US panel advises intensive behavioural counselling for children with obesity
A panel of experts in the United States has revised its guidance for paediatric obesity screening, with new recommendations highlighting the necessity for intensive behavioural interventions for children over the age of six who have a high body mass index (BMI). This update, issued by the U.S. Preventive Services Task Force, was published in the Journal of the American Medical Association (JAMA) Tuesday, 18th of June, 2024.
Replacing their 2017 advice, the Task Force previously suggested that primary care providers merely screen children for obesity. The urgency of the update is underscored by data showing that nearly 20% of U.S. children are classified as having obesity, a condition defined as having a BMI at or above the 95th percentile for a child’s age and sex. The prevalence of obesity is notably higher among Latino, Native American, and Black children, as well as those from lower-income backgrounds.
Dr. Wanda Nicholson, Chair of the Task Force and a professor of prevention and community health at George Washington University, emphasised the complexity of factors contributing to childhood obesity but pointed to strong evidence supporting intensive counselling. “Fortunately, we know that there are proven ways that primary care clinicians can help many children and teens to address the high BMI,” Dr. Nicholson stated. She highlighted that “Our evidence shows that the behavioural counselling intervention of 26 or more hours can help them achieve a healthy weight and improve their quality of life.”
Notably, the new recommendations do not advocate for the prescription of weight-loss drugs such as Ozempic or other GLP-1 medications for children, citing insufficient research on the benefits and potential harms of such treatments in younger populations. “We’re calling for more research into both the benefits and potential harms of medication therapy for kids and teens,” Dr. Nicholson explained.
The advised behavioural interventions typically encompass three core elements: education on healthy eating habits, counselling on weight-related behavioural changes—including goal-setting—and supervised exercise sessions.
The Task Force has awarded these recommendations a ‘B’ grade, reflecting a high degree of confidence in the moderate benefits of the interventions. Importantly, this grade also mandates that the recommended services be covered by most private health insurance plans in the U.S. without a copayment, as per federal law.
Despite the clear benefits, Dr. Nicholson acknowledged the challenges these recommendations might pose for affected families. “Twenty-six hours of counselling is a commitment both by the child or teen and their parents,” she remarked, noting that obstacles such as finding a provider who offers intensive counselling or reliable transportation to sessions could limit access to these essential services.
Dr. Nicholson expressed optimism about the potential outcomes of these investments in health. She mentioned that most of the research reviewed by the Task Force spanned six to twelve months of counselling, but stressed the need for further studies to explore the impacts of longer-term counselling initiatives.
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Research shows effective parental approaches to managing children’s avid eating behaviours
A recent study, published in the journal Appetite, provides an in-depth exploration of how parents cope with their preschool-aged children’s intense eating behaviours, which are often characterised by an elevated responsiveness to food cues. These eating patterns are closely associated with risks of overweight and obesity in children, making the understanding of parental experiences and strategies essential for developing tailored interventions aimed at promoting healthy eating habits.
The research highlights the significance of recognising eating behavioural patterns in children rather than focusing solely on individual eating behaviours. Through the use of Latent Profile Analysis, researchers have identified various eating profiles among preschoolers. These profiles are typically marked by a pronounced enjoyment of food, emotional overeating, minimal fussiness, reduced sensitivity to satiety signals, and a rapid pace of eating. Genetic factors play a substantial role in these appetitive traits, which are also influenced by environmental interactions, thereby affecting the expression of eating behaviours and the potential for obesity.
Parental feeding practices are pivotal in shaping these behaviours, with key practices involving coercive control, structured feeding, and the support of child autonomy. Qualitative research underscores the challenges parents face in managing feeding interactions, especially with children prone to obesity.
The study forms part of the “Appetite in Preschoolers: Producing Evidence for Tailoring Interventions Effectively” (APPETItE) programme. It adheres to pre-registration and qualitative research reporting guidelines, involving parents of 3-5-year-old children who exhibit these intense eating behaviours. A group of 15 parents participated, providing valuable insights through interviews conducted via video calls. Data collected included demographics, food security, and detailed eating behaviour profiles.
Thematic analysis was employed to inductively scrutinise the interview transcripts, with a focus on parental experiences. This process was rigorous, involving regular discussions and maintained reflexivity to ensure integrity in the analysis. The approach followed the systematic six-step process outlined by Braun and Clarke, fostering a comprehensive understanding of the feeding practices applicable to children with intense eating behaviours.
Four primary themes emerged from the analysis:
- Persistent Hunger: Parents noted their children’s continuous requests for food, with some perceiving this as a natural trait, while others expressed concern. Despite frequent eating, the level of satiety control varied among children, with some lacking a clear ‘stop button’.
- Duty of Parenthood: Parents expressed a strong sense of responsibility to keep their children sufficiently fed and to limit exposure to unhealthy foods. They employed various strategies to regulate food intake, focusing on health implications and setting boundaries.
- Instilling Healthy Habits: There was a concerted effort by parents to foster healthy lifelong eating patterns, provide balanced diets, and educate children on the impact of food on health. Monitoring of food intake throughout the day was common, alongside promoting healthier alternatives and encouraging children’s autonomy in food choices.
- Navigational Strategies: Parents described ‘picking their battles’ by establishing clear rules for eating times and occasionally using coercive feeding practices to alleviate personal stress. They balanced routine with flexibility, sometimes allowing children autonomy in food choices.
The research highlights the effectiveness of an authoritative feeding approach that blends control with warmth and responsiveness. However, some parents also resorted to emotional feeding and the use of food as a reward, which could reinforce intense eating behaviours.
Despite providing rich qualitative insights, the study’s findings are limited by a lack of diversity in the sample and potential self-selection bias, which may affect the generalisability of the results. Future research should incorporate objective measures, such as body mass index, to enhance understanding.
In conclusion, this study illuminates the complex dynamics of feeding children with intense eating behaviours and advocates for responsive, nuanced approaches to foster healthy dietary habits.
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Oxford study shows doctors’ communication style crucial for patient weight loss success
A groundbreaking study from the University of Oxford, recently published in the Annals of Internal Medicine, has revealed that the manner in which doctors communicate with patients about obesity plays a pivotal role in their weight loss success. This innovative research delves into the nuances of communication, showing that not only do the words doctors use matter, but also their tone and delivery have a profound impact over both short and long-term patient outcomes in a medical setting.
Conducted by the Nuffield Department of Primary Care Health Sciences, the study analysed 246 recordings of consultations and discovered that even subtle elements like the choice of words and vocal tone significantly affect patient responses. The findings have emerged amidst obesity treatment guidelines urging doctors to initiate weight loss discussions and suggest weight loss services. However, effective communication on this front occurs for only about 5% of those affected annually, indicating a significant gap between policy and practice.
Many doctors express reluctance to broach sensitive topics like obesity due to fears of offending patients or feeling uncertain about handling such discussions. From the patients’ perspective, negative experiences stemming from certain tones or word choices can inadvertently harm the doctor-patient relationship.
This research, funded by the National Institute for Health and Care Research School for Primary Care Research and Foundation for the Sociology of Health and Illness, utilised conversation analysis techniques on audio recordings from the BWel trial. In this trial, doctors offered patients referrals to a 12-week weight loss programme, and the researchers observed how different communicative approaches – categorised as ‘good news’, ‘bad news’, or neutral – influenced patient engagement and satisfaction.
Statistical analysis revealed that patients were more likely to enrol in, attend, and lose more weight in programmes when the referral was framed as ‘good news’. Specifically, 83% of patients offered programmes in a positive light attended, compared to only 50% for neutrally framed offers. Those who received ‘good news’ also lost about half a stone (3.6kg) more compared to the ‘neutral’ or ‘bad’ news groups.
Dr Charlotte Albury, the study’s lead author, emphasised that framing weight loss conversations positively encourages patients to participate more actively in programmes, yielding better weight loss outcomes. She noted that while both ‘neutral’ and ‘negative’ framings led to similar levels of programme acceptance and weight loss, the ‘good news’ approach stood out for its effectiveness.
The study identified specific characteristics of ‘good’ and ‘bad’ news delivery. In the ‘good news’ approach, doctors focused on the benefits of weight loss in an optimistic manner, confidently shared advantages, and communicated fluently and cheerfully. In contrast, the ‘bad news’ framing centred on health issues related to overweight and emphasised patient effort, often marked by slower delivery and hesitations. The neutral approach maintained a steady tone without leaning towards either benefits or issues.
Dr Albury highlighted the importance of these findings for medical professionals, suggesting that adopting a ‘good news’ approach could significantly enhance patient motivation and success in weight management. By transforming discussions into positive and empowering dialogues, doctors can effectively encourage patients to adopt healthier lifestyles.
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Can cognitive behavioural therapy (CBT) help with weight loss?
Cognitive behavioural therapy (CBT) is a type of talk therapy that focuses on identifying unhelpful thoughts and behaviours and replacing them with more positive and constructive ones.
This therapy aims to help people overcome a variety of issues, including anxiety, depression, phobias, substance use disorders, eating disorders, insomnia, relationships, self-esteem, and personality disorders. CBT is not intended to be ongoing, and typically involves regular sessions with a therapist for anywhere from 4 to more than 20 sessions, depending on the issue being addressed.
CBT can be particularly helpful for people who struggle with weight management, as it focuses on changing the behavioural patterns that contribute to weight gain. For example, if someone tends to overeat in response to stress, CBT can help them develop more positive coping strategies to manage their stress. CBT is also considered a preferred treatment for obesity and binge-eating disorder (BED).
To use CBT for weight loss, a therapist will help an individual set specific and attainable goals, such as reaching a target weight range or adopting a healthier lifestyle. The therapist will also encourage self-monitoring to help the individual become aware of their eating behaviours and to identify potential setback triggers, such as boredom or stress eating.
By identifying these triggers early on, the individual can take steps to correct them and avoid undoing their progress. The therapist may also offer feedback and reinforcement to help the individual stay motivated and track their progress. While CBT can be a highly effective way to change habits and patterns of thinking, it’s important to remember that lifestyle and behavioural training can take time, and progress may not happen overnight.
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Positive parenting can reduce the risk that children develop obesity
Children with positive, early interactions with their caregivers — characterised by warmth, responsiveness, and a stimulating home environment — were at reduced risk of childhood obesity according to new research from Pennsylvania State University in the United States.
The study, “Family Psychosocial Assets, Child Behavioral Regulation, and Obesity,” appeared in the journal Pediatrics. In the article, Brandi Rollins, assistant research professor of biobehavioural health and Lori Francis, associate professor of biobehavioural health, analysed data from over 1,000 mother-child pairs and found that children’s early exposures to family psychosocial assets — including a quality home environment, emotional warmth from the mother, and a child’s ability to self-regulate — reduced the risk of developing childhood obesity.
“A lot of the discussion around childhood obesity and other health risks focuses on identifying and studying the exposure to risk,” said Rollins, “We took a strength-based approach in our analysis. We found that a supportive family and environment early in a child’s life may outweigh some of the cumulative risk factors that children can face.”
An especially encouraging aspect of the study found that these factors were protective even when children faced familial risks for obesity, including poverty, maternal depression, or residence in a single-parent home.
“Research on parenting has shown that these types of family assets influence children’s behaviour, academic success, career, and — not surprisingly — health,” Rollins said. “It is significant that these factors also protect against childhood obesity because the family assets we studied are not food or diet-specific at all. It is heartening to know that, by providing a loving, safe environment, we can reduce the risk that children will develop obesity.”
Children are deemed to have obesity when their body mass indices (BMIs) are greater than 95% of other children their age and gender. There is a great deal of variance, however, in the BMIs of children who exceed the obesity threshold. Children whose BMI is 20% higher than the obesity threshold are considered to have severe obesity.
The researchers found that children who had early-onset severe obesity did not face greater levels of family risk than children who were not obese. Children with severe obesity, however, did have fewer family assets than children who were not obese or who displayed moderate levels of obesity. More research is needed to understand which factors contribute to the development of severe obesity and which factors reduce the risk.
“Though the findings on severe obesity may seem discouraging, they offer some hope,” Rollins explained. “Some risk factors, like household poverty, can be very difficult to change. Assets, on the other hand, may be easier to build. People can learn to parent responsively. It is encouraging that parenting really matters, that family matters.”
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Clinic and Home-Based Behavioral Intervention for Obesity in Preschoolers: A Randomized Trial
In this phase III randomised controlled trial of 151 children, published in the Journal of Pediatrics, the authors sought to investigate whether a skills-based behavioural family clinic and home-based intervention (LAUNCH) would be more effective at reducing BMI than motivational interviewing or to standard care in preschool-aged children with obesity.
LAUNCH is an 18-session clinic and home, family-based behavioral weight management intervention. Motivational interviewing was a parent only intervention consisting of 18 sessions over 6 months and focused on making changes to the child’s caregiver by encouraging diet and activity changes. Standard care informed caregivers of their child’s weight status during the recruitment process, but neither the children nor caregivers received any treatment.
LAUNCH demonstrated a mean (±SD) decrease in BMIz of −0.32 (±0.33) while motivational interviewing yielded a decrease of −0.05 (±0.27), standard care yielded a decrease of −0.13 (±0.31). Children in motivational interviewing and standard care gained almost triple the amount of weight during the 6-month period as children in LAUNCH. This slowing of weight gain resulted in a 4.45% decrease in percent overweight for LAUNCH, while both motivational interviewing and standard care increased in their percent overweight by 2.43% and 1.45%, respectively. Thus, the decrease in BMIz for LAUNCH was not only statistically significant, but clinically meaningful as well.
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New type of treatment achieves sustained weight loss
Acceptance-Based Behavioural Treatment (ABT) has helped more people lose weight and keep it off than Standard Behavioural Treatment (SBT) – which involves reduced caloric intake and increased physical activity. ABT attaches a higher personal value to weight loss that helps people adhere to diets and physical activity and a recent study, published in Obesity, has found it to be more effective that standard treatments. The study found that those who received ABT lost 13.3% of their initial weight after one year, compared to 9.8% of SBT participants.
Further to this the likelihood of maintaining a 10% weight loss at 12 months was one-third greater for ABT than SBT. ABT itself emphasises the principles of choosing goals from personal values, such as living a longer and healthier life, also the recognition that weight control behaviours will inevitably be uncomfortable. It also aims to increase awareness of how cues impact activity related decision making – including eating. 190 people took part in this study over a 1-year period and the results have been extremely promising so far, with many issues surrounding current treatments being related to the poor long-term sustainability of weight loss. However, as with all new findings, the results will need to be repeated in more studies in order for the treatment to be validated for use.
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Online behavioural counselling effective at sustaining weight loss
Behavioural counselling has been used as a treatment option for obesity, alongside diet and lifestyle changes. However, previous studies have suggested that intensive counselling and support is needed for it to be effective. A new online weight reduction programme called Positive Online Weight Reduction (POWeR)+ has been proven to be highly effective at weight loss and weight loss maintenance, these results have been published in Lancet Diabetes & Endocrinology. Professor Paul Little, the developer of the programme, explained that it not only helped people lose weight, but it enabled them to manage their weight going forward.
The programme itself involves brief online contacts from a nurse that teaches self-regulation and cognitive behavioural techniques, providing long-term solutions to weight loss. The study itself included 818 people over 30 who were participating in the course for over 6 months. The researchers explain that online interventions that are effective have the ability to save the NHS money by reducing the amount of time and funding given to face-to-face contact.
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Fathers have key role in developing healthy behaviours
A new study performed at the University of Guelph found that parents, and especially fathers, play a key role in developing healthy behaviours and preventing obesity in young adults. The study involved over 6,000 participants, aged between 14 and 24. The researchers noted that adolescents who grew up in stable families were more likely to have a healthy lifestyle and were less likely to be obese. Interestingly, they found that the mother-son relationship did not matter as much as the father-son relationship when it came to predicting whether the young male would be overweight or obese.
The authors are now hoping to develop strategies to help fathers support the development of health behaviours in their children, however more research is needed to explore the mechanisms by which this relationship operates, and to compare why this does not seem to be the case with the mother-daughter or mother-son relationship.
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