Knoxville Area Psychological Association

The Profession's Pulse: Information for the Practice of Psychology 

The American Psychological Association’s New Clinical Practice Guideline for the Treatment Of Obesity and Overweight in Children and Adolescents

Family-based, multicomponent behavioral interventions with 26 or more contact hours...

by Kristen Lott, M.S.

     Tennessee Neuropsychology

In March of 2018 the American Psychological Association (APA) released new recommendations on Clinical Practice Guidelines for the Treatment of Obesity and Overweight Children and Adolescents by the Members of the guideline development panel (GDP). The panel relied on research by the Kaiser Permanente Research Affiliates Evidence-Based Practice Center as its primary evidence base. The panel was made up of health professionals from psychology, medicine, nursing, and nutrition, as well as community members who self-identified as personally dealing with being overweight or obesity.

Recommendations

The panel considered four factors as it drafted recommendations:

• 1)      Overall strength of the evidence
• 2)      Balance of benefits vs. harms/burdens
• 3)      Patient values and preferences
• 4)      Applicability generalizability across populations, interventions, comparators, outcomes, timing, and settings

For children and adolescents who are overweight and obese in the 2-18 age range, the panel recommends family-based multicomponent behavioral intervention, initiated as soon as possible and lasting a minimum of 26 contact hours. This would specifically address behavior change, diet, and physical activity that is sufficiently intense. The panel found that out of 24 efficacy and comparative efficacy trials for children or adolescents with overweight or obesity conditions, family-based multicomponent behavioral interventions with 26 or more contact hours achieved a Body Mass Index z-score (zBMI) reduction greater than or equal to -0.25 in 58.3% of the trials. Those trials that had less than 26 hours reported achieving a zBMI reduction of -0.04. Treatment was most effective at a pre-school age, reporting all trials showing a benefit, whereas 27% of trials failed to show benefit in elementary school aged children, and that raised to 36% when reaching adolescents.

There was no evidence to suggest factors like parental obesity, race and ethnicity, or socioeconomic status made a difference in treatment. There were some differences shown in the effectiveness of treatment with these factors; however, they were not assessed with all the age groups, so it could not conclusively be determined to have a significant effect.

The panel found there was insufficient evidence to determine the comparative effectiveness of selected strategies of family-based multicomponent behavioral interventions, including:

    Goals and planning

    Comparison of outcomes

    Self-monitoring of behavior

    Self-monitoring of outcome

    Contingent reward or threat

    Stimulus control

    Modeling of healthy lifestyle behaviors by parents

    Motivational interviewing

    Parenting skills training

Practitioners have flexibility in selecting an efficacious family-based multicomponent behavioral intervention program of sufficient intensity that addresses physical activity, nutrition, and behavior change with strategies used to accomplish change appropriate for particular patients and local implementation needs. None of the trials included motivational interviewing, self-monitoring of behavior and outcome, contingent reward or threat, stimulus control, or parental modeling for comparison of outcomes.

There was insufficient evidence in the study to determine whether specific intervention characteristics or strategies were associated with patient adherence (other than attendance), engagement, or retention. Higher attendance was associated with greater efficacy, but there was insufficient evidence to determine whether patient adherence (beyond attendance) was associated with efficacy. Patient adherence had no consistent definition or reporting throughout the trials.

Potential Harms and Burdens

While the panel found no evidence of potential physical harm throughout the study, concerns of psychological harm did present. Few of the studies assessed psychological well-being, and of the 11 that did, only one suggested possible negative impact from the intervention. Some problems that could arise are familial conflict and the children developing psychological issues relating to the success or failure of the intervention.

Recognized burdens included lack of access to safe physical activity, healthy foods, and easy access to treatment, which may be difficult in certain geological areas. Another burden is family involvement, as treatment requires at least two participants, a child and parent, to be effective. The amount of time required for this treatment was also an issue, as it can impact income for the family if the parents take time off work, and the child could suffer academically if they must leave school. The panel suggested addressing these burdens during intervention.

Conclusion

In articles that did address BMI and its effect on children and adolescents, there was little specificity regarding factors involved like gender, race/ethnicity, and socioeconomic status. These factors could guide us from possible pitfalls when attempting to minimize harm, lead to more culturally sound treatments, including in communities where potential patients are not be coming to professionals for help. In my opinion more research is needed to address the questions that remain unanswered by this panel.

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