What Else Can Be Done to Treat Children who are Overweight?

1. What Else Can Be Done to Treat Children who are Overweight? Kerri Boutelle, Ph.D. Associate Professor, Pediatrics and Psychiatry University of California, San Diego Rady Children’s Hospital kboutelle@ucsd.edu

2. Disclosures No financial conflicts of interest Pictures of study participants are used with consent

3. Thank you! • Children and parents in Minnesota and San Diego • Collaborators Scott Crow and Carol Peterson (Univ of MN), Nancy Zucker (Duke), Guy Cafri (UCSD) • Len Epstein (Univ of Buffalo) and Denise Wilfley (Washington University St. Louis) for their support and training • Interventionists • MN: Mary Alm, Aimee Arikian, Robyn Birkeland, Heather Libbey, Diane Rubright • CA: Kristy Center, Taya Cromley, Tammy Manginot, Roxanne Rockwell, Erika Swift • University of Minnesota Obesity Center (NIH NIDDK/5P30-DK050456-14) and University of California, San Diego, Academic Senate Award

4. Rates of childhood obesity are increasing

5. Why focus on youth? • Obesity tracks from preschool years to preteens, and from childhood and adolescence to adulthood • Key risk developmental periods for adult obesity • 30% of children who complete treatment are no longer overweight in adulthood 10 years later • As a method of preventing adult obesity Dietz, 1997Epstein 1990; 1994Wright 2001, Maffeis, 2002, Whitaker, 1997, Nader, 2006

6. Psychosocial comorbities • Poor self-esteem • Verbal abuse • Teasing • Increased risk for using unhealthy weight control behaviors • More likely to be peripheral to social networks • Similar quality of life as children with cancer • At greater risk for the development of clinical and subclinical depression Thompson, 1999, Strauss 2000, 2003, Jackson, 2000, Schwimmer, 2003, Boutelle, 2003, 2006

7. Medical comorbidities • Type 2 diabetes • Metabolic syndrome • High blood pressure • Asthma and other respiratory problems • Sleep disorders • Liver disease • Early puberty or menarche • Eating disorders • Skin infections

8. Definitions of obesity in childhood • Instead of using body mass index (BMI), we plot height and weight on age and gender adjusted charts (CDC) • >85th% is considered “overweight” • >95% is considered “obese”

9. Current treatments for childhood obesity • Family-based • Behavioral treatment including a strong focus on behavior therapy and reinforcement • **Note, giving exercise and nutrition advice is not behavior therapy

10. Structure of Childhood Obesity Treatment • Parent and child separate groups • Parent and child together goal setting with individual therapist • 4 months of weekly meetings • 2 months of biweekly meetings • Follow-up 6, 12 and 24 months

11. Content of treatment

12. Parenting Skills

13. Outcome data • Studies show that 8-12 year olds can lose 6-18 pounds on average • Ten year longitudinal data show that 1/3 of children who participated in family based program were no longer overweight in adulthood Epstein, 1990; 1994

14. If behavior therapy is so great, why don’t all children respond? • The effects of biological and environmental factors can not be overcome through behavioral methods • The optimal psychological treatment to manage obesity may not be developed yet • Adults and children who are overweight are a heterogeneous group

15. Options for improving childhood obesity treatment Improve dissemination Improve procedures for implementing behavior therapy Improve treatment methods

16. Options for improving childhood obesity treatment • Improve dissemination • Improve procedures for implementing behavior therapy • Improve treatment methods

17. Improve Dissemination • Clinic based programs are fairly time and cost intensive, and there is a shortage of clinic programs • One way of disseminating these programs, is to develop a method for health care professionals that is cost effective

18. Guided Self-Help • Method for delivering treatment that involves a manual and 20 minute visits every 2 weeks • Has been successful in other areas (binge eating, anxiety, depression) • Currently recruiting 8-12 year old moderately overweight children and their parents for this study

19. Options for improving childhood obesity treatment Improve dissemination Improve procedures for implementing behavior therapy Improve treatment methods

20. Targets for childhood obesity • Current treatment is parent and child separate groups, with individualized goal setting • Fairly intensive, and requires 4-6 therapists to implement • Wonder if parent-only would be effective in delivering treatment?

21. Parents are very important • Reinforce and support the acquisition and maintenance of eating and exercise behaviors • Parent-only treatments are used to deliver treatments for other child behavioral issues • tantrums, self-destructive behaviours, verbal aggression, excessive crying, thumb sucking, school phobia, and oppositional behaviour Johnson, Katz, 1973

22. Additional benefits • Potential for cost savings • Developmental appropriateness for the child • Greater potential generalizability

23. Parent As the Agent of Change (PAAC) • The purpose of this project is to compared a standardized behavioral parent-only program for childhood obesity to a standardized behavioral parent+child program on • Child weight • Child physical activity and eating • Parent weight

24. Participants • Recruited 80 families from community in Minneapolis and San Diego • 8-12 year old child >85% BMI • 1 parent or guardian willing to participate • Not involved in weight loss treatment or taking medications which could affect weight or appetite

25. Demographics

26. Study flow

27. Measures • Parent and child body size: Standardized protocols measure height and weight • Child usual dietary intake • Child usual physical activity

28. Analysis • Mixed-effects repeated measures analysis of variance models • Non-inferiority testing was used to test the hypothesis that the parent-only intervention is not inferior to the parent and child intervention

29. Child Weight Change Over Time by Group in BMI-P

30. Child Weight Change Over Time by Group in BMI-Z

31. Results • Parent-only was not inferior to parent+child on child body weight change, parent body weight change and child physical activity changes during the study • We were unable show non-inferiority for child dietary intake

32. Conclusions • Parent-only group was not inferior to the parent + child group on most important outcomes • Could be equivalent in terms of treatment, and more cost-effective and easier to disseminate

33. Options for improving childhood obesity treatment Improve dissemination Improve procedures for implementing behavior therapy Improve treatment methods

34. “Food stimulated” child • Identified in clinic • Very sensitive to food cues • Came home every day and asked for something to eat • Planned for next meal as she was eating the first • Did not seem anxious or obsessive in other ways • Mom was at her “wits” end as child continued to gain weight

35. Externality theory of obesity • Schachter, 1960s • Obese humans and rats are • More sensitive to external cues to eat • Less sensitive to internal cues and satiety Thus, obesity could be caused or sustained by susceptibility to (over)eating in an environment that contains a plethora of accessible foods

36. Do obese people differentially respond to food? • Adult binge eaters (obese and normal weight) differentially respond to food cues in fMRI • In adolescents, obese girls showed • greater activation bilaterally in the gustatory cortex and in somatosensory regions • And decreased activation in the caudate nucleus ….in response to chocolate milkshake (vs. a tasteless solution) Geitlieber, 2007, Stice, 2008

37. Obesiogenic environment • Encourages excess energy intake • (e.g., increased portion size; increased availability of cheap, energy-dense foods and snacks) • Discourages energy expenditure • (e.g., increased television viewing; computer and internet use; sedentary lifestyles)

38. Classical conditioning • Remember Pavlov’s Dog? • Cues such as sight, smell, taste of food, rituals for eating, environment where eating occurs elicits physiological response to eat (cravings)

39. Classical conditioning • Food intake-Unconditioned stimulus • Physiological responses-Unconditioned responses • Food cues-Conditioned stimuli • Cue reactivity-Conditioned responses • Learned cue reactivity increases the probability of eating

40. Two factor model of conditioning related to overeating

41. What can we do to help people who respond to food in this manner? • Two options based on Schachter’s theory • Increase focus on internal cues (hunger) • Decrease focus on external cues (food cues to overeat)

42. Increasing responsiveness to internal cues • Appetite Awareness Training • Evaluated in a few small studies • Focus is not on forbidding food, but eating less of it • Monitor and learn about hunger and internal cues to stop eating Craighead, 2007

43. Decreasing focus on external cues • Cue exposure treatment • Focuses on repeated non-reinforced exposures to a stimulus to extinguish the individual’s conditioned response, such as a craving, to the stimulus or cue

44. Cue exposure treatment • Shown to decrease cue reactivity in alcohol, drug, smoking and purging • Decrease sensitivity to external cues by extinguishing relationship between CS and US in presence of cues Drummond, 1994, O’Brien, 1990, Niaura, 1999, Rosen, 1982

45. How to measure food cue responsivity in children? • Eating in the absence of hunger (EAH) is defined as behavioral measure of eating in the presence of palatable foods when physiologically satiated • EAH is stable over time, and linked to higher BMI over time • Represents disinhibited eating in adults

46. EAH measurement • Child eats dinner at the clinic (pizza, carrots, juice, cookies) • Requested to eat to satiety (scale of 1-5) • 10 minute break • Rate one bite of 11 snack foods on liking scale • Asked to wait in the EAH room for the research assistant for 10 minutes with 11 snack foods and toys, games and books • Percent of age and gender adjusted daily caloric intake consumed in EAH assessment

47. Regulation of Cues (ROC) study • Compare 2 multi-component interventions focused on cues for overweight 8-12 year old children who eat in the absence of hunger; Volcravo and Children’s Appetite Awareness Training (CAAT) • Integrate results and compare the newly developed treatment to a waitlist control

48. Volcravo • Focus is regulate eating by responding to external cues to overeat (cravings) • Self-monitor cravings • Coping skills are used to address urges to eat when craving specific foods • Participants created hierarchy of 6 craved foods, and brought to clinic for CET

49. C.A.A.T. • Focus is regulate eating by responding to hunger and appetite • Self-monitor hunger signals • Learn about “Hunger Traps”, situations or hunger states that could lead to overeating past satiety. • Coping skills are used to address urges to eat when not hungry • Participants bring 6 dinners and monitor hunger in meetings

50. Coping skills taught in both Volcravo and CAAT • Behavioral Skills (Delay, Activity Substitution, Anti- craving/Anti-hunger superhero) • Cognitive skills (Distraction, Imagery, Self-Motivational Statements) • Body skills (Relaxation, Deep Breathing) • Cost benefit analyses • Assertiveness skills • Planning for high risk situations • Problem solving • Parenting skills (Modeling, motivation systems, praise, reinforcement)