic information system. RESULTS: Families successfully made healthy home environment modifications during FBT. Regression models showed reducing RED (e.g. high-energy-dense and low-nutrient-dense) foods and electronics in the home during FBT had positive effects on child weight and weight-related outcomes. No neighbourhood food or recreation environment variables were significantly related to outcomes, although having a larger density of public recreation spaces was associated with increases in physical activity at the trend-level. CONCLUSIONS: Modifying the home environment, specifically reducing RED foods and electronics, may be particularly important for FBT success.

A randomized controlled trial to prevent obesity among Latino paediatric patients.

BACKGROUND: Obesity disproportionately affects Latino youth. Community clinics are an important resource, yet there is little evidence for the efficacy of clinic-based approaches in this population. OBJECTIVE: The purpose of this study was to test the efficacy of a clinic-based intervention to lower body mass index (BMI) and improve body composition among overweight Latino children. METHODS: A randomized trial (2 group × 3 repeated measures) was conducted among 297 randomly sampled, overweight paediatric patients (5-10 years old) and their parents. The 12-month family-based culturally tailored behavioural intervention (Luces de Cambio) was based on the 'traffic light' concepts to address behaviour change and was delivered by clinic health educators and mid-level providers. The primary study outcome was child BMI (kg m-2 ) assessed at baseline, 6-month (n = 191) and 12-month (n = 201) post-baseline. A subsample of the children was examined for overall and site-specific adiposity using dual-energy X-ray absorptiometry (n = 79). RESULTS: There were no significant intervention effects on child BMI (p > 0.05); however, intervention children showed significantly (p < 0.05) lower total and trunk per cent fat compared with the usual care condition. CONCLUSIONS: The Luces intervention did not reduce child BMI, yet small but significant reductions were observed for child per cent body fat. Further research is needed to identify and reduce barriers to recruitment and participation among Latino families.

Weight change in the management of youth-onset type 2 diabetes: the TODAY clinical trial experience.

BACKGROUND: The Treatment Options for type 2 Diabetes in Adolescents and Youth (TODAY) clinical trial documented that metformin plus rosiglitazone, but not metformin plus lifestyle intervention, provided superior durability of glycemic control relative to metformin monotherapy. OBJECTIVES: We examined weight changes among TODAY participants that completed at least 6 months of treatment, evaluated predictors of lifestyle outcome, and examined whether weight changes were related to cardiometabolic outcomes across treatment arms. METHODS: The 595 youth with type 2 diabetes, (85.1% of randomized participants aged 11-17 years) completed assessments of weight-related and cardiometabolic measures at months 0, 6, 12 and 24. Repeated measures models were used to investigate associations over time. RESULTS: Lifestyle intervention did not enhance outcome relative to metformin alone and no predictors of response to lifestyle treatment were identified. However, changes in percent overweight across treatment arms were associated with changes in multiple cardiometabolic risk factors, and decreases of ≥ 7% in overweight were associated with significant benefits over 24 months. CONCLUSIONS: Although adjunctive intensive lifestyle intervention did not improve weight-related outcomes, weight changes in the full TODAY sample were associated with small, but significant improvements in cardiometabolic status, highlighting the importance of optimizing weight management in youth with T2DM.

An evolving scientific basis for the prevention and treatment of pediatric obesity.

The 2013 Pennington Biomedical Research Center's Scientific Symposium focused on the treatment and management of pediatric obesity and was designed to (i) review recent scientific advances in the prevention, clinical treatment and management of pediatric obesity, (ii) integrate the latest published and unpublished findings and (iii) explore how these advances can be integrated into clinical and public health approaches. The symposium provided an overview of important new advances in the field, which led to several recommendations for incorporating the scientific evidence into practice. The science presented covered a range of topics related to pediatric obesity, including the role of genetic differences, epigenetic events influenced by in utero development, pre-pregnancy maternal obesity status, maternal nutrition and maternal weight gain on developmental programming of adiposity in offspring. Finally, the relative merits of a range of various behavioral approaches targeted at pediatric obesity were covered, together with the specific roles of pharmacotherapy and bariatric surgery in pediatric populations. In summary, pediatric obesity is a very challenging problem that is unprecedented in evolutionary terms; one which has the capacity to negate many of the health benefits that have contributed to the increased longevity observed in the developed world.

Obesity prevention in defined (high school) populations.

BACKGROUND: A challenge for the widespread dissemination of Internet-based programs designed to produce weight maintenance/loss in defined (high school) populations is to adapt them to local needs and interests, whereas demonstrating effectiveness and salience for both universal and targeted populations. OBJECTIVE: The objective of this study is to examine the feasibility of providing an inexpensive, Internet-based universal (healthy weight regulation) and targeted (weight maintenance/loss) health program to all ninth-grade students in a high school serving a lower socioecnomic status, diverse population. DESIGN: A total of 118 normal-weight and 64 overweight/obese students in the same ninth-grade class completed a baseline screen and were allocated to a healthy weight regulation program or a weight-loss maintenance program. Both groups simultaneously received a 10-week Internet-based intervention. Program implementation required minimal teacher time. Measurement included self-reported fruit, vegetable and high-fat/-calorie food consumption, self-reported change in body mass index (BMI), weight and shape concerns, as well as program engagement. RESULTS: The program was successfully implemented in nine classes, with minimal help from the investigators. There was a significant increase in self-reported consumption of fruits and vegetables (P=0.001). There was a significant reduction in self-reported BMI in the overweight/obese group (P=0.001). Students found the program helpful and engaging. There was a significant reduction in weight and shape concerns in the high-risk female students, consistent with a reduced risk for the development of an eating disorder. Providing a universal and targeted online healthy weight regulation program to ninth-grade students is feasible and inexpensive. The results suggest the program can serve as 'core' for future studies using adaptive, continuous quality-improvement designs.

Who is really at risk? Identifying risk factors for subthreshold and full syndrome eating disorders in a high-risk sample.

BACKGROUND: Numerous longitudinal studies have identified risk factors for the onset of most eating disorders (EDs). Identifying women at highest risk within a high-risk sample would allow for focusing of preventive resources and also suggests different etiologies. METHOD: A longitudinal cohort study over 3 years in a high-risk sample of 236 college-age women randomized to the control group of a prevention trial for EDs. Potential risk factors and interactions between risk factors were assessed using the methods developed previously. Main outcome measures were time to onset of a subthreshold or full ED. RESULTS: At the 3-year follow-up, 11.2% of participants had developed a full or partial ED. Seven of 88 potential risk factors could be classified as independent risk factors, seven as proxies, and two as overlapping factors. Critical comments about eating from teacher/coach/siblings and a history of depression were the most potent risk factors. The incidence for participants with either or both of these risk factors was 34.8% (16/46) compared to 4.2% (6/144) for participants without these risk factors, with a sensitivity of 0.75 and a specificity of 0.82. CONCLUSIONS: Targeting preventive interventions at women with high weight and shape concerns, a history of critical comments about eating weight and shape, and a history of depression may reduce the risk for EDs.

Selective processing of body image words in women at-risk for developing an eating disorder: a preliminary study.

We evaluated the utility of the Modified Stroop task as a measure of body image concerns in women at-risk for an eating disorder. Data were collected among 31 participants from an eating disorder prevention program. The Modified Stroop was significantly associated with overeating episodes and an explicit measure of shape concern. The traditional Stroop effect was found while the Modified Stroop effect was non-significant. The results raise questions about the Modified Stroop task's utility in identifying at-risk women. Methodological and clinical implications are discussed.

Anorexia nervosa trios: behavioral profiles of individuals with anorexia nervosa and their parents.

BACKGROUND: Anorexia nervosa (AN) is associated with behavioral traits that predate the onset of AN and persist after recovery. We identified patterns of behavioral traits in AN trios (proband plus two biological parents). METHOD: A total of 433 complete trios were collected in the Price Foundation Genetic Study of AN using standardized instruments for eating disorder (ED) symptoms, anxiety, perfectionism, and temperament. We used latent profile analysis and ANOVA to identify and validate patterns of behavioral traits. RESULTS: We distinguished three classes with medium to large effect sizes by mothers' and probands' drive for thinness, body dissatisfaction, perfectionism, neuroticism, trait anxiety, and harm avoidance. Fathers did not differ significantly across classes. Classes were distinguished by degree of symptomatology rather than qualitative differences. Class 1 (approximately 33%) comprised low symptom probands and mothers with scores in the healthy range. Class 2 ( approximately 43%) included probands with marked elevations in drive for thinness, body dissatisfaction, neuroticism, trait anxiety, and harm avoidance and mothers with mild anxious/perfectionistic traits. Class 3 (approximately 24%) included probands and mothers with elevations on ED and anxious/perfectionistic traits. Mother-daughter symptom severity was related in classes 1 and 3 only. Trio profiles did not differ significantly by proband clinical status or subtype. CONCLUSIONS: A key finding is the importance of mother and daughter traits in the identification of temperament and personality patterns in families affected by AN. Mother-daughter pairs with severe ED and anxious/perfectionistic traits may represent a more homogeneous and familial variant of AN that could be of value in genetic studies.

Toward an understanding of risk factors for anorexia nervosa: a case-control study.

BACKGROUND: Prospective, longitudinal studies of risk factors for anorexia nervosa (AN) are lacking and existing cross-sectional studies are generally narrow in focus and lack methodological rigor. Building on two studies that used the Oxford Risk Factor Interview (RFI) to establish time precedence and comprehensively assess potential risk correlates for AN, the present study advances this line of research and represents the first case-control study of risk factors for AN in the USA. METHOD: The RFI was used for retrospective assessment of a broad range of risk factors, while establishing time precedence. Using a case-control design, 50 women who met DSM-IV criteria for AN were compared to those with non-eating disorder DSM-IV psychiatric disorders (n=50) and those with no psychiatric disorder (n=50). RESULTS: Women with psychiatric disorders reported higher rates of negative affectivity, maternal and paternal parenting problems, family discord, parental mood and substance disorder, and physical and sexual abuse than women with no psychiatric disorder. Women with AN specifically reported greater severity and significantly higher rates of negative affectivity, perfectionism and family discord, and higher parental demands than women with other psychiatric disorders. The role of weight and shape concerns was most salient in the year preceding onset of AN. CONCLUSIONS: Convergent data identifying common risk factors as well as those more severe in the development of AN are emerging to inform longitudinal risk factor and prevention studies for this disorder.

Treatment options for type 2 diabetes in adolescents and youth: a study of the comparative efficacy of metformin alone or in combination with rosiglitazone or lifestyle intervention in adolescents with type 2 diabetes.

Despite the increased prevalence of type 2 diabetes mellitus (T2DM) in the pediatric population, there is limited information about the relative effectiveness of treatment approaches. This article describes the rationale and design of a National Institutes of Health-sponsored multi-site, randomized, parallel group clinical trial designed to test the hypothesis that aggressive reduction in insulin resistance early in the course of T2DM is beneficial for prolongation of glycemic control, as well as improvement in associated abnormalities and risk factors. Specifically, the trial compares treatment with metformin with two alternate approaches, one pharmacologic (combining metformin treatment with rosiglitazone) and one combining metformin with an intensive lifestyle intervention program. The Treatment Options for Type 2 Diabetes in Adolescents and Youth (TODAY) study recruits 800 patients over a 4-yr period and follows them for a minimum of 2 yr and maximum of 6 yr. Patients are 10-17 yr of age, within 2 yr of diagnosis of diabetes at the time of randomization, lack evidence of autoimmunity, and have sustained C-peptide secretion. The primary outcome is time to loss of glycemic control, defined as a hemoglobin A1c >8% for 6 consecutive months. Secondary outcomes include the effect of the alternative treatments on insulin secretion and resistance, body composition, nutrition, physical activity and fitness, cardiovascular risk monitoring, microvascular complications, quality of life, depression, eating pathology, and resource utilization. TODAY is the first large-scale, systematic study of treatment effectiveness for T2DM in youth. When successfully completed, this study will provide critical new information regarding the natural history of T2DM in youth, the benefits of initiating early aggressive treatment in these patients, and the efficacy of delivering an intensive and sustained lifestyle intervention to children with T2DM.

A comparison of black and white women with binge eating disorder.

OBJECTIVE: Binge eating disorder was introduced in DSM-IV as a psychiatric disorder needing further study. This community-based study describes the relationship between race and clinical functioning in black and white women with and without binge eating disorder. METHOD: A group of 150 women with binge eating disorder (52 black, 98 white) and a race-matched group of 150 healthy comparison subjects were recruited from the community. Eating and psychiatric symptoms were assessed through interviews and self-report. RESULTS: Black and white women with binge eating disorder differed significantly on numerous eating disorder features, including binge frequency, restraint, history of other eating disorders, treatment-seeking behavior, and concerns with eating, weight, and shape. Black and white healthy comparison subjects differed significantly in obesity rates. CONCLUSIONS: For both black and white women, binge eating disorder was associated with significant impairment in clinical functioning. Yet, racial differences in clinical presentation underscore the importance of considering race in psychopathology research.

A multicomponent program for nutrition and physical activity change in primary care: PACE+ for adolescents.

BACKGROUND: Most adolescents do not meet national recommendations for nutrition and physical activity. However, no studies of physical activity and nutrition interventions for adolescents conducted in health care settings have been published. The present study was an initial evaluation of the PACE+ (Patient-centered Assessment and Counseling for Exercise plus Nutrition) program, delivered in primary care settings. PARTICIPANTS: Adolescents aged 11 to 18 years (N = 117) were recruited from 4 pediatric and adolescent medicine outpatient clinics. Participants' mean (SD) age was 14.1 (2.0) years, 37% were girls, and 43% were ethnic minorities. INTERVENTION: Behavioral targets were moderate physical activity, vigorous physical activity, fat intake, and fruit and vegetable intake. All patients completed a computerized assessment, created tailored action plans to change behavior, and discussed the plans with their health care provider. Patients were then randomly assigned to receive no further contact or 1 of 3 extended interventions: mail only, infrequent telephone and mail, or frequent telephone and mail. MEASURES: Brief, validated, self-report measures of target behaviors were collected at baseline and 4 months later. RESULTS: All outcomes except vigorous physical activity improved over time, but adolescents who received the extended interventions did not have better 4-month outcomes than those who received only the computer and provider counseling components. Adolescents who targeted a behavior tended to improve more than those who did not target the behavior, except for those who targeted vigorous physical activity. CONCLUSIONS: A primary care-based interactive health communication intervention to improve physical activity and dietary behaviors among adolescents is feasible. Controlled experimental research is needed to determine whether this intervention is efficacious in changing behaviors in the short- and long-term.

Bias in binge eating disorder: how representative are recruited clinic samples?

The aim of this study was to investigate sampling bias as it affects recruited clinic samples of binge eating disorder (BED). Demographic and clinical characteristics of a recruited clinic sample were compared with a community sample. The 2 groups met the same operational definition of BED and were assessed using the same primarily interview-based methods. Ethnicity, severity of binge eating, and social maladjustment were found to increase treatment seeking among participants with BED rather than levels of psychiatric distress or comorbidity. These findings suggest that previous studies using recruited clinic samples have not biased estimates of psychiatric comorbidity in BED.

Changes in eating disorder symptoms with pediatric obesity treatment.

OBJECTIVE: To evaluate the effects of behavioral, family-based treatment on disordered eating and child behavior problems for obese 8- to 12-year-old children. STUDY DESIGN: We examined disordered eating in children and parents using the Kids' Eating Disorder Survey (KEDS) and the Binge Eating Scale, respectively; and psychologic problems in children and their parents using the Child Behavior Checklist and Symptom Checklist-90, respectively, in 47 families who participated in a family-based obesity treatment program. RESULTS: Obese children showed significant decreases (-12.5 +/- 13.5) in percent overweight, internalizing problems (-7.0 +/- 7.3), and total behavior problems (-4.8 +/- 6.6) and increases in behavioral competence (3.7 +/- 5.0) over 2 years of measurement; and their parents showed significant decreases in weight (-5.0 +/- 8.3 kg) and reductions in parental distress (-2.3 +/- 7.6) and in disturbed eating and weight-related cognition (-3.2 +/- 5.3). No significant changes were observed in total KEDS (-0.2 +/- 1.9), weight dissatisfaction (-0.3 +/- 1.7), or purging/restricting (0.2 +/- 0.6) scores. Decreases in total KEDS were related to decreases in total behavior problems and externalizing behavior problems. CONCLUSIONS: These results document improvements in child behavior problems and competence and no change in symptoms of disordered eating in a standardized behavioral weight control program.

An interactive internet-based intervention for women at risk of eating disorders: a pilot study.

OBJECTIVE: The Internet serves as a potentially effective method of treatment delivery through widespread education and interaction via synchronous Internet relay chat (IRC). The current study explores the feasibility of IRC in the delivery of an eating disorders prevention intervention. METHOD: This small pilot study describes the delivery of an efficacious eating disorder treatment using a novel medium. The on-line sessions are based on cognitive-behavioral treatment and are facilitated by a moderator. In addition to feasibility, preliminary evidence of acceptability and efficacy for an on-line intervention with college-aged women is reported. RESULTS: Results indicate that IRC is an acceptable and feasible format for treatment delivery. In addition, descriptive and qualitative data suggest that this method of treatment delivery is potentially effective. DISCUSSION: This pilot study provides increased knowledge of the viability of treatment delivery over the Internet, specifically, a psychoeducational IRC for eating disorder prevention.

Comparison of binge eating disorder and bulimia nervosa in a community sample.

OBJECTIVE: This study examined the relationship between binge eating disorder (BED), a newly proposed eating disorder, and bulimia nervosa (BN). METHOD: Three groups recruited from the community were compared: women with BED (n = 150), women with purging BN (n = 48), and women with nonpurging BN (n = 14). RESULTS: The three groups did not differ significantly in education, weight or shape concern, and current or lifetime prevalence of nine major mental disorders. Women with BED, compared with women with purging BN, were older, less likely to have a history of anorexia nervosa, and less likely to have been treated for an eating disorder. Obesity was more commonly associated with BED than with either subtype of BN. DISCUSSION: Our results lend some support to BED as an eating disorder distinct from purging BN. More research is needed to clarify the position of nonpurging BN relative to BED and purging BN.

Reducing risk factors for eating disorders: targeting at-risk women with a computerized psychoeducational program.

OBJECTIVE: This controlled study evaluated whether an 8-week program offered over the Internet would significantly decrease body image dissatisfaction, disordered eating patterns, and preoccupation with shape/weight among women at high risk for developing an eating disorder. METHOD: Fifty-six college women were recruited on the basis of elevated scores (> or =110) on the Body Shape Questionnaire (BSQ). Psychological functioning, as measured by the Eating Disorder Inventory Drive for Thinness (EDI-DT) subscale, Eating Disorder Examination-Questionnaire (EDE-Q), and the BSQ, was assessed at baseline, posttreatment, and at 10-week follow-up. RESULTS: All participants improved over time on most measures, although effect sizes suggest that the program did impact the intervention group. DISCUSSION: Findings suggest that technological interventions may be helpful for reducing disordered eating patterns and cognitions among high-risk women. Future research is needed to assess whether such programs are effective over time for prevention of and reduction in eating disorder symptomatology.

Effects of a physical activity intervention on body image in university seniors: project GRAD.

Project GRAD (Graduate Ready for Activity Daily) was a randomized controlled study to teach university seniors behavioral skills necessary for increasing and/or maintaining physical activity habits in preparation for the transition to working adult roles after graduation. This study examines the secondary effects of this intervention on body image concerns among college-aged men and women. Three hundred thirty-eight undergraduates (54%female, Mage = 24years, SD = 1.95; MBody Mass Index = 24.26, SD = 4.0) were studied. The sample was 61/% Anglo, 16% Latino, 16% Asian/Pacific Islander, 4% African American, and 3% Native American/Other Body image concerns were assessed at pre- and posttreatment using 2 subscales of the Eating Disorder Inventory: Drive for Thinness and Body Dissatisfaction. Because the latter concentrates on body parts typically associated with female concerns (e.g., thighs, hips, buttocks), a parallel scale was developed to target body parts that may be of more concern to men (e.g., legs, shoulders, arms, stomach). Results indicated that compared to the control group, women in the intervention showed a significant increase in drive for thinness without any changes in body dissatisfaction. For men, there were no significant changes in drive for thinness or body dissatisfaction. These results suggest that physical activity interventions may have some negative consequences of increasing concerns about thinness in women. This negative effect occurred despite intervention content designed to prevent concern over eating, dieting, and the importance of weight. Health promotion studies should include assessments of potential negative side effects.

The Yale Interpersonal Stressor (YIPS): affective, physiological, and behavioral responses to a novel interpersonal rejection paradigm.

Given links between interpersonal functioning and health as well as the dearth of truly interpersonal laboratory stressors, we present a live rejection paradigm, the Yale Interpersonal Stressor (YIPS), and examine its effects on mood, eating behavior, blood pressure, and cortisol in two experiments. The YIPS involves one or more interaction(s) between the participant and two same-sex confederates in which the participant is made to feel excluded and isolated. In Experiment 1, 50 female undergraduates were randomly assigned to the YIPS or a control condition. Participants in the YIPS condition experienced greater negative affect and less positive affect than did those in the control condition. Further, restrained eaters ate more following the YIPS than did nonrestrained eaters. In Experiment 2, 25 male and female undergraduates completed the YIPS. The YIPS induced significant increases in tension, systolic blood pressure (SBP), and diastolic blood pressure (DBP) from baseline, while significantly decreasing positive affect. The YIPS appeared particularly relevant for women, resulting in significantly greater increases in cortisol and SBP for women compared to men. The YIPS, then, provides an alternative to traditional, achievement-oriented laboratory stressors and may allow for the identification of individuals most vulnerable to interpersonal stress.

Comorbid psychopathology in binge eating disorder: relation to eating disorder severity at baseline and following treatment.

Individuals with binge eating disorder (BED) have high rates of comorbid psychopathology, yet little is known about the relation of comorbidity to eating disorder features or response to treatment. These issues were examined among 162 BED patients participating in a psychotherapy trial. Axis I psychopathology was not significantly related to baseline eating disorder severity, as measured by the Structured Clinical Interview for DSM-III-R (SCID-I and SCID-II) and the Eating Disorder Examination. However, presence of Axis II psychopathology was significantly related to more severe binge eating and eating disorder psychopathology at baseline. Although overall presence of Axis II psychopathology did not predict treatment outcome, presence of Cluster B personality disorders predicted significantly higher levels of binge eating at 1 year following treatment. Results suggest the need to consider Cluster B disorders when designing treatments for BED.