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The Effectiveness of Nutrition Specialists on Pediatric Weight Management Outcomes in Multicomponent Pediatric Weight Management Interventions: A Systematic Review and Exploratory Meta-Analysis

Published:March 02, 2019DOI:https://doi.org/10.1016/j.jand.2018.12.008

      Abstract

      Background

      Nutrition specialists are considered key members of multicomponent pediatric weight management intervention teams, but to date, their contribution has not been quantified.

      Objective

      The purpose of this systematic review was to estimate the effectiveness of interventions provided by treatment teams that include a nutrition specialist on pediatric weight management outcomes, including body mass index (BMI), BMI z score, and waist circumference when compared with treatment teams that do not include a nutrition specialist.

      Methods

      The results of a comprehensive literature search and a systematic and more targeted update of that search were included in the meta-analyses: a search of controlled trials published between July 2005 and April 2012, conducted during the 2015 Pediatric Weight Management Update Project of the Academy of Nutrition and Dietetics Evidence Analysis Library, and an update search of controlled trials published between May 2012 and December 2015 focusing on a more specific topic within the previous search. Studies included overweight and/or obese patients aged 6 to 18 years receiving outpatient weight management treatment. Data extraction of all studies identified was performed using a standardized tool. The resulting data from the search and the systematic update were merged. Ninety-nine studies and 209 study arms were included in the analysis. An exploratory meta-analysis using alternative meta-analytic methods designed for complex, heterogenous interventions was conducted to identify relative contributions by intervention provider category at selected time points. Meta-regression analyses were used to evaluate significant differences from the reference category for each provider category.

      Results

      The nutrition specialist-only condition resulted in increased reductions in BMI z score compared with behavioralist-only, combined nutrition specialist and behavioralist, and neither nutrition specialist or behavioralist category (reference) throughout the analysis. Meta-regression analysis indicated that the difference in BMI z score between the nutrition specialist-only category and the reference category was significant at 3 to <6 months, 6 months to <1 year, and 1-year to 2-year time points (P=0.01, P=0.05, and P=0.01, respectively). There were smaller increases in BMI over time for the nutrition specialist-only provider category compared with reference categories, and this difference was significant at the 3 to <6 months and 1-year to 2-years time points (P=0.001 and P=0.05, respectively). There were no significant differences among provider categories for waist circumference at any time point.

      Conclusions

      Indirect evidence indicated that pediatric weight management outcomes for BMI z score and BMI at selected time points appeared to be better when a nutrition specialist was involved in delivering care.

      Keywords

      The Continuing Professional Education (CPE) quiz for this article is available for free to Academy members through the MyCDRGo app (available for iOS and Android devices) and through www.jandonline.org (click on “CPE” in the menu and then “Academy Journal CPE Articles”). Log in with your Academy of Nutrition and Dietetics or Commission on Dietetic Registration username and password, click “Journal Article Quiz” on the next page, then click the “Additional Journal CPE quizzes” button to view a list of available quizzes. Non-members may take CPE quizzes by sending a request to [email protected] . There is a fee of $45 per quiz (includes quiz and copy of article) for non-member Journal CPE. CPE quizzes are valid for 1 year after the issue date in which the articles are published.
      Research Question: Are pediatric weight management outcomes better when interventions are provided by treatment teams that include a nutrition specialist compared with teams that do not include a nutrition specialist?
      Key Findings: In this systematic review and exploratory meta-analysis utilizing alternative meta-analytic methods for handling data from complex and heterogenous interventions, indirect evidence indicated that pediatric weight management outcomes for body mass index z score and body mass index at selected time points appeared to be better when a nutrition specialist was involved in delivering care.
      Nutrition interventions are inherently complex.
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      Managing complexity in evidence analysis: A worked example in pediatric weight management.
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      Nutrients, endpoints, and the problem of proof.
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      A research and development agenda for systematic reviews that ask complex questions about complex interventions.
      It is difficult, and perhaps impossible in many cases, to completely control nutrition intervention studies (with rare exceptions; for example, intensive supervision of subjects confined in specially equipped metabolic rooms located in dedicated research facilities).
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      • Thompson K.L.
      • Ziegler J.
      • Handu D.
      Managing complexity in evidence analysis: A worked example in pediatric weight management.
      • Heaney R.
      Nutrients, endpoints, and the problem of proof.
      When nutrition research encompasses educational and counseling components, as is the case with pediatric weight management (PWM) interventions, the level of complexity increases by orders of magnitude.
      • Byrne D.
      • Callaghan G.
      Complexity Theory and the Social Sciences: The State of the Art.
      Many nutrition interventions, particularly those dealing with nutrition education and counseling, are a challenge to analyze meta-analytically because they are multicomponent (ie, multiple intervention modalities are incorporated) and heterogenous in that there is usually no typical or standard configuration of intervention components to use as a basis for comparisons.
      • Parrott J.S.
      • Henry B.
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      • Handu D.
      Managing complexity in evidence analysis: A worked example in pediatric weight management.

      Parrott J. Unpackaging context dependence in systematic reviews of complex interventions: A methodological approach for managing double-layered complexity. Paper presented at the 23rd Cochrane Colloquium, October 4, 2015, Vienna, Austria.

      In addition, nutrition studies are contextually situated; that is, occurring within an overarching environment that makes it difficult to isolate the effect of particular components. Thus, the outcomes of complex nutrition interventions are likely to be heavily influenced by the structure and configuration of the intervention as well as by the context in which it is situated.
      • Noyes J.
      • Gough D.
      • Lewin S.
      • et al.
      A research and development agenda for systematic reviews that ask complex questions about complex interventions.
      Unlike classic intervention studies, in which it is possible to compare a subject receiving a particular agent with a subject whose influence by that agent is either negligible or a known quantity, studies that seek to examine the contextually situated and adaptive interplay of clinician and patient behavior cannot be so tightly controlled. Thus, significant and complex methodology problems in aggregating data across studies and drawing conclusions from that data are commonplace for nutrition researchers and nutrition and dietetics practitioners.
      • Pigott T.
      • Noyes J.
      • Umscheid C.A.
      • et al.
      AHRQ series on complex intervention systematic reviews—paper 5: Advanced analytic methods.
      PWM interventions serve as only one example of a pervasive issue confronting the dietetics profession: The challenge of conducting evidence analysis, including systematic reviews and meta-analyses, for complex, multicomponent heterogenous interventions. PWM interventions are multicomponent in that they usually include multiple dietary manipulations (eg, hypocaloric diet, reduced carbohydrate diet, targeted nutrition education, plate method, or the stoplight plan), physical activity training (eg, individual or group physical activity instruction, physical activity sessions, pedometers, technological devices to measure physical activity, and alternatives to sedentary activity), and behavioral interventions (eg, family and/or individual counseling, journaling, support groups, cognitive behavioral therapy, mindful eating, and training in parenting skills).
      • Parrott J.S.
      • Henry B.
      • Thompson K.L.
      • Ziegler J.
      • Handu D.
      Managing complexity in evidence analysis: A worked example in pediatric weight management.
      Academy of Nutrition and Dietetics Evidence Analysis Library
      Pediatric weight management project 2015.
      • Henry B.W.
      • Ziegler J.
      • Parrott J.S.
      • Handu D.
      Pediatric weight management evidence-based practice guidelines: Components and contexts of interventions.
      • Barlow S.E.
      Expert committee recommendations regarding the prevention, assessment, and treatment of child and adolescent overweight and obesity: Summary report.
      Such interventions are heterogenous in that there is no typical configuration of either treatment or comparison conditions that can be used as a reference standard for comparisons across studies.
      • Parrott J.S.
      • Henry B.
      • Thompson K.L.
      • Ziegler J.
      • Handu D.
      Managing complexity in evidence analysis: A worked example in pediatric weight management.
      In fact, even a cursory examination of the PWM literature demonstrates that it is not uncommon for the treatment condition in one study to be very similar to the comparison condition in another study.
      The analytic challenges in this situation are daunting. For instance, if only one of five different dietary manipulation modalities within a PWM intervention is paired with only one of five different physical activity interventions, a simple mathematical calculation reveals the possibility of 36 possible intervention configurations. This example calculation is radically simplified compared with the reality of most PWM interventions. Evidence analysis for the recently published Academy of Nutrition and Dietetics Pediatric Weight Management Guideline resulted in the coding of 30 different weight management intervention characteristics: Calculations reveal more than 1 billion possible configurations for PWM interventions.
      • Parrott J.S.
      • Henry B.
      • Thompson K.L.
      • Ziegler J.
      • Handu D.
      Managing complexity in evidence analysis: A worked example in pediatric weight management.
      • Henry B.W.
      • Ziegler J.
      • Parrott J.S.
      • Handu D.
      Pediatric weight management evidence-based practice guidelines: Components and contexts of interventions.
      Classic systematic review and meta-analytic methods, which compare a single intervention to a standard comparison condition, are simply not equipped to deal with this level of complexity.
      The approach of the authors of this study was to conduct a systematic review in cooperation with the Academy of Nutrition and Dietetics Evidence Analysis Library (EAL), using standardized EAL procedures for updating an existing search database and conducting a literature review, and employing alternative methodologic techniques for aggregating and analyzing data.
      • Parrott J.S.
      • Henry B.
      • Thompson K.L.
      • Ziegler J.
      • Handu D.
      Managing complexity in evidence analysis: A worked example in pediatric weight management.
      • Noyes J.
      • Gough D.
      • Lewin S.
      • et al.
      A research and development agenda for systematic reviews that ask complex questions about complex interventions.
      • Henry B.W.
      • Ziegler J.
      • Parrott J.S.
      • Handu D.
      Pediatric weight management evidence-based practice guidelines: Components and contexts of interventions.
      • Handu D.
      • Moloney L.
      • Wolfram T.
      • Ziegler P.
      • Acosta A.
      • Steiber A.
      Academy of Nutrition and Dietetics methodology for conducting systematic reviews for the Evidence Analysis Library.
      • Lorenc T.
      • Felix L.
      • Petticrew M.
      • et al.
      Meta-analysis, complexity, and heterogeneity: A qualitative interview study of researchers’ methodological values and practices.
      • Melendez-Torres G.J.
      • Bonell C.
      • Thomas J.
      Emergent approaches to the meta-analysis of multiple heterogeneous complex interventions.
      • Petticrew M.
      • Anderson L.
      • Elder R.
      • et al.
      Complex interventions and their implications for systematic reviews: A pragmatic approach.
      • Anderson L.M.
      • Oliver S.R.
      • Michie S.
      • Rehfuess E.
      • Noyes J.
      • Shemilt I.
      Investigating complexity in systematic reviews of interventions by using a spectrum of methods.
      Whereas classic meta-analysis aggregates the effects of multiple direct comparisons among studies, the methodology used in this study results in an epidemiologic analysis in which a variable’s effects are evaluated by its ability to reduce unexplained heterogeneity.
      • Melendez-Torres G.J.
      • Bonell C.
      • Thomas J.
      Emergent approaches to the meta-analysis of multiple heterogeneous complex interventions.
      • Petticrew M.
      • Anderson L.
      • Elder R.
      • et al.
      Complex interventions and their implications for systematic reviews: A pragmatic approach.
      • Anderson L.M.
      • Oliver S.R.
      • Michie S.
      • Rehfuess E.
      • Noyes J.
      • Shemilt I.
      Investigating complexity in systematic reviews of interventions by using a spectrum of methods.
      This methodology makes it possible to assess diverse outcomes resulting from complex interventions.
      • Parrott J.S.
      • Henry B.
      • Thompson K.L.
      • Ziegler J.
      • Handu D.
      Managing complexity in evidence analysis: A worked example in pediatric weight management.
      • Pelletier D.L.
      • Porter C.M.
      • Aarons G.A.
      • Wuehler S.E.
      • Neufeld L.M.
      Expanding the frontiers of population nutrition research: New questions, new methods, and new approaches.
      The meta-analysis was exploratory in the sense that, because no head-to-head trials were identified for analysis, the investigators considered the study to be hypothesis-generating with further research needed to clarify findings.
      The purpose of the study was to synthesize evidence, via systematic review with subsequent meta-analysis as appropriate, on the contribution of nutrition specialists to interprofessional teams delivering multicomponent treatment programs for children and adolescents with obesity. The research question was: In overweight/obese children and adolescents aged 6 to 18 years (Population), are multicomponent PWM interventions provided by treatment teams that include a nutrition specialist (Intervention) associated with better clinical outcomes (ie, body mass index [BMI], BMI z scores, and waist circumference [WC]) at 3 to <6 months, 6 months to <1 year, 1 year to 2 years, and >2 years time points (Outcomes) than multicomponent PWM interventions provided by treatment teams that do not include a nutrition specialist? (Comparison)
      Throughout this article, the term nutrition specialist is used to refer to registered dietitians or registered dietitian nutritionists credentialed by the Commission on Dietetic Registration (CDR), or registered dietitians credentialed in countries that maintain reciprocity agreements with CDR; and dietetics professionals credentialed by their respective international credentialing agencies or considered qualified in their own countries by educational attainment.
      Academy of Nutrition and Dietetics
      What is a registered dietitian nutritionist?.
      Accreditation Council for Education in Nutrition and Dietetics
      Dietetics education and credentialing requirements for individuals with foreign degrees. 2016.
      The role of nutrition specialists in included studies was defined by the authors as delivery of the nutrition components of multicomponent interventions, including the provision of medical nutrition therapy, nutrition counseling, nutrition-focused physical examination, and other nutrition services.

      Methods

      Methods for conducting this review were established before undertaking the review. The methodology for the review was evaluated and approved by a group of qualified academic researchers through the research proposal review process of the School of Health Professions, Rutgers, the State University of New Jersey. Any significant deviations from the planned methodology are described in this article. Because of the exploratory nature of this investigation, no protocol was registered.
      The procedures used to conduct this study were adapted from the Cochrane Handbook for Systematic Reviews of Interventions, and were used within the context of the EAL Methodology for updating a literature review, which integrates the Cochrane standards within its processes.
      Academy of Nutrition and Dietetics Evidence Analysis Library
      Pediatric weight management project 2015.

      Cochrane Library. Cochrane handbook for systematic reviews of interventions, v.5.1.0. In: Higgin JPT, Green S, eds: The Cochrane Collaboration, 2011. https://training.cochrane.org/handbook. Accessed October 14, 2015.

      The preferred reporting items for systematic reviews and meta-analyses were used to structure the methodology and results sections of this article.
      • Moher D.
      • Liberati A.
      • Tetzlaff J.
      • Altman D.G.
      Preferred reporting items for systematic reviews and meta-analyses: The PRISMA statement.
      The research question examined the effect of delivery of nutrition interventions by a nutrition specialist as part of an interprofessional team treating child and adolescent overweight and obesity with regard to three selected outcomes: BMI, BMI z score, and WC. BMI was defined as the mathematical result of dividing a pediatric patient’s weight in kilograms by height in meters squared.
      Centers for Disease Control and Prevention
      Defining childhood obesity: BMI for children and teens. 2015.
      BMI z score was defined as the location of an individual pediatric BMI on an age- and sex-specific normal curve.
      • Flegal K.M.
      • Ogden C.L.
      Childhood obesity: Are we all speaking the same language?.
      The BMI z score is written as the number of standard deviations above or below the mean; thus, a BMI z score of 1.5 indicates a BMI that is ±1.5 above the mean.
      • Flegal K.M.
      • Ogden C.L.
      Childhood obesity: Are we all speaking the same language?.
      BMI z scores are expressed as percentiles in reference to a particular age- and sex-specific distribution of BMIs.
      • Flegal K.M.
      • Ogden C.L.
      Childhood obesity: Are we all speaking the same language?.
      WC was defined as suggested by McCarthy and colleagues
      • McCarthy H.D.
      • Jarrett K.V.
      • Crawley H.F.
      The development of waist circumference percentiles in British children aged 5.0-16.9 years.
      as the measurement obtained by encircling the area halfway between the 10th rib and the iliac crest with an inflexible tape measure, expressed in centimeters.

      Search Strategy

      This systematic review was conducted using a database encompassing the results of a systematic search of the literature and an update of that search. The Academy EAL conducted a review of PWM literature published between July 2005 and April 2012 during the 2015 Pediatric Weight Management Project (PWMP 2015); these search results have been previously reported in the published Academy Pediatric Weight Management Evidence-based Guideline.
      • Henry B.W.
      • Ziegler J.
      • Parrott J.S.
      • Handu D.
      Pediatric weight management evidence-based practice guidelines: Components and contexts of interventions.
      Academy of Nutrition and Dietetics
      Evidence analysis manual. 2015.
      Data extracted from articles included in the PWMP 2015 were compiled in a permanent Pediatric Weight Management Database (2005-2012 PWMD search) maintained by the EAL. The authors of this study conducted a systematic search update, focusing on a more specific topic within the previous search, and encompassing controlled trials published or in press between May 2012 and December 2015 (2012-2015 search update).
      • Henry B.W.
      • Ziegler J.
      • Parrott J.S.
      • Handu D.
      Pediatric weight management evidence-based practice guidelines: Components and contexts of interventions.
      • Handu D.
      • Moloney L.
      • Wolfram T.
      • Ziegler P.
      • Acosta A.
      • Steiber A.
      Academy of Nutrition and Dietetics methodology for conducting systematic reviews for the Evidence Analysis Library.
      Academy of Nutrition and Dietetics
      Evidence analysis manual. 2015.
      Both the original search and the search update were conducted according to EAL methodology, which is designed to reduce bias in the completed search.
      • Henry B.W.
      • Ziegler J.
      • Parrott J.S.
      • Handu D.
      Pediatric weight management evidence-based practice guidelines: Components and contexts of interventions.
      The EAL methodology for conducting systematic literature reviews is found in the Academy Evidence Analysis Manual,
      Academy of Nutrition and Dietetics
      Evidence analysis manual. 2015.
      and has been described by Handu and colleagues
      • Handu D.
      • Moloney L.
      • Wolfram T.
      • Ziegler P.
      • Acosta A.
      • Steiber A.
      Academy of Nutrition and Dietetics methodology for conducting systematic reviews for the Evidence Analysis Library.
      and Papoutsakis and colleagues
      • Papoutsakis C.
      • Moloney L.
      • Sinley R.C.
      • Acosta A.
      • Handu D.
      • Steiber A.L.
      Academy of Nutrition and Dietetics methodology for developing evidence-based nutrition practice guidelines.
      previously.

      2015 PWMP

      Articles analyzed as part of the 2015 PWMP encompass studies conducted between July 2005 and April 2012 that were located based on a search of the Cochrane Database of Clinical Trials (CENTRAL).
      Academy of Nutrition and Dietetics Evidence Analysis Library
      Pediatric weight management project 2015.
      The 2005-2012 PWMD search was intended to be used as a basis for future work in PWM, including studies on outcomes of PWM interventions; therefore, the search was performed with few limits and without specific evidence analysis questions in mind. Rather, the expert committee conducting the search sought to capture the broad scope of PWM research during the time period of interest. The 2015 PWMP expert working group chose to utilize CENTRAL to identify high-quality controlled trials conducted during the established search dates. CENTRAL is highly focused on randomized controlled trials and obtains its bibliographic entries largely from MEDLINE and Embase.
      • Cochrane Library
      Cochrane Central Register of Controlled Trials (CENTRAL). 2015.
      The expert working group reasoned that the broad spectrum of high-quality PWM literature would be reflected in the CENTRAL database.
      The 2015 PWMP expert working group chose the search dates of 2005 to 2012 to ensure that the updated 2015 guidelines were based on the most recent patterns of PWM practice. In addition, before the search period, there were no Academy PWM nutrition practice guidelines, no PWM certification program had been established, and approaches to treatment were continuing to evolve.

      2012-2015 Search Update

      A research librarian with expertise in systematic review methodology served as a coinvestigator, and assisted in developing the 2012-2015 search update strategy. The search update was conducted during December 2015 by the principal investigator and was reviewed by the coinvestigators. The search encompassed articles published or in press from May 1, 2012, through December 31, 2015. To confirm the final search syntax, preliminary searches were conducted within PubMed. Medical subject headings terms, keywords, and other relevant terms from identified studies were recorded. Test searches using various combinations of terms were conducted and search strategies of relevant systematic reviews were considered.
      The following databases were included in the search: PubMed, Scopus, the Cumulative Index to Nursing and Allied Health Literature, and CENTRAL. The search was limited to controlled trials and systematic reviews with human participants aged 6 to 18 years (ie, elementary and secondary school age, the same age range used in the 2005-2012 PWMD search) in the English language, published or in press between May 1, 2012, and December 31, 2015. Search terms encompassed medical subject headings terms and keywords. Terms included pediatric obesity, Obesity, Overweight, Child, Adolescent, Body Mass Index, Body Weight, BMI, Weight, Waist Circumference, Skinfold thickness, Body Weight Changes, Body Size, and Body Composition. The publication types were specified as randomized controlled trial, controlled trial, and systematic reviews. The reference lists of guideline articles and systematic reviews were mined for primary references. Search details were recorded to ensure the transparency and reproducibility of each search. An example of search syntax used to search the PubMed database is found in Figure 1.
      Figure 1Sample search syntax used to identify pediatric weight management research articles with specified outcomes: PubMed database.
      Search History—December 21, 2015
      DatabaseSearch termsNo. of hits
      PubMed1. ("Pediatric Obesity"[Mesh] OR "Obesity"[Mesh] OR "Overweight"[Mesh] OR obese OR obesity OR overweight) AND ("Child"[Mesh] OR "Adolescent"[Mesh] OR child OR children OR youth) AND ("Body Mass Index"[Mesh] OR "Body Weight"[Mesh] OR BMI OR body mass index OR weight OR "Waist Circumference"[Mesh] OR "Skinfold Thickness"[Mesh] OR "Body Weight Changes"[Mesh] OR "Body Size"[Mesh] OR "Body Composition"[Mesh]) AND ("2012/05/01"[PDAT] : "2016/12/31"[PDAT]) AND (("Randomized Controlled Trial" [Publication Type])Limit to humans, English language: 942
      Relevant websites and conference proceedings were identified through discussion with the co-investigators. Four sources were chosen by the principal investigator and topic expert coinvestigators as broadly representing the gray literature on the study topic: the American Academy of Pediatrics, the Obesity Society, the Food and Nutrition Conference and Expo and the Obesity Week conference. The American Academy of Pediatrics and the Obesity Society websites were searched using a Google Site Search. The Food and Nutrition Conference and Expo and the Obesity Society Obesity Week conference proceedings from 2012 to 2015 were mined for references. The entire search strategy was reviewed by the principal investigator and coinvestigators; any disagreements were resolved by consensus among the investigators.
      Abstracts (N=2,424) were exported to Endnote X6,

      Endnote X6. Philadelphia, PA: Claivate Analytics; 2012.

      and 234 duplicates were deleted. Four records were identified through a search of gray literature and mining of the reference lists of systematic reviews. A total of 2,194 abstracts were screened according to the predetermined inclusion and exclusion criteria. All abstracts were independently evaluated by two screeners: the principal investigator and a topic expert coinvestigator. In cases of disagreement, consensus was reached by discussion between the two screeners. A total of 2,070 abstracts were excluded based on the inclusion/exclusion criteria. The remaining 124 abstracts were retained for further screening. Full-text articles were obtained for each of these abstracts.
      Full-text articles were evaluated according to predetermined inclusion/exclusion criteria that were identical for both the 2005-2012 PWMD search and the 2012-2015 search update. Inclusion/exclusion criteria are found in Table 1. Because direct comparisons between multicomponent interventions, including a nutrition specialist and identical multicomponent arms without a nutrition specialist were lacking in the literature, the investigators decided to compare active treatment arms across studies. Research indicates that the quality of controlled studies tends to be higher than studies including only one arm; for this reason, included studies were limited to controlled trials providing at least two arms for comparison.

      Ip S, Paulus JK, Balk EM, Dahabreh IJ, Avendano EE, Lau J. Role of Single Group Studies in Agency for Healthcare Research and Quality Comparative Effectiveness Reviews. Rockville, MD: Agency for Healthcare Research and Quality; 2013. AHRQ Publication no. 13-EHC007-EF.

      Table 12005-2012 and 2012-2015 Literature search inclusion and exclusion criteria for articles to include in a meta-analysis performed to quantify the role of nutrition and dietetics practitioners in multicomponent pediatric weight management interventions
      Date of literature reviews: April 2012, December 2015
      Inclusion criteria
      • Age: Children and adolescents 6-18 y;
      • Setting: Outpatient, or primarily outpatient/ambulatory care (weight management program or other program with weight management as a primary goal such as a diabetes treatment program; length of intervention ≥12 wk; multicomponent, including nutrition component; outcomes must include adiposity measure[s]);
      • Health status: Healthy other than overweight/obesity, type 2 diabetes, obesity-related hypertension; not taking weight loss medication; no history of bariatric surgery;
      • Problem/condition: “Obesity” or “overweight”;
      • Study design preference: Controlled clinical trials;
      • Size of study groups: ≥10 Persons per study group;
      • Dropout rate: <20%;
      • Year range of publication dates: 2005-2012 search: June 2005-April 2012, 2012-2015 search: May 2012-December 2015;
      • Authorship: If the same author is included in more than 1 review article or clinical trial, and the articles are similar in content, the most recent article will be accepted and the others will be rejected. In the case that the same author is included in more than 1 review article or clinical trial, and the articles are different in content, all the articles may be accepted; and
      • Language: English.
      Exclusion criteria
      • Age: <6 y, >18 y, or studies with subjects outside the age range in which it is not possible to stratify data by age;
      • Setting: School-based in the case that all students are subject to the intervention; no nutrition component in the study; exclusively inpatient; not multicomponent;
      • Health status: Pregnant, taking weight loss medications, history of bariatric surgery;
      • Problem/condition: None;
      • Study design preference: Observational, noncontrolled trials;
      • Size of study groups: <10 Persons per group;
      • Dropout rate: >20%;
      • Year range of publication dates: Before January 2005, before May 2012;
      • Authorship: Not meeting inclusion criteria; and
      • Language: Languages other than English.
      Two independent reviewers, the principal investigator and a topic expert coinvestigator, evaluated the full-text articles. To maintain consistency with the earlier 2005-2012 PWMD search, the new search did not limit articles by country. For the same reason, studies were not limited to those including nutrition specialists credentialed by the CDR or by countries maintaining reciprocity with CDR. The reference lists of four systematic reviews were mined for citations before excluding. Ninety-eight full-text articles were excluded based on the inclusion-exclusion criteria. Twenty-six studies were identified for final inclusion in the 2012-2015 search update. At all stages in the search and the article selection process, the coinvestigators provided guidance and oversight based on their areas of expertise (statistician, meta-analytic methodology expert, evidence analysis and EAL expert, two topic experts, and a research librarian). Any disagreements were resolved through discussion among the principal investigator and the coinvestigators.
      Because the 2005-2012 PWMD search was designed to find any controlled trial on childhood overweight/obesity, it would have necessarily identified any study meeting the more narrow 2012-2015 search update criteria. The 2012-2015 search update was designed to address a question that was more focused and specific than those included in the 2015 PWMP; however, the existing PWMD provided information that could be used to answer that question.
      Academy of Nutrition and Dietetics
      Purpose and structure of the Evidence-Based Practice Committee. 2016.
      Thus, by combining the data extracted from the original search and the systematic search update, a comprehensive database was available for analysis. A flow chart illustrating the results of the combined 2005-2012 PWMD search and the 2012-2015 search update is provided in Figure 2.
      Academy of Nutrition and Dietetics Evidence Analysis Library
      Pediatric weight management project 2015.
      Figure thumbnail gr1
      Figure 2Flow diagram of the search strategy and selection process used in the 2005-2012 Evidence Analysis Library search and the 2012-2015 systematic update of that search, conducted to identfy the studies included in an exploratory meta-analysis to quantify the contribution of nutrition professionals to pediatric weight management treatment teams. CINAHL=Cumulative Index to Nursing and Allied Health Literature. CENTRAL=Cochrane Central Register of Controlled Trials.

      Data Extraction and Quality Appraisal

      Data extraction for the 2005-2012 search update was performed by trained evidence analysts, and was reviewed for accuracy by EAL staff.
      • Henry B.W.
      • Ziegler J.
      • Parrott J.S.
      • Handu D.
      Pediatric weight management evidence-based practice guidelines: Components and contexts of interventions.
      Data extraction for the 2012-2015 search update was completed by this study’s principal investigator, who is a trained evidence analyst. The statistician coinvestigator reviewed all extracted data for accuracy; any discrepancies were resolved by consensus. The same data extraction tool was used to compile identical data points from articles identified in both the 2005-2012 PWMD search and the search update. Extracted data for all studies included quality rating, study design, funding source, study group or population, information regarding subjects, study groups, type of intervention components, health care providers delivering the intervention, outcomes comparisons (ie, BMI, BMI z score, and WC), funding source, and primary conclusions. All studies were evaluated using the EAL Quality Criteria Checklist, which complies with Cochrane Collaboration tools for assessing risk of bias.
      • Handu D.
      • Moloney L.
      • Wolfram T.
      • Ziegler P.
      • Acosta A.
      • Steiber A.
      Academy of Nutrition and Dietetics methodology for conducting systematic reviews for the Evidence Analysis Library.

      Cochrane Library. Cochrane handbook for systematic reviews of interventions, v.5.1.0. In: Higgin JPT, Green S, eds: The Cochrane Collaboration, 2011. https://training.cochrane.org/handbook. Accessed October 14, 2015.

      Academy of Nutrition and Dietetics
      Evidence analysis manual. 2015.
      The Quality Criteria Checklist includes—among other criteria—an assessment of bias related to study allocation methods, blinding or lack thereof, outcomes analysis, and financial disclosures.
      Academy of Nutrition and Dietetics
      Evidence analysis manual. 2015.
      Each study was assigned a rating of positive, neutral, or negative quality. A co-investigator who is an expert in EAL methodology provided advisement, review, and technical support throughout the data extraction phase of the search and the systematic update. Data were available for intervention time points 3 to <6 months, 6 months to <1 year, 1 to 2 years, and >2 years.

      Statistical Analysis

      All data were crosschecked by the principal investigator and statistician coinvestigator for accuracy and consistency. The principal investigator of this systematic review identified an error in the results section of one study identified for inclusion during the 2012-2015 search update; the principal investigator of the study in question was contacted and provided corrected information.
      • Hofsteenge G.H.
      • Chinapaw M.J.
      • Delemarre-van de Waal H.A.
      • Weijs P.J.
      Long-term effect of the Go4it group treatment for obese adolescents: A randomised controlled trial.
      In six 2012-2015 search update studies in which data were presented as (mean and 95% confidence interval) or (mean±standard error) rather than (mean±standard deviation), Open Meta-Analyst software was used to back-calculate standard deviations for the purpose of standardization of data before meta-analysis.
      Center for Evidence Synthesis in Health,
      Brown School of Public Health. 2019. OpenMeta[Analyst].
      Data extracted from the studies identified during the 2012-2015 search update were then downloaded into an Excel

      Excel. Version 2013. Redmond, WA: Micrsoft Corp; 2013.

      data grid generated by the EAL data extraction platform. The statistician coinvestigator merged the 2012 – 2015 search update data with the pre-existing 2005-2012 PWMD search data from the PWMD. The data were cleaned and imported into Stata version 14 statistical software for meta-analysis.
      • Stata Statistical Software
      Release 14.
      Preliminary meta-analyses were conducted in order to further evaluate the data for inconsistencies. Outliers were identified independently by the principal investigator and statistician coinvestigator, and the results were discussed and either confirmed or corrected.

      Alternative Meta-Analytic Methods: Meta-Regression

      Variables were created within Stata
      • Stata Statistical Software
      Release 14.
      for four provider categories, referred to as interventionist combination variables, and were intended to identify the results of specialist-provided nutrition therapy by isolating the nutrition specialist-delivered therapy from the behavioralist (eg, psychologist or social worker) delivered therapy. The four provider categories, or interventionist combination variables, used in this analysis were Nutrition Specialist Only (nutrition specialist but not behavioralist), Behavioralist Only (behavioralist but not nutrition specialist), Combined nutrition specialist+behavioralist (both nutrition specialists and behavioral therapists were included, although the intervention team may also have included members from other specialties), and Neither Nutrition Specialist nor Behavioralist (although other specialists, including medical interventionists, including physicians, physician assistants, and nurses, could have delivered the intervention).
      American Psychological Association
      Glossary of psychological terms: Behavior modification. 2002.
      The focus on nutrition vs behavior interventionists, rather than nutrition vs medical interventionists, was based on consideration of the roles of the various members of the interprofessional team. The 2015 PWMP made a distinction between medical interventionists and nonmedical interventionists, who were most commonly found to be nutrition specialists or behavioralists. Delivery of services among medical, nutrition, and behavior professionals are not absolute. Nutrition specialists provide medical nutrition therapy and behavior change counseling, whereas medical interventionists and behavioralists often offer dietary interventions as a component of treatment. So, to obtain a clearer measure of contributions of the specific nonmedical professions (rather than the type of intervention), it was necessary to split the contributions of the nutrition specialist and the behavioralist. The question of the effectiveness of PWM treatment in the absence of medical interventionists was not addressed in this study, although it remains an important avenue of research.

      Meta-Regression Analysis

      Because none of the identified studies made head-to-head comparisons of interventions varying only the interventionists involved, the studies were broken into separate treatment arms, each providing data on a particular configuration of treatment components. This so-called dismantling approach has been used in the analysis of complex interventions.
      • Melendez-Torres G.J.
      • Bonell C.
      • Thomas J.
      Emergent approaches to the meta-analysis of multiple heterogeneous complex interventions.
      Rather than synthesizing the effects of multiple head-to-head comparisons (as in classic meta-analyses), this approach transforms the question into an epidemiologic analysis whereby the effect of a particular component is evident in its reduction of unexplained heterogeneity (similar to a reduction in variance in a classic regression). Implemented within the context of a meta-analysis, this results in an adjusted R2 whereby the estimated variance when covariates are fit in the model (τˆ2) is compared with the estimated variance in the model without covariates (τˆ02). The adjusted R2 then represents the relative reduction in between-study variance due to the inclusion of the covariates in the model (Radj2=(τˆ02τˆ2)/τˆ02).
      • Stata Statistical Software
      Release 14.
      Thus, an improvement in model fit due to inclusion of the covariates signals a reduction of heterogeneity—when the Radj2 is meaningfully positive we can conclude that the covariate has useful explanatory power.
      Meta-analysis and meta-regression were carried out using the Stata metaan and metareg procedures.
      • Stata Statistical Software
      Release 14.
      • Harbord R.M.
      • Higgins J.P.T.
      Meta-regression in Stata.
      • Kontopantelis E.
      • Reeves D.
      Metaan: Random-effects meta-analysis.
      The DerSimonian-Laird random-effects model was used to evaluate the following outcomes: BMI, BMI z score, and WC. Because the DerSimonian-Laird model may produce overly narrow CIs when sample sizes are small or effects are widely divergent, when possible (n≥6 within the subgroup), permutated CIs were computed.
      • Cornell J.E.
      • Mulrow C.D.
      • Localio R.
      • et al.
      Random-effects meta-analysis of inconsistent effects: A time for change.
      • Follmann D.A.
      • Proschan M.A.
      Valid inference in random effects meta-analysis.
      The permutation approach provides a more conservative CI estimation and thus avoids an inflation in the type I error rate. Statistical significance of effect size was set at P<0.05. The I2 and H2 statistics were used to determine the degree of heterogeneity in the calculated effect size, and I2 levels of 25%, 50%, and 75% were, respectively, considered low, moderate, and high. Random effects meta-regression analysis of each outcome category and time point were conducted to determine significant differences between the Neither Nutrition Specialist or Behavioralist and other provider categories. To assess the possibility of publication bias, funnel plots were generated for the studies used in analyses of each of the four interventional combination variables.

      Results

      Study Characteristics

      A total of 2,413 abstracts were identified across both the 2005-2012 search and the 2012-2015 search update. The application of inclusion-exclusion criteria resulted in the elimination of 2,191 abstracts. After review of a total of 222 full-text articles, 99 articles met inclusion criteria. Of the 99 studies, 44 out of 99 (44%) were of positive quality, 55 out of 99 (56%) were of neutral quality, and no studies were of negative quality. A χ2 analysis of the association between study quality (positive, neutral, or negative) and any of the four provider categories found no association (P=0.792 [not significant]). The combined dataset provided 209 study arms for comparison.
      The number of study arms available for analysis at each time point along with period by provider category subgroup meta-analyses are reported in Table 2. The Behavioralist Only group provided the fewest arms for analysis and for the WC analysis there were no Behavioralist Only arms available at the 3 to <6 month and the 6-month to <1-year time point. The reader is cautioned about interpreting the results for any particular group at the analyzed time points when there are fewer than three study arms available for analysis. When fewer than two study arms were available, model parameters were not computed.
      Table 2Number of study arms by intervention provider category and time point for each outcome included in a meta-analysis performed to quantify the role of nutrition and dietetics practitioners in multicomponent pediatric weight management interventions
      Time Periods of Outcome MeasurementTotalIntervention Provider Category
      Body mass index z score
      The location of an individual pediatric body mass index on an age- and sex-specific normal curve.21
      Nutrition specialist onlyBehavioralist onlyNutrition specialist and behavioralist combinedNeither nutrition specialist or behavioralist
      3-<6 mo38106517
      6 mo-<1 y42165813
      1-2 y642251423
      >2 y2310436
      Body mass index
      The mathematical result of dividing a pediatric patient’s weight in kilograms by height in meters2.20
      3-<6 mo541741518
      6 mo-<1 y38122816
      1-2 y521411324
      >2 y2062111
      Waist circumference
      The measurement obtained by encircling the area halfway between the 10th rib and the iliac crest with an inflexible tape measure, expressed in centimeters.21,22
      3-<6 mo208048
      6 mo-<1 y2890613
      1-2 y38102917
      >2 y133136
      a The location of an individual pediatric body mass index on an age- and sex-specific normal curve.
      • Flegal K.M.
      • Ogden C.L.
      Childhood obesity: Are we all speaking the same language?.
      b The mathematical result of dividing a pediatric patient’s weight in kilograms by height in meters2.
      Centers for Disease Control and Prevention
      Defining childhood obesity: BMI for children and teens. 2015.
      c The measurement obtained by encircling the area halfway between the 10th rib and the iliac crest with an inflexible tape measure, expressed in centimeters.
      • Flegal K.M.
      • Ogden C.L.
      Childhood obesity: Are we all speaking the same language?.
      • McCarthy H.D.
      • Jarrett K.V.
      • Crawley H.F.
      The development of waist circumference percentiles in British children aged 5.0-16.9 years.
      The included study arms encompassed 12,541 subjects, including 7,986 treatment subjects. All of the studies included pediatric patients aged 6 to 18 years. Participants comprised a variety of ethnic and cultural populations residing in developed and developing countries.
      • Guo H.
      • Zeng X.
      • Zhuang Q.
      • Zheng Y.
      • Chen S.
      Intervention of childhood and adolescents obesity in Shantou city.
      • Aparecida Alves Bianchini J.
      • Fernandes da Silva D.
      • Jaeger Hintze L.
      • et al.
      Obese adolescents who gained/maintained or lost weight had similar body composition and cardiometabolic risk factors following a multidisciplinary intervention.
      • Esfarjani F.
      • Khalafi M.
      • Mohammadi F.
      • et al.
      Family-based intervention for controlling childhood obesity: An experience among Iranian children.
      • Weigensberg M.J.
      • Lane C.J.
      • Ávila Q.
      • et al.
      Imagine HEALTH: Results from a randomized pilot lifestyle intervention for obese Latino adolescents using Interactive Guided ImagerySM.
      • Berry D.C.
      • Schwartz T.A.
      • McMurray R.G.
      • et al.
      The family partners for health study: A cluster randomized controlled trial for child and parent weight management.
      • Boudreau A.D.A.
      • Kurowski D.S.
      • Gonzalez W.I.
      • Dimond M.A.
      • Oreskovic N.M.
      Latino families, primary care, and childhood obesity: A randomized controlled trial.
      • Falbe J.
      • Cadiz A.A.
      • Tantoco N.K.
      • Thompson H.R.
      • Madsen K.A.
      Active and Healthy Families: A randomized controlled trial of a culturally tailored obesity intervention for Latino children.
      • Adam S.
      • Westenhöfer J.
      • Rudolphi B.
      • Kraaibeek H.K.
      Effects of a combined inpatient-outpatient treatment of obese children and adolescents.
      • Atabek M.E.
      • Pirgon O.
      Use of metformin in obese adolescents with hyperinsulinemia: A 6-month, randomized, double-blind, placebo-controlled clinical trial.
      • Demol S.
      • Yackobovitch-Gavan M.
      • Shalitin S.
      • Nagelberg N.
      • Gillon-Keren M.
      • Phillip M.
      Low-carbohydrate (low & high-fat) versus high-carbohydrate low-fat diets in the treatment of obesity in adolescents.
      • Díaz R.G.
      • Esparza-Romero J.
      • Moya-Camarena S.Y.
      • Robles-Sardín A.E.
      • Valencia M.E.
      Lifestyle intervention in primary care settings improves obesity parameters among Mexican youth.
      • Naar-King S.
      • Ellis D.
      • Kolmodin K.
      • et al.
      A randomized pilot study of multisystemic therapy targeting obesity in African-American adolescents.
      • Robinson T.N.
      • Matheson D.M.
      • Kraemer H.C.
      • et al.
      A randomized controlled trial of culturally tailored dance and reducing screen time to prevent weight gain in low-income African American girls: Stanford gems.
      Subjects were overweight or obese according to Centers for Disease Control and Prevention standards for pediatric patients, or, in a few cases, according to country-specific standards.
      Centers for Disease Control and Prevention
      Defining childhood obesity: BMI for children and teens. 2015.
      • Hofsteenge G.H.
      • Chinapaw M.J.
      • Delemarre-van de Waal H.A.
      • Weijs P.J.
      Long-term effect of the Go4it group treatment for obese adolescents: A randomised controlled trial.
      • Kokkvoll A.
      • Grimsgaard S.
      • Steinsbekk S.
      • Flaegstad T.
      • Njolstad I.
      Health in overweight children: 2-year follow-up of Finnmark Activity School—A randomised trial.
      The majority of studies excluded children and adolescents with comorbidities requiring the use of pharmaceuticals that could affect weight; Luca and colleagues,
      • Luca P.
      • Dettmer E.
      • Khoury M.
      • et al.
      Adolescents with severe obesity: Outcomes of participation in an intensive obesity management programme.
      in a study of extremely overweight adolescents, included subjects with comorbidities who became eligible for bariatric surgery during the study. Several studies included pharmaceutical treatment arms; however, no drug treatment arms were included in the meta-analysis performed for the 2015 PWMP or for this study. One study included a lap-banding surgical arm, but this arm was not included in the analysis.
      • O’Brien P.E.
      • Sawyer S.M.
      • Laurie C.
      • et al.
      Laparoscopic adjustable gastric banding in severely obese adolescents: A randomized trial.
      The interventions included a wide variety of treatment configurations. Multicomponent approaches included modules delivered by nutrition, behavior, physical activity, and medical specialists.
      • Aparecida Alves Bianchini J.
      • Fernandes da Silva D.
      • Jaeger Hintze L.
      • et al.
      Obese adolescents who gained/maintained or lost weight had similar body composition and cardiometabolic risk factors following a multidisciplinary intervention.
      • Berry D.C.
      • Schwartz T.A.
      • McMurray R.G.
      • et al.
      The family partners for health study: A cluster randomized controlled trial for child and parent weight management.
      • Díaz R.G.
      • Esparza-Romero J.
      • Moya-Camarena S.Y.
      • Robles-Sardín A.E.
      • Valencia M.E.
      Lifestyle intervention in primary care settings improves obesity parameters among Mexican youth.
      • Kokkvoll A.
      • Grimsgaard S.
      • Steinsbekk S.
      • Flaegstad T.
      • Njolstad I.
      Health in overweight children: 2-year follow-up of Finnmark Activity School—A randomised trial.
      • Banks J.
      • Sharp D.J.
      • Hunt L.P.
      • Shield J.P.H.
      Evaluating the transferability of a hospital-based childhood obesity clinic to primary care: A randomised controlled trial.
      • Nemet D.
      • Oren S.
      • Pantanowitz M.
      • Eliakim A.
      Effects of a multidisciplinary childhood obesity treatment intervention on adipocytokines, inflammatory and growth mediators.
      • Boodai S.A.
      • McColl J.H.
      • Reilly J.J.
      National Adolescent Treatment Trial for Obesity in Kuwait (NATTO): Project design and results of a randomised controlled trial of a good practice approach to treatment of adolescent obesity in Kuwait.
      • Marild S.
      • Gronowitz E.
      • Forsell C.
      • Dahlgren J.
      • Friberg P.
      A controlled study of lifestyle treatment in primary care for children with obesity.
      • Waling M.
      • Bäcklund C.
      • Lind T.
      • Larsson C.
      Effects on metabolic health after a 1-year-lifestyle intervention in overweight and obese children: A randomized controlled trial.
      • Clarson C.L.
      • Mahmud F.H.
      • Baker J.E.
      • et al.
      Metformin in combination with structured lifestyle intervention improved body mass index in obese adolescents, but did not improve insulin resistance.
      • Croker H.
      • Viner R.M.
      • Nicholls D.
      • et al.
      Family-based behavioural treatment of childhood obesity in a UK National Health Service setting: Randomized controlled trial.
      • Berkowitz R.I.
      • Fujioka K.
      • Daniels S.R.
      • et al.
      Effects of sibutramine treatment in obese adolescents: A randomized trial.
      • Budd G.
      • Hayman L.
      • Crump E.
      • et al.
      Weight loss in obese African American and Caucasian adolescents: Secondary analysis of a randomized clinical trial of behavioral therapy plus sibutramine.
      • Burgert T.S.
      • Duran E.J.
      • Goldberg-Gell R.
      • et al.
      Short-term metabolic and cardiovascular effects of metformin in markedly obese adolescents with normal glucose tolerance.
      • Coppins D.F.
      • Margetts B.M.
      • Fa J.L.
      • Brown M.
      • Garrett F.
      • Huelin S.
      Effectiveness of a multi-disciplinary family-based programme for treating childhood obesity (The Family Project).
      • DeBar L.L.
      • Stevens V.J.
      • Perrin N.
      • et al.
      A primary care-based, multicomponent lifestyle intervention for overweight adolescent females.
      • Doyle A.C.
      • Goldschmidt A.
      • Huang C.
      • Winzelberg A.J.
      • Taylor C.B.
      • Wilfley D.E.
      Reduction of overweight and eating disorder symptoms via the Internet in adolescents: A randomized controlled trial.
      • Eliakim A.
      • Nemet D.
      • Balakirski Y.
      • Epstein Y.
      The effects of nutritional-physical activity school-based intervention on fatness and fitness in preschool children.
      • Godoy-Matos Al
      • Carraro L.
      • Vieira A.
      • et al.
      Treatment of obese adolescents with sibutramine: A randomized, double-blind, controlled study.
      • Garipağaoğlu M.
      • Sahip Y.
      • Darendeliler F.
      • Akdikmen Ö.
      • Kopuz S.
      • Sut N.
      Family-based group treatment versus individual treatment in the management of childhood obesity: Randomized, prospective clinical trial.
      • Goldschmidt A.B.
      • Stein R.I.
      • Saelens B.E.
      • Theim K.R.
      • Epstein L.H.
      • Wilfley D.E.
      Importance of early weight change in a pediatric weight management trial.
      • Hughes A.R.
      • Stewart L.
      • Chapple J.
      • et al.
      Randomized, controlled trial of a best-practice individualized behavioral program for treatment of childhood overweight: Scottish Childhood Overweight Treatment Trial (SCOTT).
      • Jiang J.X.
      • Xia X.L.
      • Greiner T.
      • Lian G.L.
      • Rosenqvist U.
      A two year family based behaviour treatment for obese children.
      • Johnston C.A.
      • Tyler C.
      • Palcic J.L.
      • Stansberry S.A.
      • Gallagher M.R.
      • Foreyt J.P.
      Smaller weight changes in standardized body mass index in response to treatment as weight classification increases.
      • Jones M.
      • Luce K.H.
      • Osborne M.I.
      • et al.
      Randomized, controlled trial of an Internet-Facilitated intervention for reducing binge eating and overweight in adolescents.
      • Kalarchian M.A.
      • Levine M.D.
      • Arslanian S.A.
      • et al.
      Family-based treatment of severe pediatric obesity: Randomized, controlled trial.
      • Kalavainen M.P.
      • Korppi M.O.
      • Nuutinen O.M.
      Clinical efficacy of group-based treatment for childhood obesity compared with routinely given individual counseling.
      • Kalavainen M.
      • Korppi M.
      • Nuutinen O.
      Long-term efficacy of group-based treatment for childhood obesity compared with routinely given individual counselling.
      • Nemet D.
      • Barkan S.
      • Epstein Y.
      • Friedland O.
      • Kowen G.
      • Eliakim A.
      Short- and long-term beneficial effects of a combined dietary–behavioral–physical activity intervention for the treatment of childhood obesity.
      • Nemet D.
      • Barzilay-Teeni N.
      • Eliakim A.
      Treatment of childhood obesity in obese families.
      • Pedrosa C.
      • Oliveira B.M.P.M.
      • Albuquerque I.
      • Simões-Pereira C.
      • Vaz-de-Almeida M.D.
      • Correia F.
      Metabolic syndrome, adipokines and ghrelin in overweight and obese schoolchildren: Results of a 1-year lifestyle intervention programme.
      • Reinehr T.
      • de Sousa G.
      • Toschke A.M.
      • Andler W.
      Long-term follow-up of cardiovascular disease risk factors in children after an obesity intervention.
      • Reinehr T.
      • Kleber M.
      • Toschke A.M.
      Lifestyle intervention in obese children is associated with a decrease of the metabolic syndrome prevalence.
      • Rezvanian H.
      • Hashemipour M.
      • Kelishadi R.
      • Tavakoli N.
      • Poursafa P.
      A randomized, triple masked, placebo-controlled clinical trial for controlling childhood obesity.
      • Sacher P.M.
      • Kolotourou M.
      • Chadwick P.M.
      • et al.
      Randomized controlled trial of the MEND program: A family-based community intervention for childhood obesity.
      • Wafa S.W.
      • Talib R.A.
      • Hamzaid N.H.
      • et al.
      Randomized controlled trial of a good practice approach to treatment of childhood obesity in Malaysia: Malaysian Childhood Obesity Treatment Trial (MASCOT).
      • Weigel C.
      • Kokocinski K.
      • Lederer P.
      • Dötsch J.
      • Rascher W.
      • Knerr I.
      Childhood obesity: Concept, feasibility, and interim results of a local group-based, long-term treatment program.
      • Wilfley D.E.
      • Stein R.I.
      • Saelens B.E.
      • et al.
      Efficacy of maintenance treatment approaches for childhood overweight: A randomized controlled trial.
      • Wilson D.M.
      • Abrams S.H.
      • Aye T.
      • et al.
      Metformin extended release treatment of adolescent obesity: A 48-week randomized, double-blind, placebo-controlled trial with 48-week follow-up.
      Nutrition-focused interventions employed various diet manipulations along with eating behavior modification.
      • Berkowitz R.I.
      • Wadden T.A.
      • Gehrman C.A.
      • et al.
      Meal replacements in the treatment of adolescent obesity: A randomized controlled trial.
      • Yackobovitch-Gavan M.
      • Nagelberg N.
      • Demol S.
      • Phillip M.
      • Shalitin S.
      Influence of weight-loss diets with different macronutrient compositions on health-related quality of life in obese youth.
      • Chanoine J.
      • Richard M.
      Early weight loss and outcome at one year in obese adolescents treated with orlistat or placebo.
      • Epstein L.H.
      • Paluch R.A.
      • Beecher M.D.
      • Roemmich J.N.
      Increasing healthy eating vs. reducing high energy-dense foods to treat pediatric obesity.
      • Krebs N.F.
      • Gao D.
      • Gralla J.
      • Collins J.S.
      • Johnson S.L.
      Efficacy and safety of a high protein, low carbohydrate diet for weight loss in severely obese adolescents.
      • Rosado J.L.
      • del R Arellano M.
      • Montemayor K.
      • García O.P.
      • Caamaño Mdel C.
      An increase of cereal intake as an approach to weight reduction in children is effective only when accompanied by nutrition education: A randomized controlled trial.
      • Shalitin S.
      • Ashkenazi-Hoffnung L.
      • Yackobovitch-Gavan M.
      • et al.
      Effects of a twelve-week randomized intervention of exercise and/or diet on weight loss and weight maintenance, and other metabolic parameters in obese preadolescent children.
      • Williams C.L.
      • Strobino B.A.
      • Brotanek J.
      Weight control among obese adolescents: A pilot study.
      Behavioral interventions included stress management, parent education, stimulus control, guided imagery, therapy aimed at increasing self-efficacy and self-esteem, and nutrition education.
      • Bloom T.
      • Sharpe L.
      • Mullan B.
      • Zucker N.
      A pilot evaluation of appetite-awareness training in the treatment of childhood overweight and obesity: A preliminary investigation.
      • Munsch S.
      • Roth B.
      • Michael T.
      • et al.
      Randomized controlled comparison of two cognitive behavioral therapies for obese children: Mother versus mother-child cognitive behavioral therapy.
      • Boutelle K.N.
      • Zucker N.
      • Peterson C.B.
      • Rydell S.
      • Carlson J.
      • Harnack L.J.
      An intervention based on Schachter's externality theory for overweight children: The regulation of cues pilot.
      • Epstein L.H.
      • Roemmich J.N.
      • Stein R.I.
      • Paluch R.A.
      • Kilanowski C.K.
      The challenge of identifying behavioral alternatives to food: clinic and field studies (Study 1).
      • Ford A.L.
      • Bergh C.
      • Södersten P.
      • et al.
      Treatment of childhood obesity by retraining eating behaviour: Randomised controlled trial.
      • Hart C.N.
      • Jelalian E.
      • Raynor H.A.
      • et al.
      Early patterns of food intake in an adolescent weight loss trial as predictors of BMI change.
      • Jelalian E.
      • Hart C.N.
      • Mehlenbeck R.S.
      • et al.
      Predictors of attrition and weight loss in an adolescent weight control program.
      • Sato A.F.
      • Jelalian E.
      • Hart C.N.
      • et al.
      Associations between parent behavior and adolescent weight control.
      • Stice E.
      • Marti C.N.
      • Spoor S.
      • Presnell K.
      • Shaw H.
      Dissonance and healthy weight eating disorder prevention programs: Long-term effects from a randomized efficacy trial.
      • Epstein L.H.
      • Roemmich J.N.
      • Stein R.I.
      • Paluch R.A.
      • CK K.
      The challenge of identifying behavioral alternatives to food: Clinic and field studies (Study 2).
      The physical activity component of interprofessional interventions included education on general lifestyle activity, activity-specific training, and the use of devices such as pedometers.
      • Robinson T.N.
      • Matheson D.M.
      • Kraemer H.C.
      • et al.
      A randomized controlled trial of culturally tailored dance and reducing screen time to prevent weight gain in low-income African American girls: Stanford gems.
      • Nemet D.
      • Oren S.
      • Pantanowitz M.
      • Eliakim A.
      Effects of a multidisciplinary childhood obesity treatment intervention on adipocytokines, inflammatory and growth mediators.
      • DeBar L.L.
      • Stevens V.J.
      • Perrin N.
      • et al.
      A primary care-based, multicomponent lifestyle intervention for overweight adolescent females.
      • Dreyer-Gillette M.L.
      • Odar Stough C.
      • Best C.M.
      • Beck A.R.
      • Hampl S.E.
      Comparison of a condensed 12-week version and a 24-week version of a family-based pediatric weight management program.
      • Endevelt R.
      • Elkayam O.
      • Cohen R.
      • et al.
      An intensive family intervention clinic for reducing childhood obesity.
      • Harder-Lauridsen N.M.
      • Birk N.M.
      • Ried-Larsen M.
      • et al.
      A randomized controlled trial on a multicomponent intervention for overweight school-aged children - Copenhagen, Denmark.
      • Kalavainen M.
      • Utriainen P.
      • Vanninen E.
      • Korppi M.
      • Nuutinen O.
      Impact of childhood obesity treatment on body composition and metabolic profile.
      • Larsen L.M.
      • Hertel N.T.
      • Mølgaard C.
      • Christensen R.D.
      • Husby S.
      • Jarbøl D.E.
      Early intervention for childhood overweight: A randomized trial in general practice.
      • Collins C.E.
      • Okely A.D.
      • Morgan P.J.
      • et al.
      Parent diet modification, child activity, or both in obese children: An RCT.
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      The effect of sibutramine on energy expenditure and body composition in obese adolescents.
      Medical interventions included general nutrition education and ongoing monitoring of weight-related parameters and management of comorbidities, and were delivered by physicians, nurses, nurse practitioners, and clinical specialist nurses.
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      Lifestyle intervention in primary care settings improves obesity parameters among Mexican youth.
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      • et al.
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      • Matheson D.M.
      • Kraemer H.C.
      • et al.
      A randomized controlled trial of culturally tailored dance and reducing screen time to prevent weight gain in low-income African American girls: Stanford gems.
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      • Russell A.
      • Chung R.J.
      • Armstrong S.C.
      A “Novel” intervention: A pilot study of children's literature and healthy lifestyles.
      • Jelalian E.
      • Lloyd-Richardson E.E.
      • Mehlenbeck R.S.
      • et al.
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      ‘Adventure therapy’ combined with cognitive-behavioral treatment for overweight adolescents.
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      • Perry R.A.
      • Baur L.A.
      • et al.
      A parent-led family-focused treatment program for overweight children aged 5 to 9 years: The PEACH RCT.
      Specific ethnic populations were the focus of some studies.
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      • Lane C.J.
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      • et al.
      Imagine HEALTH: Results from a randomized pilot lifestyle intervention for obese Latino adolescents using Interactive Guided ImagerySM.
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      Efficacy of an internet-based behavioral weight loss program for overweight adolescent African-American girls.
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      • et al.
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      • et al.
      Two-year Internet-based randomized controlled trial for weight loss in African-American girls.
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      • et al.
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      Studies took place in a variety of settings, including but not limited to outpatient hospital and primary care clinics, community centers, and school-based clinics.
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      School-based health center intervention improves body mass index in overweight and obese adolescents.
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      Study characteristics are found in Table 3 (available at www.jandonline.org).

      BMI z Score

      Although all conditions resulted in significant decreases from baseline at each of the four time points, the nutrition specialist-only condition resulted in increased reductions in BMI z score compared with Behavioralist Only, Combined Nutrition Specialist+Behavioralist, or Neither Behavioralist Or Nutrition Specialist interventions throughout the analysis (Table 4 and Table 5). The Neither Nutrition Specialist or Behavioralist condition demonstrated a significant reduction from baseline in BMI z score over a 2-year time period.
      Table 4Short-term changes from baseline in pediatric weight status measures by outcome, time period, and provider category as indicated by an exploratory meta-analysis performed to quantify the role of nutrition and dietetics practitioners in multicomponent pediatric weight management interventions
      nChange from baselineEffect LCI
      LCI=lower 95% CI.
      Effect UCI
      UCI=upper 95% CI.
      I2I2 LCII2 UCIH2
      BMIZ
      BMIZ=body mass index z scores (or standard deviation scores); that is, the location of an individual pediatric body mass index on an age- and sex-specific normal curve.21
      <6 mo
      Nutrition only10–0.24
      Values in boldface type indicate statistically significant within arm changes from baseline.
      –1.02–0.0293.0589.0096.0013.39
      Behavior only6–0.18–1.110.0047.750.0079.000.91
      Nutrition+behavior5–0.14
      Values in italic type were generated using a nonpermutated DerSimonian-Laird model due to limitations in sample size. All non-italicized values were generated via a permutated DerSimonian-Laird model.
      –0.21–0.0776.6243.0090.003.28
      Neither17–0.06–0.19–0.0177.5564.0086.003.46
      6-12 mo
      Nutrition only16–0.19–0.54–0.0598.2598.0099.0056.22
      Behavior only5–0.16–0.26–0.0590.7681.0095.009.83
      Nutrition+behavior8–0.15–0.98–0.0292.1987.0095.0011.80
      Neither13–0.07–0.290.0097.1596.0098.0034.05
      BMI
      BMI=body mass index.20
      <6 mo
      Nutrition only17–1.15–3.48–0.3387.7782.0092.007.18
      Behavior only4–0.14–0.640.350.000.0085.00
      Dashes indicate values that could not be computed due to limitations in sample size.
      Nutrition+behavior15–1.35–4.49–0.3289.1384.0093.008.28
      Neither180.10–0.850.2088.6384.0092.007.80
      6-12 mo
      Nutrition only12–0.65–3.370.0598.5798.0099.0068.92
      Behavior only2–0.02–1.010.9874.052.85
      Nutrition+behavior8–1.09–7.16–0.0988.4780.0093.007.68
      Neither160.01–0.470.2289.0584.0093.008.13
      WC
      WC=waist circumference; that is, the measurement obtained by encircling the area halfway between the 10th rib and the iliac crest with an inflexible tape measure, expressed in centimeters.21,22
      <6 mo
      Nutrition only8–0.34–8.641.1099.75100100402.44
      Behavior only0
      Nutrition+behavior4–1.01–2.950.9471.0615.0085.002.46
      Neither8–0.03–4.010.6688.5780.0094.007.75
      6-12 mo
      Nutrition only9–1.04–5.700.3790.7985.0094.009.86
      Behavior only0
      Nutrition+behavior6–2.57–15.850.0764.8715.0085.001.85
      Neither130.53–0.971.2490.0085.0093.009.00
      a LCI=lower 95% CI.
      b UCI=upper 95% CI.
      c BMIZ=body mass index z scores (or standard deviation scores); that is, the location of an individual pediatric body mass index on an age- and sex-specific normal curve.
      • Flegal K.M.
      • Ogden C.L.
      Childhood obesity: Are we all speaking the same language?.
      d Values in boldface type indicate statistically significant within arm changes from baseline.
      e Values in italic type were generated using a nonpermutated DerSimonian-Laird model due to limitations in sample size. All non-italicized values were generated via a permutated DerSimonian-Laird model.
      f BMI=body mass index.
      Centers for Disease Control and Prevention
      Defining childhood obesity: BMI for children and teens. 2015.
      g Dashes indicate values that could not be computed due to limitations in sample size.
      h WC=waist circumference; that is, the measurement obtained by encircling the area halfway between the 10th rib and the iliac crest with an inflexible tape measure, expressed in centimeters.
      • Flegal K.M.
      • Ogden C.L.
      Childhood obesity: Are we all speaking the same language?.
      • McCarthy H.D.
      • Jarrett K.V.
      • Crawley H.F.
      The development of waist circumference percentiles in British children aged 5.0-16.9 years.
      Table 5Longer-term changes from baseline in pediatric weight status measures by outcome, time period, and provider category as indicated by an exploratory meta-analysis performed to quantify the role of nutrition and dietetics practitioners in multicomponent pediatric weight management interventions
      nChange from baselineEffect LCI
      LCI=lower 95% CI.
      Effect UCI
      UCI=upper 95% CI.
      I2I2 LCII2 UCIH2
      BMIZ
      BMIZ=body mass index z scores (or standard deviation scores); that is, the location of an individual pediatric body mass index on an age- and sex-specific normal curve.21
      12-24 mo
      Nutrition only22–0.20
      Values in boldface type indicate statistically significant within-arm changes from baseline.
      –0.48–0.0786.888191.006.62
      Behavior only5–0.15
      Values in italic types were generated using a nonpermutated DerSimonian-Laird model due to limitations in sample size. All nonitalicized values were generated via a permutated DerSimonian-Laird model.
      –0.20–0.1041.530780.71
      Nutrition+ behavior14–0.16–0.51–0.0486.0378916.16
      Neither23–0.08–0.24–0.0198.51989965.97
      >24 mo
      Nutrition only10–0.24–0.98–0.0487.2579926.84
      Behavior only4–0.12–0.240.0079.8847923.97
      Nutrition+ behavior3–0.22–0.30–0.150.00090
      Value could not be computed due to limitations in sample size.
      Neither6–0.15–0.24–0.0579.4755913.87
      BMI
      BMI=body mass index.20
      12-24 mo
      Nutrition only14–0.13–1.500.3795.2193.0097.0019.86
      Behavior only1
      Nutrition+ behavior13–0.77–3.42–0.0480.4667.0088.004.12
      Neither240.610.240.9090.3587.0093.009.36
      >24 mo
      Nutrition only60.33–0.401.0687.0374.0094.006.71
      Behavior only20.970.511.4380.354.09
      Nutrition+ behavior1
      Neither111.130.461.7095.0593.0097.0019.22
      WC
      WC=waist circumference; that is, the measurement obtained by encircling the area halfway between the 10th rib and the iliac crest with an inflexible tape measure, expressed in centimeters.21,22
      12-24 mo
      Nutrition only101.74–1.693.4499.75100100399.58
      Behavior only22.59–0.065.2467.30
      Nutrition+ behavior90.65–6.991.0796.81959830.35
      Neither172.380.453.4199.159999116.47
      >24 mo
      Nutrition only3–0.64–4.633.3586.8462956.60
      Behavior only1
      Nutrition+ behavior33.04–0.466.5486.1760956.23
      Neither64.520.007.8692.49869612.32
      a LCI=lower 95% CI.
      b UCI=upper 95% CI.
      c BMIZ=body mass index z scores (or standard deviation scores); that is, the location of an individual pediatric body mass index on an age- and sex-specific normal curve.
      • Flegal K.M.
      • Ogden C.L.
      Childhood obesity: Are we all speaking the same language?.
      d Values in boldface type indicate statistically significant within-arm changes from baseline.
      e Values in italic types were generated using a nonpermutated DerSimonian-Laird model due to limitations in sample size. All nonitalicized values were generated via a permutated DerSimonian-Laird model.
      f Value could not be computed due to limitations in sample size.
      g BMI=body mass index.
      Centers for Disease Control and Prevention
      Defining childhood obesity: BMI for children and teens. 2015.
      h WC=waist circumference; that is, the measurement obtained by encircling the area halfway between the 10th rib and the iliac crest with an inflexible tape measure, expressed in centimeters.
      • Flegal K.M.
      • Ogden C.L.
      Childhood obesity: Are we all speaking the same language?.
      • McCarthy H.D.
      • Jarrett K.V.
      • Crawley H.F.
      The development of waist circumference percentiles in British children aged 5.0-16.9 years.
      Meta-regression analysis indicated that the difference in BMI z score between the Nutrition Specialist-Only category and the neither Nutrition Specialist or Behavioralist category was significantly lower at the 3 to <6 months, 6 months to <1 year, and 1-year to 2-years time points (P values 0.01, 0.05, and 0.01, respectively) (Table 6). The Combined Nutrition Specialist+Behavioralist category was significantly lower than the Neither Nutrition Specialist or Behavioralist condition at the 1-year to 2-years time point (P<0.05). There was a significant reduction from baseline in BMI z score in the Neither Nutrition Specialist or Behavioralist Category at the 6-month to <1-year time point, the 1-year to 2-years time point, and the >2-years time point (P<0.005 for all). Twenty-three total study arms were available for the >2-years analysis, with only a few arms available for each of the Behavioralist-Only (4 study arms), Combined Nutrition Specialist+Behavioralist (3 study arms), and Neither Nutrition Specialist or Behavioralist (6 study arms) conditions. Thus, the meta-regression analysis for BMI z score at the >2-year time point may have been overfit or distorted by adjustment for variables. Caution should be exercised in drawing conclusions from the available data for the latter time period.
      Table 6Results of meta-regression analysis of body mass index z score at 4 time points, conducted to quantify the role of nutrition and dietetics practitioners in multicomponent pediatric weight management interventions: Difference in comparison to “Neither” provider type
      ProviderTime Period of Outcome Measurement
      3 mo to <6 mo6 mo to <1 y1 y to <2 y>2 y
      Nutrition specialist only
      Coefficients indicate mean difference from the Neither Nutrition Specialist or Behavioralist condition.
      –0.355
      P<0.01.
      (–2.90)
      Values in parentheses are t values of difference between comparison group and Neither Nutrition Specialist or Behavioralist.
      –0.119
      P<0.05.
      (–2.63)
      –0.167
      P<0.01.
      (–2.99)
      –0.0938 (–1.32)
      Behavioralist only
      Coefficients indicate mean difference from the Neither Nutrition Specialist or Behavioralist condition.
      –0.0752 (–0.50)–0.0867 (–1.37)–0.0589 (–0.62)0.0256 (0.28)
      Combined nutrition specialist and behavioralist
      Coefficients indicate mean difference from the Neither Nutrition Specialist or Behavioralist condition.
      –0.153 (–1.05)–0.0775 (–1.43)–0.157
      P<0.01.
      (–2.57)
      –0.120 (–1.13)
      Neither nutrition specialist or behavioralist
      Coefficient represents absolute pooled value of change from baseline for the Neither Nutrition Specialist or Behavioralist arm.
      –0.0970 (–1.26)–0.0695
      P<0.05.
      (–2.12)
      –0.0893
      P<0.05.
      (–2.28)
      –0.142
      P<0.05.
      (–2.50)
      No. of Study Arms
      44427023
      Analyses
      I2 (%)92.7097.3198.1183.00
      Adjusted R2 (%)11.8110.0011.15–7.34
      P value0.04740.08460.01640.3414
      a Coefficients indicate mean difference from the Neither Nutrition Specialist or Behavioralist condition.
      b Values in parentheses are t values of difference between comparison group and Neither Nutrition Specialist or Behavioralist.
      c Coefficient represents absolute pooled value of change from baseline for the Neither Nutrition Specialist or Behavioralist arm.
      P<0.01.
      ∗∗ P<0.05.
      The I2 statistic indicated high heterogeneity and ranged from approximately 83% to 98%. Adjusted R2 statistics (the improvement in the fit of the models due to the inclusion of the interventionist variables) were approximately 10% for the first three time points, indicating that provider category explained some intrastudy variation. The adjusted R2 value at the >2-years time point was negative, implying that none of the intrastudy variation at that time point was explained by any of the four variables indicating provider category.
      • Harbord R.M.
      • Higgins J.P.T.
      Meta-regression in Stata.

      BMI

      At the >2-years time point, Nutrition Specialist-Only intervention resulted in a smaller increase in BMI compared with baseline (mean difference [MD]=0.33, 95% CI –0.40 to 1.06) than Behavioralist-Only (MD=0.97, 95% CI 0.51 to 1.43), or Neither Nutrition Specialist or Behavioralist interventions (MD=1.13, 95% CI, 0.46 to 1.70) (Table 5). The point estimates of the Behavioralist-Only group should be interpreted with caution as only two study arms were available at the >2-years time point. Within-group significant declines from baseline were observed for the Combined Nutrition Specialist+Behavioralist condition at the 3 to <6 months, 6 to <12 months, and 12 to <24 months time points. In contrast, significant within-group improvements in BMI were seen for the Nutrition Specialist-Only group only at the 3- to <6- month period (Tables 4 and 5). For the Behavioralist-Only condition, there were significant increases over baseline at >2-year time points. In the Neither Nutrition Specialist or Behavioralist category, significant increases from baseline were observed at the 1-year to 2-years and >2-year time points (Table 5). It should be noted that all significant differences >1 year indicate increases in BMI, which would be expected over time for growing children and adolescents.
      Meta-regression analysis (Table 7) indicated that the difference of the nutrition specialist-only category from the Neither Nutrition Specialist or Behavioralist category was significant at the 3- to <6-months and 1-year to 2-years time points (P values=0.001 and 0.05, respectively). The Combined Nutrition Specialist+Behavioralist category was significantly different from the Neither Nutrition Specialist or Behavioralist condition at the 3- to <6-months, 6-months to <1-year, and 1-year to 2-years time points (P values=0.001, 0.01, and 0.001, respectively). The Neither Nutrition Specialist or Behavioralist category reported a significant increase in BMI at the 1-year to 2-years and the >2-years time points (P=0.01 for both). Although heterogeneity was high throughout the analyses, ranging from approximately 87% to 97%, adjusted R2 statistics ranging from about 17% to 35% suggest that substantial amounts of intrastudy variation were explained by the four variables indicating provider category.
      Table 7Results of meta-regression analysis of body mass index at 4 time points, conducted to quantify the role of nutrition and dietetic practitioners in multicomponent pediatric weight management interventions: Difference in comparison to “Neither” provider type
      ProviderTime Period of Outcome Measurement
      3 to <6 mo6 mo to <1 y1 y to 2 y>2 y
      Nutrition specialist only
      Coefficients indicate mean difference from the Neither Nutrition Specialist or Behavioralist condition.
      –1.057
      P<0.001.
      (–3.76)
      Values in parentheses are t values of difference between comparison group and Neither Nutrition Specialist or Behavioralist.
      –0.664 (–1.99)–0.738
      P<0.001.
      (–2.02)
      –0.795 (–1.41)
      Behavioralist only
      Coefficients indicate mean difference from the Neither Nutrition Specialist or Behavioralist condition.
      –0.153 (–0.30)–0.0709 (–0.11)0.160 (0.15)–0.130 (–0.16)
      Combined nutrition specialist and behavioralist
      Coefficients indicate mean difference from the Neither Nutrition Specialist or Behavioralist condition.
      –1.243
      P<0.001.
      (–3.99)
      –1.109
      P<0.01.
      (–2.87)
      –1.401
      P<0.001.
      (–3.57)
      0.204 (0.16)
      Neither nutrition specialist or behavioralist
      Coefficient represents absolute pooled value of change from baseline for the Neither Nutrition Specialist or Behavioralist arm.
      –0.0988 (–0.49)0.0220 (0.10)0.610
      P<0.01.
      (2.77)
      1.096
      P<0.01.
      (3.40)
      No. of Study Arms
      54385220
      Analyses
      I2 (%)87.8496.5091.5993.49
      Adjusted R2 (%)35.2518.6019.42–5.35
      P value0.00040.03560.00630.5578
      a Coefficients indicate mean difference from the Neither Nutrition Specialist or Behavioralist condition.
      b Values in parentheses are t values of difference between comparison group and Neither Nutrition Specialist or Behavioralist.
      c Coefficient represents absolute pooled value of change from baseline for the Neither Nutrition Specialist or Behavioralist arm.
      P<0.001.
      ∗∗ P<0.01.

      Waist Circumference

      Results for WC are discussed for the 1-year to 2-years time point, as the small number of study arms and lack of Behavioralist-Only studies at other time points precluded effective meta-analysis. All conditions resulted in an increase in WC at the selected time point, as would be expected in children and adolescents who are growing. There were no significant differences among provider categories for the WC measures. (Table 4 and Table 5). There was a significant increase in WC from baseline for the Neither Nutrition Specialist or Behavioralist category. A meta-regression analysis of WC was not carried out because there were not enough studies reporting WC to provide a reliable meta-regression.

      Heterogeneity

      Heterogeneity statistics were very high throughout all meta-analyses, indicating substantial variability among included studies as would be expected with a complex heterogenous intervention such as PWM. Just as in an ordinary least squares regression, the adjusted R2 reported in the meta-regressions (Table 6 and Table 7) can be interpreted as a reduction in unexplained variance.
      • Harbord R.M.
      • Higgins J.P.T.
      Meta-regression in Stata.
      Thus, including the provider category as a covariate significantly decreased this heterogeneity, indicating variation in provider category as a primary source of the between study heterogeneity reflected in the meta-analysis I2. Provider category explained the largest reduction of heterogeneity at the 3- to <6-month, 6-month to <1-year, and 1-year to 2-years time points, but made little contribution (indicated by the negative values) at the >2-year time points for BMI and BMI z score.
      Funnel plots generated for each analysis suggested the possibility of publication bias. Plots provided for each analysis at the 1-year to 2-years time point indicate that studies with unfavorable results may not have been reported. A funnel plot of the BMI z score analysis is provided as an example (Figure 3).
      Figure thumbnail gr2
      Figure 3Funnel plot illustrating the possiblity of publication bias among studies providing body mass index z score (BMIZ) data, created during a meta-analysis to quantify the contribution of nutrition professionals to pediatric weight management treatment teams; the red oval indicates the area where studies with negative results would fall on the funnel plot.

      Discussion

      To the best of the investigators’ knowledge, this exploratory research constitutes the first meta-analytic study to provide quantitative evidence of the importance of utilizing a nutrition specialist to deliver nutrition components of multicomponent PWM interventions. In addition, this study applies alternative meta-analytic techniques designed for complex, heterogenous interventions to data derived from PWM research. Nutrition treatment is generally viewed as an integral part of child weight management interventions, but whether there was any additional clinical benefit to having the nutrition interventions delivered by a nutrition specialist has been, until now, unknown.
      Academy of Nutrition and Dietetics Evidence Analysis Library
      Pediatric weight management project 2015.
      • Hoelscher D.M.
      • Kirk S.
      • Ritchie L.
      • Cunningham-Sabo L.
      From the Academy: Position of the Academy of Nutrition and Dietetics: Interventions for the prevention and treatment of pediatric overweight and obesity.
      Although between-study heterogeneity (I2 measures) warrants caution when interpreting the absolute pooled effect sizes at any given time point, this does not influence the investigators’ confidence in the findings of relative changes reported for each of the provider categories. Using meta-regression on the dismantled trial arms, it was demonstrated that Nutrition Specialist-Only provider arms or Combined Nutrition Specialist+Behavioralist arms often showed significantly greater improvement for BMI z score and BMI relative to arms where neither of these interventionist groups were involved. No significant differences were noted among provider groups for WC at the 1-year to 2-years time point; however, the small number of study arms— specifically the lack of any studies in the behavioralist category at two time points—precluded effective meta-analysis and meta-regression for this outcome indicator. Further studies are needed comparing the effects of provider configurations on WC outcomes in PWM interventions. In addition, the fact that there was no association between study quality ratings and intervention provider variables suggests that these effect size variations were not a matter of differences in study quality. Rather, the finding that provider category explained reductions in heterogeneity at selected time points during treatment provides quantitative evidence that the nutrition specialist provider category contributed to treatment effects.
      This analysis also supported the idea first posited by the 2015 PWMP: There is a range of nutrition specialist effects on outcomes, and these effects are influenced by the specific configurations of interventions and interventionists, as well as effect modifiers such as length of the intervention.
      Academy of Nutrition and Dietetics Evidence Analysis Library
      Pediatric weight management project 2015.
      The influence of nutrition specialists’ contributions—as well as the contributions of other providers—appears to vary over time as interventions are delivered. For example, nutrition specialist intervention during early stages of treatment may result in dramatic changes that tend to attenuate over time, whereas behavioralist interventions may be more important in maintaining behavior change over time. The Neither Nutrition Specialist or Behavioralist condition resulted in a significant decrease in BMI z score from baseline, possibly indicating the effects of medical treatment alone, or reflecting the BMI z score’s lack of sensitivity to weight status change in severely obese children.
      • Freedman D.S.
      • Butte N.F.
      • Taveras E.M.
      • et al.
      BMI z-scores are a poor indicator of adiposity among 2- to 19-year-olds with very high BMIs, NHANES 1999-2000 to 2013-2014.
      • Freedman D.S.
      • Butte N.F.
      • Taveras E.M.
      • Goodman A.B.
      • Ogden C.L.
      • Blanck H.M.
      The limitations of transforming very high body mass indexes into z-scores among 8.7 million 2- to 4-year-old children.
      Exploratory research is, by definition, hypothesis-generating. The interpretation of this study’s findings suggests important areas for further investigation. For example, this research noted differing patterns among interventionist categories, but did not explore the mechanisms by which varying treatment configurations exert their effects. The identification of treatment configuration effects as an important avenue for future study highlights the exploratory nature of this study.

      Strengths and Limitations

      This study had several strengths. The literature search encompassed more than a decade of pediatric obesity literature and described a wide variety of PWM interventions, and included 209 study arms, thus increasing the power of the meta-analysis to detect effect sizes. The use of the identical data extraction and data management tools for the original search and the systematic update provided consistency. The body of evidence analyzed encompassed a substantial number of positive-quality studies (44%) and contained no negative quality studies. Overall, the body of evidence supporting this meta-analysis is of moderate quality.
      The investigators acknowledge several study limitations. Systematic review and meta-analyses of the considerable body of research on PWM are challenging for several reasons, all of which were encountered in this analysis. Typical issues surrounding child weight management interventions include variability among studies, high dropout rates, challenging implementation and management of lengthy and complex studies, and the difficulty of assessing weight status in growing children.
      • Brown L.
      • Dolisca S.-B.
      • Cheng J.K.
      Barriers and facilitators of pediatric weight management among diverse families.

      Buscemi J, Blumstein L, Kong A, et al. Retaining traditionally hard to reach participants: Lessons learned from three childhood obesity studies. Contemp Clin Trials.42:98-104.

      • Kwitowski M.
      • Bean M.K.
      • Mazzeo S.E.
      An exploration of factors influencing attrition from a pediatric weight management intervention.
      • Skelton J.A.
      • Beech B.M.
      Attrition in paediatric weight management: A review of the literature and new directions.
      • Findholt N.E.
      • Davis M.M.
      • Michael Y.L.
      Perceived barriers, resources, and training needs of rural primary care providers relevant to the management of childhood obesity.
      Thus, even in the case that children are improving their weight status, BMI, BMI z scores, and WC measurements may be difficult to interpret—especially in very obese children—and may not accurately reflect outcomes over time.
      • Freedman D.S.
      • Butte N.F.
      • Taveras E.M.
      • et al.
      BMI z-scores are a poor indicator of adiposity among 2- to 19-year-olds with very high BMIs, NHANES 1999-2000 to 2013-2014.
      • Freedman D.S.
      • Butte N.F.
      • Taveras E.M.
      • Goodman A.B.
      • Ogden C.L.
      • Blanck H.M.
      The limitations of transforming very high body mass indexes into z-scores among 8.7 million 2- to 4-year-old children.
      In the future, measurement of fat mass and fat-free mass, perhaps through the use of bioelectrical impedance, may become the most accurate method of determining actual weight management outcomes.
      • Weber D.R.
      • Leonard M.B.
      • Zemel B.S.
      Body composition analysis in the pediatric population.
      Although a majority of included studies utilized differing varieties of intention-to-treat statistical analysis, there may have been an inherent bias in favor of study completers. In studies utilizing last-measurement-carried-forward analysis, positive results attained before participant dropout may have favorably biased the results.
      This meta-analysis used BMI z score as a primary outcome indicator. BMI z score is a measure of pediatric adiposity plotted on age- and sex-specific curves; thus, it provides a comparator for evaluating weight status apart from the effects of normal growth.
      • Flegal K.M.
      • Ogden C.L.
      Childhood obesity: Are we all speaking the same language?.
      BMI z scores, adjusted for age, height, and sex, are meant to provide a means of evaluating weight management progress that accounts for normal growth and facilitates comparisons in statistical analysis.
      • Flegal K.M.
      • Ogden C.L.
      Childhood obesity: Are we all speaking the same language?.
      • Must A.
      • Anderson S.E.
      Body mass index in children and adolescents: Considerations for population-based applications.
      However, a substantial body of evidence indicates that BMI z scores are often misleading and/or inaccurate for severely obese children and adolescents whose weights fall above 120% of the 95th BMI percentile or whose BMI z scores are >3.
      • Freedman D.S.
      • Butte N.F.
      • Taveras E.M.
      • et al.
      BMI z-scores are a poor indicator of adiposity among 2- to 19-year-olds with very high BMIs, NHANES 1999-2000 to 2013-2014.
      • Freedman D.S.
      • Butte N.F.
      • Taveras E.M.
      • Goodman A.B.
      • Ogden C.L.
      • Blanck H.M.
      The limitations of transforming very high body mass indexes into z-scores among 8.7 million 2- to 4-year-old children.
      • Woo J.G.
      Using body mass index Z-score among severely obese adolescents: A cautionary note.
      • Kelly A.S.
      • Barlow S.E.
      • Rao G.
      • et al.
      Severe obesity in children and adolescents: identification, associated health risks, and treatment approaches: A scientific statement from the American Heart Association.
      • Flegal K.M.
      • Wei R.
      • Ogden C.L.
      • Freedman D.S.
      • Johnson C.L.
      • Curtin L.R.
      Characterizing extreme values of body mass index-for-age by using the 2000 Centers for Disease Control and Prevention growth charts.
      Measurements of changes in fat mass and fat-free mass over the course of pediatric weight interventions, using biometric tools designed to evaluate body composition, may provide more accurate measurements of weight status change.
      • Weber D.R.
      • Leonard M.B.
      • Zemel B.S.
      Body composition analysis in the pediatric population.
      There were an insufficient number of studies reporting body composition to conduct a meta-analysis. Although imperfect, BMI z score was utilized in this study as an outcome indicator because the score is pervasively used to evaluate PWM interventions, and data were readily available. Readers are cautioned in interpreting absolute values for effect sizes for participants with severe obesity, because BMI z scores appear to be insensitive; that is, small changes in the BMI z score may correspond with relatively larger changes in BMI and thus inaccurately reflect weight status change. However, the direction and consistency of the BMI z score results suggest that the general pattern of positive contributions by nutrition specialists holds true even in the case that the outcome measures are less than ideal.
      No studies meeting inclusion criteria directly addressed the research question. Unlike a classic meta-analysis of head-to-head comparisons in randomized controlled trials, there were no studies that provided a direct measure of the effect of including a nutrition specialist vs not including a nutrition specialist where all other intervention characteristics remained the same. The position of this article is that the degree to which, or indeed even whether, this constitutes a real limitation is open for discussion.
      • Kontopantelis E.
      • Reeves D.
      Performance of statistical methods for meta-analysis when true study effects are non-normally distributed: A simulation study.
      In complex interventions where components combine in a nonlinear and nonadditive fashion (which is suspected to be the case in PWM interventions), a single, true effect is unlikely to exist.
      Academy of Nutrition and Dietetics Evidence Analysis Library
      Pediatric weight management project 2015.
      • Kahwati L.
      • Jacobs S.
      • Kane H.
      • Lewis M.
      • Viswanathan M.
      • Golin C.E.
      Using qualitative comparative analysis in a systematic review of a complex intervention.
      Thus, even head-to-head clinical trials would be unlikely to provide a measure of effect that could be generalized across all multicomponent programs. For these reasons, alternative meta-analytic methods designed for the analysis of complex heterogenous interventions were chosen to conduct this study.
      Statistical analysis revealed very high levels of heterogeneity among the included studies. As noted above, although this decreases confidence in the precision of the absolute pooled effect sizes, it does not influence the investigators’ confidence in the relative effects of the interventionist groups. In other words, although the investigators would expect the findings of any future PWM intervention to differ somewhat from the pooled effect sizes reported here based on differences in study design and sample, the results of meta-regression support the assertion that nutrition specialists make an important and quantifiable contribution to those weight status changes for BMI z score and BMI relative to interventions that do not include a nutrition specialist. Indeed, given that the power to detect differences between interventionist groups was limited for many of the measure/time point comparisons—even with the large number of arms included in this analysis—it is anticipated that future meta-regressions that include more studies may be able to more accurately identify differences that the current study failed to find statistically significant in the meta-regressions.

      Conclusions

      This study found that indirect comparisons of a large number of active treatment arms provides some evidence that nutrition treatment provided by a nutrition specialist as part of a treatment team contributes to improved outcomes in regard to BMI and BMI z score at selected time points. No significant differences among provider categories were found for WC results. This research provides some support for the assertions that nutrition specialists are essential members of PWM treatment teams, that nutrition intervention provided by nutrition specialists enhances BMI and BMI z score outcomes, and that nutrition specialists’ contributions may be especially important at particular intervention time points.
      An important function of exploratory studies is to identify directions and possible hypotheses for future investigation. As a result of this research, the authors concluded that studies are needed that are intentionally designed to manipulate and compare the various constituents—medical, nutritional, physical, and behavioral—of multicomponent PWM interventions. In particular, studies are needed that compare the effects of including a nutrition specialist as a member of the treatment team with the effects of not including a nutrition specialist when all other study components remain the same. By defining best practices for achieving desired outcomes, such studies could result in improved access to effective treatment for overweight and obese children and adolescents in need of quality weight management services.

      What Is the Current Knowledge on this Topic?

      Nutrition specialists are considered key members of multicomponent pediatric weight management (PWM) intervention teams, but to date, their contribution has not been quantified.

      How Does this Research Add to Knowledge on this Topic?

      This research provides some support for the assertion that improved body mass index (BMI) z scores and BMIs may result from including nutrition specialists in PWM treatment teams, especially during certain treatment phases.

      How Might this Knowledge Influence Current Dietetics Practice?

      The results of this meta-analysis provides some support for the assertion that nutrition components of multicomponent PWM interventions should be delivered by nutrition specialists.

      Acknowledgements

      This study was completed in partial fulfillment of requirements for the Doctorate in Clinical Nutrition degree offered by the Department of Nutritional Sciences, School of Health Professions, Rutgers, the State University of New Jersey.
      The authors thank Grace Herman, current student in the Appalachian State University Combined Graduate Program in Nutrition and Dietetic Internship (Appstate DI), and Mabel Rodriguez, MS, RD, and Dylan Rudisill, MS, RD, former students of the Appstate DI, for their assistance with Table 3.

      Author Contributions

      K. L. Thompson wrote the first draft with contributions from J. S. Parrott, M. Chung, D. Handu, M. Gutschall, S. T. Jewell, and L. Byham-Gray. S. T. Jewell and K. L. Thompson conducted the literature search update. K. L. Thompson and M. Gutschall screened the studies. D. Handu and J. S. Parrott supervised data extraction for the original Evidence Analysis Library search, and K. L. Thompson performed data extraction for the search update. J. S. Parrott and K. L. Thompson conducted the statistical analysis, with advisement from M. Chung. All authors provided advisement throughout the study, and reviewed and commented on subsequent drafts of the manuscript.

      Supplementary Materials

      Table 3Characteristics of 99 studies included in a meta-analysis performed to quantify the role of nutrition and dietetics practitioners in multicomponent pediatric weight management interventions
      Author(s), year, study design, study ratingN, sexAge group (y)Race, ethnicityStudy armsInterventionLength of interventionStudy focusOutcomes of interestFindings
      Adam and colleagues, 2009
      • Adam S.
      • Westenhöfer J.
      • Rudolphi B.
      • Kraaibeek H.K.
      Effects of a combined inpatient-outpatient treatment of obese children and adolescents.


      Hamburg, Germany

      NRCT
      NRCT=nonrandomized controlled trial.


      Neutral
      The Academy of Nutrition and Dietetics Evidence Analysis Library Quality Criteria Checklist (QCC) was used to determine quality ratings, which complies with Cochrane Collaboration tools for assessing bias.11,18 The QCC includes—among other criteria—an assessment of bias related to study allocation methods, blinding or lack thereof, outcomes analysis, and financial disclosures. Each study was assigned a rating of positive, neutral, or negative quality based on checklist scores.
      237, Both

      Intervention group: 162

      Control group: 75
      12-14Not reportedIntervention groupStructured multicomponent treatment plan: diet and nutrition education, exercise, and behavioral therapy6-12 moNot reportedBMI
      BMI=body mass index.
      , BMIZ
      BMIZ=body mass index z score.
      BMIZ significantly decreased in intervention group (P=0.05)
      Control groupNone
      Aparecida and colleagues, 2014
      • Aparecida Alves Bianchini J.
      • Fernandes da Silva D.
      • Jaeger Hintze L.
      • et al.
      Obese adolescents who gained/maintained or lost weight had similar body composition and cardiometabolic risk factors following a multidisciplinary intervention.


      Brazil

      CT
      CT=controlled trial.


      Neutral
      88, Both

      Intervention group: 44

      Control group: 44
      10-18Not reportedIntervention group (subdivided into those who lost weight and those who gained weight during the intervention)Structured multi-component treatment16 wkParent and childBMI, BMIZ, WC
      WC=waist circumference.
      BMI: Decreased significantly in both intervention and control weight loss groups (P<0.05)

      BMIZ: Decreased significantly in both intervention and control weight loss groups (P<0.05)

      WC: Decreased significantly in both intervention and control weight loss groups (P<0.05)
      Control group (Subdivided into those who lost weight and those who gained weight during the intervention)None
      Atabek and Pirgon, 2008
      • Atabek M.E.
      • Pirgon O.
      Use of metformin in obese adolescents with hyperinsulinemia: A 6-month, randomized, double-blind, placebo-controlled clinical trial.


      Konya, Turkey

      RCT
      RCT=randomized controlled trial.


      Neutral
      120, Both

      Metformin group: 90

      Control group: 30
      6-18Not reportedMetformin groupMulticomponent plus metformin3-6 moChild onlyBMIBMI: Significant reduction in metformin group (P<0.05)
      Control groupNone
      Banks and colleagues, 2012
      • Banks J.
      • Sharp D.J.
      • Hunt L.P.
      • Shield J.P.H.
      Evaluating the transferability of a hospital-based childhood obesity clinic to primary care: A randomised controlled trial.


      Great Britain

      RCT

      Neutral
      52, Both

      Primary care clinic group: 29

      Hospital-based clinic group: 23
      5-16Not reportedPrimary care clinic groupMulticomponent treatment12 moParents and childBMIZBMIZ: Significant decrease in both groups (P=0.05)
      Hospital-based clinic groupMulticomponent treatment
      Berkowitz and colleagues, 2006
      • Berkowitz R.I.
      • Fujioka K.
      • Daniels S.R.
      • et al.
      Effects of sibutramine treatment in obese adolescents: A randomized trial.


      United States

      RCT

      Neutral
      498, Both

      Sibutramine group: 368

      Behavior group: 130
      12-16Not reportedBehavior/sibutramine groupNutrition education, physical activity education, behavior modification/ psychological counseling, plus sibutramine6-12 moChild onlyBMI, WCBMI and WC: Significantly reduced in behavior/sibutramine group (P<0.01)
      Behavior/placebo groupNutrition education, physical activity education, behavior modification/ psychological counseling
      Berkowitz and colleagues, 2011
      • Berkowitz R.I.
      • Wadden T.A.
      • Gehrman C.A.
      • et al.
      Meal replacements in the treatment of adolescent obesity: A randomized controlled trial.


      NCCT
      NCCT=noncontrolled clinical trial.


      Philadelphia, PA

      Neutral
      113, Both

      Conventional diet group: 42

      Meal Replacement groups: 71
      13-18White, black,

      Other
      Conventional diet, then conventional diet for maintenance groupNutrition education, physical activity education, behavior modification/ psychological counseling12 moParents and childBMI,

      BMIZ,

      BMI%,

      WC
      BMI: Significant reduction in meal replacement groups at month 4 (P<0.01)

      No significant differences between groups for any measures during maintenance period (Months 5-12)
      Meal replacement, then conventional diet for maintenance groupNutrition education, physical activity education, behavior modification/ psychological counseling, plus meal replacement
      Meal replacement, then meal replacement for maintenance groupNutrition education, physical activity education, behavior modification/ psychological counseling, plus meal replacement
      Berry and colleagues, 2014
      • Berry D.C.
      • Schwartz T.A.
      • McMurray R.G.
      • et al.
      The family partners for health study: A cluster randomized controlled trial for child and parent weight management.


      North Carolina

      ClRCT
      CrRCT=crossover randomized controlled trial.


      Positive
      716, Both (sample includes parents and children)

      Multi-component group: 378

      Control group: 338
      7-10African American, WhiteMulticomponent groupNutrition education and physical activity9 moParents and childWCWC: Significant difference in multi-component group at 1 y (P<0.05), but not maintained at 18 mo
      Control groupNone
      Bloom and colleagues, 2013
      • Bloom T.
      • Sharpe L.
      • Mullan B.
      • Zucker N.
      A pilot evaluation of appetite-awareness training in the treatment of childhood overweight and obesity: A preliminary investigation.


      Australia

      RCT

      Neutral
      47, Both

      N=47

      Treatment group: 23

      Control group: 24
      6-12Not reportedTreatment group: Children’s Appetite Awareness TrainingChildren’s Appetite Awareness Training for 1 h per session; included hunger awareness, emotional eating, self-esteem, coping with bullying/teasing7.5 mo (1.5 mo training, 6 mo follow-up)Parents and childBMIBMI: Significantly decreased in treatment group at 6 wk; not significantly increased at 7.5 mo but no difference between 7.5 mo and baseline
      Control groupNone
      Boodai and colleagues, 2014
      • Boodai S.A.
      • McColl J.H.
      • Reilly J.J.
      National Adolescent Treatment Trial for Obesity in Kuwait (NATTO): Project design and results of a randomised controlled trial of a good practice approach to treatment of adolescent obesity in Kuwait.


      Kuwait

      RCT

      Neutral
      63, Both

      Multi-component group: 31

      Control group: 32
      10-14Not reportedMulticomponent groupBehavior change, reduction of sedentary behavior, nutrition education, and exercise education6 moParents and childBMIZ,

      WC
      BMIZ, WC: No significant differences between groups
      Control groupNone
      Boudreau and colleagues,

      2013
      • Boudreau A.D.A.
      • Kurowski D.S.
      • Gonzalez W.I.
      • Dimond M.A.
      • Oreskovic N.M.
      Latino families, primary care, and childhood obesity: A randomized controlled trial.


      Massachusetts

      RCT

      Neutral
      26, Both

      Multi-component group: 14

      Control group: 12
      9-12LatinoMulticomponent group

      Control group
      Physical activity, stress management, nutrition education, and an exercise activity

      None
      6 moParents and childBMIZBMIZ: No significant differences between groups
      Boutelle and colleagues, 2013
      • Boutelle K.N.
      • Zucker N.
      • Peterson C.B.
      • Rydell S.
      • Carlson J.
      • Harnack L.J.
      An intervention based on Schachter's externality theory for overweight children: The regulation of cues pilot.


      Minnesota

      RCT

      Neutral
      44, Both

      Treatment group: 22

      Control group: 22
      8-12White, otherTreatment groupAppetite awareness training and behavioral management of overeating4 moParents and childBMI, BMIZBMI, BMIZ: No significant differences between groups
      Control groupNone
      Bravender and colleagues, 2010
      • Bravender T.
      • Russell A.
      • Chung R.J.
      • Armstrong S.C.
      A “Novel” intervention: A pilot study of children's literature and healthy lifestyles.


      North Carolina

      RCT

      Neutral
      81, Girls

      Intervention novel group: 31

      Control novel group: 33

      No novel: 17
      9-13Not reportedIntervention novel groupIntervention novel topic was an overweight girl who discovers better health and grows in self-efficacy2 moChild onlyBMI percentileBMI percentile: Girls in the intervention novel group had a significantly greater reduction in BMI percentile than girls in the control novel group (P<0.05)

      Girls in both the intervention and control novel groups had a significantly greater reduction in BMI percentile than girls in the no novel group (P<0.05)
      Control novel groupControl novel
      Control group: No novelNo novel
      Budd and colleagues, 2007
      • Budd G.
      • Hayman L.
      • Crump E.
      • et al.
      Weight loss in obese African American and Caucasian adolescents: Secondary analysis of a randomized clinical trial of behavioral therapy plus sibutramine.


      Philadelphia

      RCT

      Positive
      79, Both

      Placebo group white: 24

      Placebo group African American: 13

      Sibutramine group white: 21

      Sibutramine group African American: 21
      13-18White, blackBehavior/placebo group:

      White
      Nutrition education, physical activity education, behavior modification/ psychological counseling6-12 moParents and childBMI, BMIZ, WCBMI: Weight loss and BMI reduction for white sibutramine group significantly greater than nondrug white group (P<0.05)

      Weight loss and BMI reduction for African-American Sibutramine group greater than the nondrug African American group, but the difference was not significant

      All groups lost weight

      WC: Participants who lost >5% body weight also had significant reductions in WC
      Behavior/placebo group:

      African American
      Nutrition education, physical activity education, behavior modification/ psychological counseling
      Behavior/sibutramine group:

      White
      Nutrition education, physical activity education, behavior modification/ psychological counseling, plus sibutramine
      Behavior/sibutramine group:

      African American
      Nutrition education, physical activity education, behavior modification/ psychological counseling, plus sibutramine
      Burgert and colleagues, 2008
      • Burgert T.S.
      • Duran E.J.
      • Goldberg-Gell R.
      • et al.
      Short-term metabolic and cardiovascular effects of metformin in markedly obese adolescents with normal glucose tolerance.


      New Haven, CT

      RCT

      Neutral
      28, Both

      Metformin group: 15

      Placebo group: 13
      13-18White, black, HispanicMetformin groupNutrition education, physical activity education, plus metformin3-6 moChild onlyBMIBMI: Metformin group had significantly decreased BMI from baseline (P<0.05)
      Placebo groupNutrition education, physical activity education
      Chanoine and Richard, 2011
      • Chanoine J.
      • Richard M.
      Early weight loss and outcome at one year in obese adolescents treated with orlistat or placebo.


      United States and Canada

      RCT

      Positive
      539, Both

      Orlistat group: 357

      Placebo group: 182
      12-16Not reportedOrlistat groupIndividual Diet Prescription, plus orlistat6-12 moParents and childBMI, WCBMI, WC: Decreased significantly in both groups
      Placebo groupIndividual diet prescription
      Clarson and colleagues, 2009
      • Clarson C.L.
      • Mahmud F.H.
      • Baker J.E.
      • et al.
      Metformin in combination with structured lifestyle intervention improved body mass index in obese adolescents, but did not improve insulin resistance.


      Ontario, Canada

      RCT

      Neutral
      25, Both

      Metformin group: 14

      Lifestyle group: 11
      6-18WhiteMetformin groupNutrition education, physical activity education, physical activity sessions, plus metformin3-6 moParent and childBMIBMI: Decreased in the metformin group but not in the lifestyle group
      Lifestyle intervention groupNutrition education, physical activity education, physical activity sessions
      Collins and colleagues, 2011
      • Collins C.E.
      • Okely A.D.
      • Morgan P.J.
      • et al.
      Parent diet modification, child activity, or both in obese children: An RCT.


      New South Wales, Australia

      RCT

      Positive
      165, Both

      Physical activity group: 63

      DIET group: 42

      Physical activity plus DIET group: 60
      6 - 11Not reportedPhysical activity groupPhysical activity education, behavior modification/ psychological counseling12 mo-2 yParents and childBMI, BMIZ, WCBMIZ: All groups reduced BMIZ from baseline (P<0.01)

      Physical activity plus DIET group and DIET group decreased BMIZ more than physical activity group
      Diet group (parent centered diet modification program)Nutrition education, behavior modification/ psychological counseling
      Physical activity plus diet groupNutrition education, physical activity education, behavior modification/ psychological counseling
      Coppins and colleagues, 2011
      • Coppins D.F.
      • Margetts B.M.
      • Fa J.L.
      • Brown M.
      • Garrett F.
      • Huelin S.
      Effectiveness of a multi-disciplinary family-based programme for treating childhood obesity (The Family Project).


      England

      CrRCT
      CrRCT=crossover randomized controlled trial.


      Positive
      65, Both

      Intervention, then Control group: 35

      Control, then Intervention group: 30
      6-14Not reportedIntervention, then Control groupNutrition education, physical activity sessions12 mo–2 yParents and childBMI, BMIZ, WCBMIZ: Statistically significant reduction in BMIZ for intervention, then control group (P<0.05)

      Control, then intervention reduced BMIZ but not statistically significant over the first year, during the second year, BMIZ continued to fall but not significantly
      Control, then Intervention groupNutrition education, physical activity sessions
      Croker and colleagues, 2012
      • Croker H.
      • Viner R.M.
      • Nicholls D.
      • et al.
      Family-based behavioural treatment of childhood obesity in a UK National Health Service setting: Randomized controlled trial.


      London, England

      RCT

      Neutral
      72, Both

      Intervention group: 37

      Control group: 35
      6-11White, black, Asian, otherIntervention groupNutrition education, physical activity sessions, behavior modification/ psychological counseling12 moParent and childBMI, BMIZBMIZ: Statistically significant reductions in BMI for both the intervention group and the control group over 6 mo (P<0.01)

      No change in BMI or BMIZ for intervention group at 12 mo
      Control groupNone
      Debar and colleagues, 2012
      • DeBar L.L.
      • Stevens V.J.
      • Perrin N.
      • et al.
      A primary care-based, multicomponent lifestyle intervention for overweight adolescent females.


      Portland, OR

      RCT

      Positive
      208, Female

      N=208

      Intervention group: 105

      Control group: 103
      12-17White, otherIntervention groupNutrition education, physical activity, behavioral and psychological training12 moChild onlyBMIZBMIZ: Significantly reduced in intervention group (P=0.01)
      Control groupUsual care
      Demol and colleagues, 2009
      • Demol S.
      • Yackobovitch-Gavan M.
      • Shalitin S.
      • Nagelberg N.
      • Gillon-Keren M.
      • Phillip M.
      Low-carbohydrate (low & high-fat) versus high-carbohydrate low-fat diets in the treatment of obesity in adolescents.


      Tel Aviv, Israel

      RCT

      Positive
      55, Both

      Low carb/low fat group: 18

      Low carb/high fat group: 17

      High carb/low fat group: 20
      12-18Not reportedLow carb/low fat groupLow carb/low fat (nutrition education, physical activity education)6-12 moNot reportedBMI, BMIZBMI, BMIZ: All diets resulted in significant reductions in all groups (P<0.05)
      Low carb/high fat groupLow carb/high fat (nutrition education, physical activity education)
      High carb/low fat groupHigh carb/low fat (nutrition education, physical activity education)
      Díaz and colleagues, 2010
      • Díaz R.G.
      • Esparza-Romero J.
      • Moya-Camarena S.Y.
      • Robles-Sardín A.E.
      • Valencia M.E.
      Lifestyle intervention in primary care settings improves obesity parameters among Mexican youth.


      Sonora, Mexico

      RCT

      Positive
      76, Both

      Lifestyle intervention group: 38

      Standard care group: 38
      6-18MexicanLifestyle intervention groupIndividual diet prescription, calorie restriction, nutrition education, physical activity education6 -12 moParents and childWeight, BMIWeight, BMI: Significantly decreased for lifestyle intervention group (P<0.01)
      Standard care groupNutrition education, reduce sedentary behaviors, general physical activity education
      Doyle and colleagues, 2008
      • Doyle A.C.
      • Goldschmidt A.
      • Huang C.
      • Winzelberg A.J.
      • Taylor C.B.
      • Wilfley D.E.
      Reduction of overweight and eating disorder symptoms via the Internet in adolescents: A randomized controlled trial.


      San Diego, CA, and St Louis, MO
      83, Both

      Behavioral intervention group: 41

      Usual care group: 42
      13-18White, black, Hispanic, otherBehavioral intervention groupNutrition education, physical activity education, behavior modification/psychological counseling, internet messages4 moChild onlyBMIZBMIZ: Reduced significantly from baseline to 3 mo in intervention group compared with usual care group; maintained at 4-mo follow-up (P<0.05)

      At 4 mo, no significant difference between groups
      Usual care groupUsual care
      Doyle-Baker and colleagues, 2011
      • Doyle-Baker P.K.
      • Venner A.A.
      • Lyon M.E.
      • Fung T.
      Impact of a combined diet and progressive exercise intervention for overweight and obese children: The B.E. H.I.P. study.


      Calgary, Alberta, Canada

      CrRCT

      Positive
      27, Both

      Immediate intervention group: 16

      Delayed intervention group: 11
      6-11Not reportedImmediate intervention groupNutrition education, physical activity sessions3 moParent and childBMI percentile, BMIZBMI percentile: Significant decrease for all participants (P<0.0001)
      Delayed intervention groupNutrition education, physical activity sessions
      Dreyer-Gillette and colleagues, 2014
      • Dreyer-Gillette M.L.
      • Odar Stough C.
      • Best C.M.
      • Beck A.R.
      • Hampl S.E.
      Comparison of a condensed 12-week version and a 24-week version of a family-based pediatric weight management program.


      Kansas City, KS

      RCT

      Neutral
      162, Both

      12-wk group: 75

      24-wk group: 87
      5-14African-American, white, Latino, other12-wk multi-component groupNutrition education, physical activity sessions, behavioral training12 wkParents and childBMIZBMIZ: Significant difference in favor of the 24-wk group at 3, 6, and 12 mo (P<0.05)
      24-wk multi-component groupNutrition education, physical activity sessions, behavioral training24 wk
      Eliakim and colleagues, 2007
      • Eliakim A.
      • Nemet D.
      • Balakirski Y.
      • Epstein Y.
      The effects of nutritional-physical activity school-based intervention on fatness and fitness in preschool children.


      Oranit, Israel

      RCT

      Neutral
      101, Both

      Intervention group: 54

      Control group: 47
      5 -6Not reportedIntervention groupNutrition education, physical activity sessions14 wkChild only (school-based)Weight, BMI percentileWeight, BMI percentile: Significant difference in favor of the intervention group (P<0.0005)
      Control groupNone
      Endevelt and colleagues, 2014
      • Endevelt R.
      • Elkayam O.
      • Cohen R.
      • et al.
      An intensive family intervention clinic for reducing childhood obesity.


      Israel

      RCT

      Neutral
      1043, Both

      Intervention group: 100

      Comparison group: 943
      5-14Not reportedIntervention groupParent training, individual child consultation, physical activity sessions6 moParents and childBMIZBMIZ: Significantly reduced post-intervention for intervention group (P=0.01)

      Reduction in intervention group sustained at 46.7 mo (P=0.01)
      Comparison groupNone
      Epstein and colleagues, 2005 (Study 1)
      • Epstein L.H.
      • Roemmich J.N.
      • Stein R.I.
      • Paluch R.A.
      • Kilanowski C.K.
      The challenge of identifying behavioral alternatives to food: clinic and field studies (Study 1).


      Buffalo, NY

      RCT

      Positive
      41, Both

      Family-based treatment group: 22

      Alternatives to eating group: 19
      8-12Not reportedComprehensive family-based treatment groupDiet prescription, calorie restriction, nutrition education, physical activity education, behavioral treatment12-24 moEntire familyBMIZBMIZ: Study 1: Both groups showed a significant and sustained decrease in BMIZ over 24 mo (P<0.01)
      Reinforcing alternatives to eating groupActivity education
      Epstein and colleagues, 2005 (Study 2)
      • Epstein L.H.
      • Roemmich J.N.
      • Stein R.I.
      • Paluch R.A.
      • CK K.
      The challenge of identifying behavioral alternatives to food: Clinic and field studies (Study 2).


      Buffalo, NY

      NCCT

      Neutral
      13, Both8-12Not reportedWithin-group study of influence of providing alternative activities to eatingActivity education, behavior modification3 moParents and childAlternatives to eatingAlternative behaviors to eating increased by ∼1 h/d (P<0.01), but there were no changes in energy intake or physical activity
      Epstein and colleagues, 2008
      • Epstein L.H.
      • Paluch R.A.
      • Beecher M.D.
      • Roemmich J.N.
      Increasing healthy eating vs. reducing high energy-dense foods to treat pediatric obesity.


      Buffalo, NY

      RCT

      Positive
      41, Both

      Increase healthful foods group: 21

      Reduce energy-dense foods group: 20
      6 - 11Not reportedIncrease healthful foods groupIncreased intake of fruits, vegetables, and low-fat dairy24 moEntire familyBMIZBMIZ: Children in the increase healthful foods group showed a greater reduction in BMIZ than the reduce energy-dense foods group
      Reduce energy-dense foods groupReduced consumption of energy-dense foods
      Esfarjani and colleagues, 2013
      • Esfarjani F.
      • Khalafi M.
      • Mohammadi F.
      • et al.
      Family-based intervention for controlling childhood obesity: An experience among Iranian children.


      Tehran, Iran

      RCT

      Neutral
      107, Both

      Multi-component group: 55

      Control group: 52
      7Not reportedMulticomponent groupNutrition education and environmental control6 moParentsBMI, WCBMI: Increased in both groups, but less in the multi-component group

      WC: Increased in both groups, but significantly less in the multi-component group (P<0.05)
      Control groupNone
      Falbe and colleagues, 2015
      • Falbe J.
      • Cadiz A.A.
      • Tantoco N.K.
      • Thompson H.R.
      • Madsen K.A.
      Active and Healthy Families: A randomized controlled trial of a culturally tailored obesity intervention for Latino children.


      California

      RCT

      Positive
      55 Parent–child dyads, Both

      Multi-component group: 28

      Control group: 27
      5-12LatinoMulticomponent groupNutrition education, physical activity, behavior modification10 wkParents and childBMI, BMIZBMI: Decreased significantly in multi-component group compared with control group (P<0.05)

      BMIZ: Decreased significantly in multi-component group compared with control group (P<0.05)
      Control groupNone
      Ford and colleagues, 2010
      • Ford A.L.
      • Bergh C.
      • Södersten P.
      • et al.
      Treatment of childhood obesity by retraining eating behaviour: Randomised controlled trial.


      England

      RCT

      Positive
      106, Both

      Group sizes not reported
      12-18White, otherStandard care groupStandard lifestyle modification therapy12 mo-2 yParents and childBMIZBMIZ: Decreased significantly in the mandometer group at 12 mo and 18 mo (P<0.01)
      Mandometer groupUse of Mandometer, computerized feedback device to slow down the pace of eating and reduce overall intake
      Garipagaoglu and colleagues, 2009
      • Garipağaoğlu M.
      • Sahip Y.
      • Darendeliler F.
      • Akdikmen Ö.
      • Kopuz S.
      • Sut N.
      Family-based group treatment versus individual treatment in the management of childhood obesity: Randomized, prospective clinical trial.


      Istanbul, Turkey

      RCT

      Neutral
      80, Both

      Family-based group: 40

      Individual treatment group: 40
      6-14Not reportedFamily-based multicomponent treatment groupNutrition education, decreased sedentary activity, behavior modification, provided in groups3 mo-1 yParents and childBMIZBMIZ: Children in both groups significantly decreased BMIZ at 3 mo (P<0.01)

      At 12 mo, only the multi-component group maintained the decrease in BMIZ (P<0.01)
      Individual treatment groupParents and child met for individual sessions with nutrition specialist
      Godoy-Matos and colleagues, 2005
      • Godoy-Matos Al
      • Carraro L.
      • Vieira A.
      • et al.
      Treatment of obese adolescents with sibutramine: A randomized, double-blind, controlled study.


      Rio de Janeiro, Brazil

      RCT

      Neutral
      60, Both

      Sibutramine group: 30

      Placebo group: 30
      13-18Not reportedSibutramine plus lifestyle groupIndividual diet prescription, calorie deficit, physical activity education3-6 moNot reportedBMIBMI: Both groups lost weight, but sibutramine plus lifestyle group lost significantly more weight than placebo plus lifestyle group (P<0.001)
      Placebo plus lifestyle groupIndividual Diet prescription (NC), calorie deficit, physical activity Education
      Golan and colleagues, 2006
      • Golan M.
      • Kaufman V.
      • Shahar D.R.
      Childhood obesity treatment: Targeting parents exclusively v. parents and children.


      Rehovot, Israel

      RCT

      Neutral
      32, Both

      Parent-only group: 13

      Parent and child: 19
      6-11Not reportedParent-only comprehensive treatment groupNutrition education, physical activity education, behavior modification/ psychological counseling6 mo-1 yParents onlyPercent overweightPercent overweight: Significant decrease in parent-only group that was maintained at 1-year follow-up (P<0.02)

      Difference between groups at both time points was significant (P<0.05)
      Parent and child comprehensive treatment groupParent+child: nutrition education, physical activity education, behavior modification/ psychological counselingParents and child
      Goldschmidt and colleagues, 2011
      • Goldschmidt A.B.
      • Stein R.I.
      • Saelens B.E.
      • Theim K.R.
      • Epstein L.H.
      • Wilfley D.E.
      Importance of early weight change in a pediatric weight management trial.


      San Diego

      RCT

      Neutral
      150, Both

      Behavioral weight maintenance group: 51

      Social environment weight maintenance group: 50

      Control group: 49
      6-11White, black, Hispanic, otherBehavioral skills groupFamily-based multicomponent weight control program, followed by behavioral weight maintenance skills treatment20 wk-2 yParents and childPercent weight changePercent weight change by session 8 of family-based multi-component treatment was the best predictor of BMIZ reduction at treatment conclusion and at 2-y follow-up
      Social facilitation groupFamily-based multi-component weight control program, followed by training in shaping the family’s social environment to support weight maintenance
      Control groupFamily-based multi-component weight control treatment only
      Guo and colleagues, 2014
      • Guo H.
      • Zeng X.
      • Zhuang Q.
      • Zheng Y.
      • Chen S.
      Intervention of childhood and adolescents obesity in Shantou city.


      Shantou City, China

      NCCT

      Neutral
      41, Both

      Multi-component arm: 24

      Control arm: 13
      Grades 3, 4, 5AsianMulticomponent groupNutrition education, physical activity, behavioral treatment1 yNot describedBMI, BMIZ, WCBMI: Both the intervention and control arms showed significantly increased BMIs (P<0.05)

      BMIZ: Significantly decreased for the intervention group only (P<0.05)

      WC: Significantly increased in the control group only (P<0.05)
      Control groupNone
      Harder-Lauridsen and colleagues, 2014
      • Harder-Lauridsen N.M.
      • Birk N.M.
      • Ried-Larsen M.
      • et al.
      A randomized controlled trial on a multicomponent intervention for overweight school-aged children - Copenhagen, Denmark.


      Copenhagen, Denmark

      RCT

      Positive
      38, Both

      Multi-component group: 19

      Control group: 19
      7-10Not reportedMulticomponent groupNutrition education, physical activity, behavioral treatment20 wkParents and childBMI,

      BMIZ,

      WC
      BMI: Significantly decreased in the intervention group vs. the control group (P<0.05)

      BMI z score: Significantly decreased in the intervention group vs the control group (P<0.05)

      Waist circumference: Significantly decreased in the intervention group vs the control group (P<0.05)
      Control groupNone
      Hart and colleagues, 2010
      • Hart C.N.
      • Jelalian E.
      • Raynor H.A.
      • et al.
      Early patterns of food intake in an adolescent weight loss trial as predictors of BMI change.


      Miriam Hospital, RI

      NCCT

      Neutral
      72, Both13-16WhiteIntervention groupCalorie-reduced diet, increased physical activity, cognitive behavioral training16 wkParents and childBMIBMI: Significant reduction in BMI was observed postintervention (P<0.01) and subjects with higher initial BMI showed greater BMI changes
      Hofsteenge and colleagues, 2014
      • Hofsteenge G.H.
      • Chinapaw M.J.
      • Delemarre-van de Waal H.A.
      • Weijs P.J.
      Long-term effect of the Go4it group treatment for obese adolescents: A randomised controlled trial.


      Amsterdam, the Netherlands

      RCT

      Positive
      122, Both

      Multi-component group: 71

      Control group: 51
      11-18Western, non-WesternMulticomponent groupNutrition education, physical activity, behavioral treatment14-21 wkParents and childBMI,

      BMIZ,

      WC
      BMI: No difference between groups at 6- or 18-mo follow-up

      BMI z score: Intervention group significantly lower at 18-mo follow up (P<0.05)

      Waist circumference: No difference between groups at 6 or 18-mo follow-up
      Regular care groupReferral to dietitian at adolescent request
      Hughes and colleagues, 2008
      • Hughes A.R.
      • Stewart L.
      • Chapple J.
      • et al.
      Randomized, controlled trial of a best-practice individualized behavioral program for treatment of childhood overweight: Scottish Childhood Overweight Treatment Trial (SCOTT).


      Edinburgh, Scotland

      RCT

      Neutral
      134, Both

      Intervention group: 69

      Control group: 65
      6-11Not reportedIntervention groupNutrition education, physical activity, behavioral treatment6-12 moParents and childBMIZBMIZ: No significant effect on BMIZ score from baseline to 6 mo and 12 mo when intervention compared with standard care

      Decreased significantly in both groups (P< 0.05)
      Control groupStandard care
      Jelalian and colleagues, 2008
      • Jelalian E.
      • Hart C.N.
      • Mehlenbeck R.S.
      • et al.
      Predictors of attrition and weight loss in an adolescent weight control program.


      Rhode Island

      RCT

      Neutral
      76, Both

      Group size not provided
      13-16Non-Hispanic whiteCognitive behavioral therapy with peer-based adventure therapy group (PEAT group)Balanced diet, physical activity, behavioral training, plus peer-based Outward Bound style training4 moParents and childBMIBMI: Both intervention groups experienced reductions in BMI
      Cognitive behavioral therapy with aerobic exercise group (EXER group)Balanced diet, physical activity, behavioral training, plus traditional supervised cardiovascular fitness activity
      Control groupStandard care
      Jelalian and colleagues, 2010
      • Jelalian E.
      • Lloyd-Richardson E.E.
      • Mehlenbeck R.S.
      • et al.
      Behavioral weight control treatment with supervised exercise or peer-enhanced adventure for overweight adolescents.


      Rhode Island

      RCT

      Positive
      118, Both

      Adventure therapy group: 62

      Exercise group: 56
      12-18White, black, Hispanic, otherCognitive behavioral therapy with peer-based adventure therapy group (PEAT group)Balanced diet, physical activity, behavioral training, plus peer-based Outward Bound style training3-6 moParents and childBMI, BMIZ, WCBMI, BMIZ, and WC: Significant reductions in all weight change outcomes post intervention and maintained at 12-mo follow-up for all groups (P<0.05)
      Cognitive behavioral therapy with aerobic exercise group (EXER group)Balanced diet, physical activity, behavioral training, plus traditional supervised cardiovascular fitness activity
      Jelalian and colleagues, 2006
      • Jelalian E.
      • Mehlenbeck R.
      • Lloyd-Richardson E.E.
      • Birmaher V.
      • Wing R.R.
      ‘Adventure therapy’ combined with cognitive-behavioral treatment for overweight adolescents.


      Rhode Island

      RCT

      Neutral
      89, Both

      Adventure therapy group: 37

      Exercise group: 39

      Control group: 13
      13-16WhiteCognitive behavioral therapy with peer-based adventure therapy group (PEAT group)Balanced diet, physical activity, behavioral training, plus peer-based Outward Bound style training16 wkParent and childWeight lossWeight loss: Both intervention groups demonstrated significant weight loss over time (P<0.01), and mean weight loss did not differ significantly between groups
      Cognitive behavioral therapy with aerobic exercise group (EXER group)Balanced diet, physical activity, behavioral training, plus traditional supervised cardiovascular fitness activity
      Control groupStandard care
      Jiang and colleagues, 2005
      • Jiang J.X.
      • Xia X.L.
      • Greiner T.
      • Lian G.L.
      • Rosenqvist U.
      A two year family based behaviour treatment for obese children.


      Beijing, China

      RCT

      Positive
      65, Both

      Intervention group: 33

      Control group: 35
      12-14AsianIntervention groupFamily-based behavioral treatment, physical activity12 mo-2 yEntire familyBMIZBMIZ: Significantly reduced in the intervention group (P<0.001)
      Control groupNone
      Johnston and colleagues, 2011
      • Johnston C.A.
      • Tyler C.
      • Palcic J.L.
      • Stansberry S.A.
      • Gallagher M.R.
      • Foreyt J.P.
      Smaller weight changes in standardized body mass index in response to treatment as weight classification increases.


      Houston, TX

      NCCT

      Neutral
      212, Both

      Overweight group: 69

      Obese group: 110

      Severely obese group: 33
      9-14Mexican AmericanOverweight groupNutrition education, physical activity, behavior modification3-12 moParents and childBMIZBMIZ: Overweight, obese, and severely obese weight categories differed significantly in BMIZ decreases at baseline, 3, 6, and 12 mo (P< 0.01)

      Only the overweight and obese students continued to show significant improvement from baseline BMIZ at 12 mo
      Obese groupNutrition education, physical activity, behavior modification
      Severely obese groupNutrition education, physical activity, behavior modification
      Jones and colleagues, 2008
      • Jones M.
      • Luce K.H.
      • Osborne M.I.
      • et al.
      Randomized, controlled trial of an Internet-Facilitated intervention for reducing binge eating and overweight in adolescents.


      Boise, ID, and Hayward, CA

      RCT

      Positive
      105, Both

      Intervention group: 52

      Control group: 53
      13 - 18White, black, Hispanic, OtherIntervention groupInternet-based nutrition education16 wkChild onlyBMI, BMIZBMIZ: Significant in BMIZ (P<0.01) and the change in BMI (P<0.01) from baseline to follow-up favoring the intervention group
      Control groupNone
      Kalarchian and colleagues, 2009
      • Kalarchian M.A.
      • Levine M.D.
      • Arslanian S.A.
      • et al.
      Family-based treatment of severe pediatric obesity: Randomized, controlled trial.


      Boise, ID

      RCT

      Neutral
      192, Both

      Intervention group: 97

      Control group: 95
      6-11Hispanic, non-Hispanic, white, African-American, Native American, Pacific Islander, Native HawaiianIntervention groupNutrition education, physical activity, behavioral training18 moParents and childPercent overweightPercent overweight: Significantly decreased in intervention group at 6 mo (P<0.05) but significant difference was not maintained at 12 or 18 mo
      Control groupUsual care
      Kalavainen and colleagues, 2007
      • Kalavainen M.P.
      • Korppi M.O.
      • Nuutinen O.M.
      Clinical efficacy of group-based treatment for childhood obesity compared with routinely given individual counseling.


      Kuopio, Finland

      RCT

      Positive
      70, Both

      Family-based group: 35

      Routine counseling group: 35
      6-11WhiteFamily-based group treatment groupNutrition education, physical activity education, behavioral treatment12 moParents and childBMI, BMIZBMI: Significant reduction for family-based group treatment (P<0.01)

      BMIZ: Significant reduction for family-based group treatment (P<0.01)
      Routine counseling group2 Counseling appointments for child
      Kalavainen and colleagues, 2011
      • Kalavainen M.
      • Korppi M.
      • Nuutinen O.
      Long-term efficacy of group-based treatment for childhood obesity compared with routinely given individual counselling.


      Kuopio, Finland

      RCT

      Positive
      68, Both

      Family-based group at 2 y: 34

      Routine counseling group at 2 y: 34
      7-9WhiteFamily-based group treatment groupNutrition education, physical activity education, behavioral treatment2-3 yParents and childBMI, BMIZNo significant differences between groups at 2- or 3-y follow-up
      Routine counseling group2 Counseling appointments for child
      Kalavainen and colleagues, 2012
      • Kalavainen M.
      • Utriainen P.
      • Vanninen E.
      • Korppi M.
      • Nuutinen O.
      Impact of childhood obesity treatment on body composition and metabolic profile.


      Kuopio, Finland

      RCT

      Positive
      70, Both

      Family-based group: 35

      Routine counseling group: 35
      7-9WhiteFamily-based group treatment groupNutrition education, physical activity education, behavioral treatment20 wkParents and childBMIZMetabolic improvements were associated with substantially reduced BMIZ, and the result was not dependent on assigned group
      Routine counseling group2 Counseling appointments for child
      Klesges and colleagues, 2010
      • Klesges R.C.
      • Obarzanek E.
      • Kumanyika S.
      • et al.
      The Memphis Girls’ Health Enrichment Multi-Site Studies (GEMS): An evaluation of the efficacy of a 2-year obesity prevention program in African American girls.


      Memphis, TN

      RCT

      Positive
      303, Female

      Intervention group: 153

      Control group: 150
      7-9BlackIntervention groupHealthy eating education, physical activity education, behavioral counseling2 yParents and childBMIBMI increased in all girls over 2 y, with no treatment effect
      Control groupBehavioral counseling to promote self-esteem and social efficacy
      Kokkvoll and colleagues, 2015
      • Kokkvoll A.
      • Grimsgaard S.
      • Steinsbekk S.
      • Flaegstad T.
      • Njolstad I.
      Health in overweight children: 2-year follow-up of Finnmark Activity School—A randomised trial.


      Norway

      RCT

      Positive
      91, Both

      Multi-family group: 46

      Single-family group: 45
      6-12WhiteMultifamily group3-d Inpatient hospital program with other families, group-based and individual follow-up, physical activity training, nutrition education, motivational interviewing2 yParents and childBMI, BMIZBMI: Increased less in the multi-family group than the single-family group (P=0.07)

      BMIZ: Significantly decreased in multi-family group compared with single-family group (P <0.05)
      Single-family groupIndividual counseling by a multidisciplinary team, motivational interviewing
      Kong and colleagues, 2013
      • Kong A.S.
      • Sussman A.L.
      • Yahne C.
      • Skipper B.J.
      • Burge M.R.
      • Davis S.M.
      School-based health center intervention improves body mass index in overweight and obese adolescents.


      Albuquerque, NM

      RCT

      Neutral
      51, Both

      Intervention group: 28

      Control group: 23
      Grades 9-11Not reportedIntervention groupOngoing nutrition education, energy balance, behavioral training, obesity risk reduction strategiesSchool yearParents and childBMI, WCBMI: Significantly decreased in intervention school students vs standard care school students (P<0.05)

      WC: Significantly decreased in intervention school students vs standard care school students (P<0.05)
      Standard care groupVisit with school nurse and educational booklet
      Krebs and colleagues, 2010
      • Krebs N.F.
      • Gao D.
      • Gralla J.
      • Collins J.S.
      • Johnson S.L.
      Efficacy and safety of a high protein, low carbohydrate diet for weight loss in severely obese adolescents.


      Denver, CO

      RCT

      Positive
      46, Both

      High protein low carbohydrate group: 24

      Low-fat group: 22
      12-18White, African American, Hispanic, AsianHigh-protein, low-carbohydrate groupHigh-protein, low-carbohydrate diet, nutrition education, physical activity12-36 wkChild onlyBMIZBMIZ: Significantly reduced in both groups

      High-protein, low-carbohydrate group BMIZ reduction significantly greater than low-fat group reduction (P=0.02)

      Both groups maintained reductions at 36-wk follow-up
      Low-fat groupReduced energy expenditure, <30% kcal from fat, nutrition education, physical activity
      Larsen and colleagues, 2015
      • Larsen L.M.
      • Hertel N.T.
      • Mølgaard C.
      • Christensen R.D.
      • Husby S.
      • Jarbøl D.E.
      Early intervention for childhood overweight: A randomized trial in general practice.


      Denmark

      RCT

      Neutral
      80, Both

      Multi-component group: 45

      General practice group: 35
      5-9WhiteMulticomponent groupMonthly, then bimonthly, consultations in a general practice clinic; lifestyle habits, physical activity, diet; plus 3 multifamily group sessions held during the first year2 yParents and childBMIZ, WCBMIZ: Significantly decreased in both groups (P<0.05)

      WC: Significant difference in favor of the general practice group (P<0.05)
      General practice groupMonthly, then bi-monthly, consultations in a general practice clinic; lifestyle habits, physical activity, diet
      Love-Osborne and colleagues, 2014
      • Love-Osborne K.
      • Fortune R.
      • Sheeder J.
      • Federico S.
      • Haemer M.A.
      School-based health center-based treatment for obese adolescents: Feasibility and body mass index effects.


      Denver, CO

      RCT

      Neutral
      149, Both

      Intervention group: 77

      Control group: 72
      Middle-school and high-school ageHispanic, otherIntervention groupStandard care in a school-based health clinic plus 5 visits with a health educator trained in motivational interviewingSchool yearChild onlyBMIZBMIZ: Significantly reduced in control group (P <0.05)

      Post hoc analysis showed that participation in athletics was significantly higher in control group compared to intervention group
      Control groupStandard care in a school-based health clinic
      Luca and colleagues, 2014
      • Luca P.
      • Dettmer E.
      • Khoury M.
      • et al.
      Adolescents with severe obesity: Outcomes of participation in an intensive obesity management programme.


      Toronto, Canada

      CT

      Neutral
      117, Both

      Multi-component group: 75

      Control group: 42
      12-17Not reportedMulticomponent groupBehavior change, nutrition education, physical activity, stress management12 moParents and childBMI, WCBMI: No significant difference in BMI between groups at 12 mo

      WC: Significant difference at 12 mo in favor of intervention group (P<0.05)
      Control groupUsual care
      Magarey and colleagues, 2011
      • Magarey A.M.
      • Perry R.A.
      • Baur L.A.
      • et al.
      A parent-led family-focused treatment program for overweight children aged 5 to 9 years: The PEACH RCT.


      Australia

      RCT

      Neutral
      N=169, Both

      Parenting skills plus healthy lifestyle group: 85

      Healthy lifestyle-only group: 84
      5-9Not reportedParenting skills plus healthy lifestyle groupNutrition education, behavior modification, parenting skills6-24 moParent and childBMIZ, WCBMIZ: 10% reduction from baseline to 6 mo that was maintained to 24 mo with no additional intervention in both groups (P<0.01)

      WC: 10% reduction from baseline to 6 mo that was maintained to 24 mo with no additional intervention in both groups (P<0.01)
      Healthy lifestyle-only groupNutrition education, behavior modification
      Marild and colleagues, 2012
      • Marild S.
      • Gronowitz E.
      • Forsell C.
      • Dahlgren J.
      • Friberg P.
      A controlled study of lifestyle treatment in primary care for children with obesity.


      Sweden

      RCT

      Neutral
      267, Both

      Medical nutrition group: 32

      Medical nutrition exercise group: 34

      Comparison group: 201
      9-13Not reportedMedical nutrition groupNutrition education, medical monitoringNot reportedParent and childBMI, BMIZBMIZ: No difference between intervention groups, but significant difference from obese subjects in comparison group (P<0.05)

      BMI: No difference between intervention groups, but significant difference from obese subjects in comparison group (P<0.05)
      Medical nutrition exercise groupNutrition education, medical monitoring, physical activity
      Comparison groupNo Treatment
      Munsch and colleagues, 2008
      • Munsch S.
      • Roth B.
      • Michael T.
      • et al.
      Randomized controlled comparison of two cognitive behavioral therapies for obese children: Mother versus mother-child cognitive behavioral therapy.


      Basel, Switzerland

      RCT

      Positive
      56, Both

      Mother and child group: 31

      Mother only group: 25
      8-12Not reportedMother and child groupNutrition education and behavioral therapy for parent and childNot reportedMother and childPercent overweightPercent overweight: Reduced significantly between baseline and 6-mo follow-up for both groups (P<0.001)
      Mother only groupNutrition education and behavioral therapy for parent only
      Naar-King and colleagues, 2009
      • Naar-King S.
      • Ellis D.
      • Kolmodin K.
      • et al.
      A randomized pilot study of multisystemic therapy targeting obesity in African-American adolescents.


      Detroit, MI

      RCT

      Positive
      49, Both

      Multi-systemic therapy group: 24

      Control group: 25
      12-17African-AmericanMultisystemic therapy groupIntensive home-based treatment including behavioral training, nutrition education using foods present in the home, engaging support6-12 moParent and childBMI, Percent overweightBMI: Trend toward decrease in MST group

      Percent overweight: Significantly decreased in MST group (P<0.05)
      Control groupTraditional multi-component group-based treatment
      Nemet and colleagues, 2005
      • Nemet D.
      • Barkan S.
      • Epstein Y.
      • Friedland O.
      • Kowen G.
      • Eliakim A.
      Short- and long-term beneficial effects of a combined dietary–behavioral–physical activity intervention for the treatment of childhood obesity.


      Tel Aviv University, Israel

      RCT

      Positive
      46, Both

      Intervention group: 24

      Control group: 22
      6-16Not reportedIntervention groupNutrition education, physical activity, behavioral treatment3-12 moParent and childBMIBMI: Significantly decreased in intervention group vs the control group (P<0.05) at 3 mo and 12 mo
      Control groupNone
      Nemet and colleagues, 2008
      • Nemet D.
      • Barzilay-Teeni N.
      • Eliakim A.
      Treatment of childhood obesity in obese families.


      Tel Aviv University, Israel

      RCT

      Neutral
      22, Both

      Intervention group: 11

      Control group: 11
      8-11Not reportedIntervention groupNutrition education, physical activity, behavioral treatment3 moParent and childBMI percentile, body weightBMI percentile: Significantly decreased in intervention group vs control group (P<0.05)

      Body weight: Significantly decreased in intervention group vs control group (P<0.05)
      Control groupNone
      Nemet and colleagues, 2013
      • Nemet D.
      • Oren S.
      • Pantanowitz M.
      • Eliakim A.
      Effects of a multidisciplinary childhood obesity treatment intervention on adipocytokines, inflammatory and growth mediators.


      Tel Aviv University, Israel

      RCT

      Positive
      41, Both

      Intervention group: 21

      Control group: 20
      6-13Not reportedIntervention groupNutrition education, physical activity3 moParents and childBMI percentile, body weight, WCBMI percentile: Significantly decreased in intervention group vs control group (P<0.05)

      Body weight: Significantly decreased in intervention group vs control group (P<0.05)

      WC: Significantly decreased in intervention group vs control group (P<0.05)
      Control groupNo treatment
      Nowicka and colleagues, 2009
      • Nowicka P.
      • Lanke J.
      • Pietrobelli A.
      • Apitzsch E.
      • Flodmark C.-E.
      Sports camp with six months of support from a local sports club as a treatment for childhood obesity.


      Malmö, Sweden

      RCT

      Neutral
      76, Both

      Intervention group: 38

      Control group: 38
      8-12Not reportedIntervention group1-wk Sports camp, nutrition education, physical activity6-12 moChild onlyBMIZBMIZ: Significantly reduced in both the intervention and control groups (P<0.05)
      Control groupNo treatment
      O’Brien and colleagues, 2010
      • O’Brien P.E.
      • Sawyer S.M.
      • Laurie C.
      • et al.
      Laparoscopic adjustable gastric banding in severely obese adolescents: A randomized trial.


      Melbourne, Australia

      RCT

      Positive
      50, Both

      Gastric banding group: 25

      Lifestyle group: 25
      14-18Not reportedGastric banding groupGastric banding and associated nutrition treatment, nutrition education, physical activity, behavioral treatment2 yParents and childPercent excess weight, BMIZPercent excess weight: Greater in gastric banding group than lifestyle group (78.8% vs 13.2%)

      BMIZ: Greater reduction in gastric banding group than lifestyle group (1.07 vs 0.15 unit decrease)
      Lifestyle intervention groupReduced energy intake, nutrition education, physical activity, behavioral treatment
      Okely and colleagues, 2010
      • Okely A.D.
      • Collins C.E.
      • Morgan P.J.
      • et al.
      Multi-site randomized controlled trial of a child-centered physical activity program, a parent-centered dietary-modification program, or both in overweight children: The HIKCUPS Study.


      Australia

      RCT

      Positive
      165, Both

      Parent-centered dietary group: 42

      Child-centered physical activity group: 63

      Combination group: 60
      5-10Not ReportedParent-centered dietary groupDiet modification3-6 moParent only, child only, parent and childBMI, WCBMI: Decreased in all groups, with parent-centered dietary group and combination group significantly decreased compared with the child-centered physical activity group (P=0.02)

      WC: No significant changes for any group
      Child-centered physical activity groupPhysical activity training
      Combination groupBoth diet modification and physical activity
      Pedrosa and colleagues, 2011
      • Pedrosa C.
      • Oliveira B.M.P.M.
      • Albuquerque I.
      • Simões-Pereira C.
      • Vaz-de-Almeida M.D.
      • Correia F.
      Metabolic syndrome, adipokines and ghrelin in overweight and obese schoolchildren: Results of a 1-year lifestyle intervention programme.


      Porto, Portugal

      RCT

      Neutral
      105, Both

      Individual treatment group: 58

      Group treatment group: 25

      Control group: 22
      7-9Not reportedIndividual conventional treatment groupNutrition, physical activity, and behavioral education at initial visit and reinforced at follow-up visits12 moParent and childBMIZ, WCBMIZ: Significantly decreased in group treatment compared with individual treatment (T<0.05)

      WC: Trend toward decrease in group treatment compared with individual treatment (T=0.079)
      Group treatment groupOngoing group sessions plus healthy eating plan, physical activity, behavioral training
      Control groupNone
      Reinehr and colleagues, 2006
      • Reinehr T.
      • de Sousa G.
      • Toschke A.M.
      • Andler W.
      Long-term follow-up of cardiovascular disease risk factors in children after an obesity intervention.


      Datteln, Germany

      NRCT

      Neutral
      252, Both

      Multi-component group: 203

      Control group: 49 (obese= 37; normal weight=12)
      6-14Not reportedMulticomponent groupNutrition education, behavioral treatment, physical activity6-12 moParent and childBMI, BMIZBMI: Significantly increased in both groups (P<0.001)

      BMIZ: Significantly decreased in the multicomponent group compared with the control group (P<0.001)
      Control groupNone
      Reinehr and colleagues, 2009
      • Reinehr T.
      • Kleber M.
      • Toschke A.M.
      Lifestyle intervention in obese children is associated with a decrease of the metabolic syndrome prevalence.


      Herdecke, Germany

      NRCT

      Neutral
      474, Both

      Multi-component group: 288

      Control group: 186
      N/ANot reportedMulticomponent groupNutrition education, behavioral treatment, physical activity12 moParent and childBMIZ, WCBMIZ: Significantly decreased in multi-component group (P<0.001)

      Significantly increased in control group (P<0.001)

      WC: Significantly decreased in multicomponent group (P=0.04)

      Significantly increased in control group (P <0.001)
      Control groupNone
      Rezvanian and colleagues, 2010
      • Rezvanian H.
      • Hashemipour M.
      • Kelishadi R.
      • Tavakoli N.
      • Poursafa P.
      A randomized, triple masked, placebo-controlled clinical trial for controlling childhood obesity.


      Iran

      RCT

      Positive
      180, Both

      Metformin group: 45

      Fluoxetine group: 45

      Combination group: 45

      Placebo group: 45
      10-16Not reportedMetformin groupMetformin+lifestyle3-6 moChild onlyBMI, WCBMI: Decreased significantly in all 3 drug treatment groups but not the placebo group (P<0.05)

      WC: Decreased in the metformin and combination groups (P<0.05)
      Fluoxetine groupFluoxetine+lifestyle
      Combination groupMetformin+Fluoxetine+lifestyle
      Placebo groupPlacebo + lifestyle
      Ribeiro and colleagues, 2005
      • Ribeiro M.M.
      • Silva A.G.
      • Santos N.S.
      • et al.
      Diet and exercise training restore blood pressure and vasodilatory responses during physiological maneuvers in obese children.


      Sao Paulo, Brazil

      RCT

      Neutral
      49, Both

      Diet plus exercise training group: 21

      Diet group: 18

      Control group: 10
      9-11Not reportedDiet plus exercise training groupHypocaloric diet, clinical nutritionist visits, exercise training4 moChild onlyBMI, BMIZ, body weightBMI: Significantly decreased in both intervention groups (P<0.05)

      BMIZ: Significantly decreased in both interventions groups (P<0.05)

      Body weight: Significantly decreased in both intervention groups (P<0.05)
      Diet groupHypocaloric diet, clinical nutritionist visits
      ControlNone
      Robinson and colleagues, 2010
      • Robinson T.N.
      • Matheson D.M.
      • Kraemer H.C.
      • et al.
      A randomized controlled trial of culturally tailored dance and reducing screen time to prevent weight gain in low-income African American girls: Stanford gems.


      Stanford University, CA

      RCT

      Positive
      261, Girls plus families

      Dance and screen time reduction group: 134 families

      Health education group: 127 families
      8-10African AmericanDance and screen time reduction groupCulturally tailored dance plus screen time reduction2 yEntire familyBMI, BMIZ, WCBMI, BMIZ, WC: No statistically significant differences between groups
      Health education groupInformation on diet, physical activity, and reducing health risks
      Rooney and colleagues, 2005
      • Rooney B.L.
      • Gritt L.R.
      • Havens S.J.
      • Mathiason M.A.
      • Clough E.A.
      Growing healthy families: Family use of pedometers to increase physical activity and slow the rate of obesity.


      United States

      RCT

      Positive
      87 families, Both

      Pedometer group: 28 families

      Pedometer + education group: 30 families

      Control group: 29 families
      2-14Not reportedPedometer groupPedometers plus instructions and step diary6-9 moParent and childBMI percentileBMI percentile: Nonsignificant decrease for children from baseline to end of intervention and at 9-mo follow-up, but did not differ by study group
      Pedometer + education groupPedometers plus instructions, step diary, nutrition and physical activity education, parenting education
      Control groupNone
      Rosado and colleagues, 2008
      • Rosado J.L.
      • del R Arellano M.
      • Montemayor K.
      • García O.P.
      • Caamaño Mdel C.
      An increase of cereal intake as an approach to weight reduction in children is effective only when accompanied by nutrition education: A randomized controlled trial.


      Queretaro, Mexico

      RCT

      Positive
      262, Both

      1 dose ready-to-eat cereal group: 46

      2 doses ready-to-eat cereal group: 48

      1 dose ready-to-eat cereal + nutrition guide group: 45

      Control group: 39
      6-12Hispanic1 dose ready-to-eat cereal group37±7 g study cereal at breakfast12 wkMother and childBody weight, BMIBody weight, BMI: Significantly reduced in the 1 dose ready-to-eat cereal plus nutrition education group (P<0.01) compared with control group

      The other intervention groups had no significant differences from the control group
      2 doses ready-to-eat cereal group37±7 g study cereal at breakfast and an equal dose at dinner
      1 dose ready-to-eat cereal + nutrition guide group37±7 g study cereal at breakfast plus nutrition education
      Control groupNone
      Sacher and colleagues, 2010
      • Sacher P.M.
      • Kolotourou M.
      • Chadwick P.M.
      • et al.
      Randomized controlled trial of the MEND program: A family-based community intervention for childhood obesity.


      London, United Kingdom

      RCT

      Positive
      116, Both

      Multi-component group: 60

      Control group: 56
      6-14White, otherMulticomponent groupNutrition education, physical activity, behavioral training, free family swimming pass6-12 moParents and childBMIZ, WCBMIZ: Significantly reduced in intervention group compared to control group (P<0.0001)

      WC: Significantly reduced in intervention group compared with control group (P<0.0001)
      Control groupNone
      Saelens and colleagues, 2011
      • Saelens B.E.
      • Grow H.M.
      • Stark L.J.
      • Seeley R.J.
      • Roehrig H.
      Efficacy of increasing physical activity to reduce children's visceral fat: A pilot randomized controlled trial.


      Seattle, WA

      RCT

      Positive
      29, Both

      Nutrition group: 15

      Physical activity group: 14
      7-11White non-Hispanic

      African American, white Hispanic,

      multiracial
      Multicomponent nutritionNutrition Education, diet, behavioral training14 wkParents and childBMI, BMIZBMI, BMIZ: No significant difference between groups for either measure
      Multicomponent physical activity groupNutrition Education, diet, behavioral training, physical activity
      Sato and colleagues, 2010
      • Sato A.F.
      • Jelalian E.
      • Hart C.N.
      • et al.
      Associations between parent behavior and adolescent weight control.


      Providence, RI

      RCT

      Positive
      86, Both

      Group size not provided but assume ∼ equal; therefore:

      Aerobic exercise group: 43

      Adventure therapy group: 43