The United States has witnessed a dramatic surge in obesity among both children and adults. Existing clinical childhood obesity treatment programs are expensive and time-consuming to implement, able to serve only limited numbers of children, not available in all communities, often inconvenient for children and families to attend, and generally produce modest outcomes. As the prevalence of childhood overweight and obesity has grown, innovative feasible, accessible, acceptable, affordable, and effective weight control programs are greatly needed. This article explores the multifaceted approach to weight loss, drawing insights from studies and interventions aimed at combating obesity and its related health issues. It examines the impact of diet, exercise, and comprehensive lifestyle changes on weight management, blood pressure reduction, and overall well-being.
The Childhood Obesity Crisis and the Need for Innovative Solutions
The increasing rates of childhood obesity present a significant public health challenge. Existing treatment programs often fall short due to various limitations, including high costs, limited accessibility, and modest results. To address these shortcomings, innovative and comprehensive weight control programs are essential.
Stanford GOALS was proposed to develop and evaluate a new community-focused model for treating overweight and obese children. To overcome the shortcomings of existing approaches, Stanford GOALS links care provided in traditional medical settings to community resources, to deliver the bulk of treatment in settings where children and families live and play. The intervention simultaneously targets multiple influences on eating, physical activity and sedentary behaviors at multiple levels and in multiple settings. Stanford GOALS is part of the Childhood Obesity Prevention and Treatment Research consortium (COPTR), sponsored by the National Heart, Lung, and Blood Institute (NHLBI)- and the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), to develop and test novel approaches to address childhood obesity. Phase 1 was an 18-month development and pilot study phase, completed in 2012. Phase 2 involves full-scale clinical trials at four field centers, Stanford University, Case Western Reserve University, University of Minnesota and Vanderbilt University, a research coordinating unit (RCU) at the University of North Carolina, Chapel Hill, and the project offices of the NHLBI and NICHD. Each field center is testing its own distinct interventions with its own unique, high-risk population and eligibility criteria, but informed by the collaborative planning, experience and results from all centers in Phase 1 and sharing a core set of common measures and protocols.
Stanford GOALS: A Multi-pronged Intervention
Stanford GOALS is a two-arm, parallel group, randomized controlled trial to test the efficacy of a multi-component, multi-level, multi-setting (MMM) approach to treating overweight and obese children. The MMM intervention includes three major components: a community-based after school team sports program designed specifically for overweight & obese children, a home-based family intervention to alter the home food/eating environment, reduce screen time, and promote self-regulatory skills for eating and activity behavior change, and a primary care provider behavioral counseling intervention linked to the community and home interventions. Participants are randomized to either the MMM intervention or a community-based health education intervention for three years. Participants are assessed at baseline and annually. The primary outcome measure is change in BMI during the 36-month study.
Two hundred and forty 7-11 year old overweight and obese participants are recruited through primary care providers and clinics, schools, community centers, churches, and other community locations in low-income, primarily Latino neighborhoods in East Palo Alto, Menlo Park and Redwood City, California, USA, near Stanford University. In our Pilot study of 40 families in just two neighborhoods, our sample was 94% Latino/Hispanic (mostly Mexican-American), 4% Black/African-American and 2% multi-racial. Prospective participants volunteer to be contacted by the research team. Participants who are potentially eligible by phone screening are scheduled for a visit to be formally assessed for eligibility. Signed consent/assent and HIPAA authorization are required from parents/guardians and children prior to participation. All study procedures have been approved by the Stanford University Administrative Panel on Human Subjects in Medical Research (Internal Review Board, IRB). Children must be 7, 8, 9, 10 or 11 years of age on the date of randomization with a BMI ≥ 85th percentile for age and sex on the 2000 CDC BMI reference at the time of baseline measurement. Children are randomized to treatment or control conditions after completing all baseline measures. All eligible children within a household are assessed for inclusion in the study. For households that contribute multiple eligible children, one child is randomly selected for randomization and inclusion in the analysis. Only the statistician is aware of which child in a multi-child household is in the analysis sample. Efron’s biased coin randomization[6] is used to promote a balanced randomization within strata defined by BMI percentile at baseline (≥ 85th and < 95th percentile, ≥ 95th percentile). It is anticipated to be challenging to retain families for the full three years of the study. The interventions are delivered over the entire three years of participation for each family. Interventions are based on Bandura's social cognitive model. In social cognitive theory, behavior develops and is altered and maintained through triadic reciprocality, the interplay of personal (cognitive), behavioral and environmental factors.
Read also: Overview of Dr. Black's Plan
With respect to this intervention, personal factors include child and parent/guardian value systems which determine the nature of incentives that influence eating and activity patterns, expectations derived from observations and experiences about the consequences of different behaviors (outcome expectancies) and expectations about personal abilities to perform behaviors which will secure desired outcomes (efficacy expectancies). Behavioral factors include the skills available in the behavioral repertoire of the child or parent/guardian, and the degree of competence attained in using these skills. Environmental factors include peers, family members, teachers, coaches and even media figures who model attitudes and behaviors regarding eating, physical activity, parenting behaviors, etc., and are in a position, through their own actions, judgments or social positions, to influence the development of the participant's value system and standards of conduct regarding those attitudes and behaviors. Environmental factors include physical or structural influences such as televisions in kitchens and bedrooms, safe playgrounds and the availability of after-school and weekend activities, as well as the environmental influences on eating that we are manipulating in this trial: glass, plate, bowl and serving utensil sizes, availability, visibility and convenience of food and beverages, and screen viewing while eating. We have chosen to highlight culture in our intervention design, specifically making Latino cultural values a central element of the intervention. There is growing consensus that prevention interventions should become more culturally appropriate by taking into consideration ethnic group differences in social, psychological, environmental, and cultural aspects of health. The young children in our study are exposed to mainstream values and content in the popular media and, to a lesser extent in school, but these exposures are interpreted within the context of their own family, community and culture. To adequately incorporate the complexity of culture into our interventions, we address both changes in surface structure (culturally matched models, music, language) and deep structure (values, social and historical influences). We address surface structure through culturally-matched providers (e.g., bilingual, Latino measurement and intervention staff), emphasis on Latino/Mexican-American foods, popular sports among Mexican-Americans, and holiday celebrations. Within the social cognitive theory framework, we are also drawing from recent research in cognitive and social psychology to frame intervention components to promote greater magnitude and more sustained effects. We are incorporating strategies that have produced durable effects on educational performance among disadvantaged/minority children. We are applying these methods because of apparent similarities in both social- and self-stereotypes of failure and alienation experienced by disadvantaged minority students in educational settings and overweight and obese children relative to their experiences with weight control.
The Power of Combined Diet and Exercise
Studies comparing the effectiveness of diet alone, exercise alone, and a combination of both have shown that the combination yields the most significant results. A study published in Contemp Clin Trials investigated the impact of a mild calorie-restricted diet (D), exercise (EX), and a combination of both (D+EX) on weight loss-induced blood pressure (BP) reduction over 24 weeks.
The study divided 90 obese, hypertensive men into three groups: diet alone, exercise alone, and a combination of diet and exercise. The results demonstrated that the combination group (D+EX) had a significantly higher prevalence of normotensive subjects compared to the diet alone or exercise alone groups. Moreover, the magnitudes of reductions in BMI, fat mass, waist-to-hip ratio, BP levels, and insulin resistance were greatest in the D+EX group.
The Interplay of Diet and Exercise on Neurohormonal Mechanisms
The study also revealed distinct patterns of changes in plasma norepinephrine (NE) and insulin resistance (HOMA-IR) between the diet alone and exercise alone groups. In the diet alone group, plasma NE levels decreased significantly at 2 weeks, followed by reductions in BMI, fat mass, and BP at 8 weeks. In contrast, the exercise alone group showed significant reductions in fat mass and HOMA-IR at 4 weeks, with plasma NE reduction at 8 weeks and BP reduction at 12 weeks.
These findings suggest that a calorie-restricted diet may lead to a normalization of sympathetic overactivity, contributing to BP reduction and improved insulin resistance. On the other hand, exercise may initially reduce fat mass and improve insulin resistance, followed by a reduction in plasma NE and subsequent BP reduction.
Read also: Weight Loss Journey
Community-Based After School Team Sports Program
One component of the MMM treatment model is a community-based after school team sports program designed specifically for overweight and obese children. Organized after school team sports can provide opportunities for regular and sustained moderate-to-vigorous physical activity and may also address neighborhood safety concerns that could keep children indoors with increased screen time and snacking. This program offers safe, supervised physical activity on a regular basis. The team sports intervention for overweight and obese children is based on our prior research demonstrating significant effects on objectively measured physical activity and BMI. After school team sports programs are offered at several community center sites in the targeted communities. The team sports program is conceptualized as an environmental intervention, available throughout the entire length of the study. Based on past study experiences, including the Phase 1 pilot study, team sports are offered five days per week year around, excluding most school holidays. Children are able to participate in as many or few of the days as they wish and may attend any one or more after school sites. The curriculum was designed in collaboration with community partners and youth sports groups to be appropriate for both boys and girls playing together. Team sports activity sessions approximate about 1-1.5 hours but, by partnering with the existing after school programs, most children attend for about 2-3 hours, including homework and tutoring periods. Based on the results of formative and pilot studies, sports are offered seasonally throughout the year. Sports are selected to allow involvement of children with limited prior sports experience and to be able to teach to children with varying skill and experience levels. An emphasis is placed on time spent in movement and game-play to promote higher intensity physical activity, and smaller groups favoring more participation and one-on-one attention. Trained lead coaches at each site are supported by trained undergraduate interns at practices. We put particular emphasis on motivational processes and ability for growth in skills. Each module includes multiple levels that each must be mastered before moving forward.
Home-Based Family Intervention: Modifying the Environment
Modules are delivered to families in participants’ homes by trained, bilingual (Spanish and English) research assistants. Evidence is mounting that small changes in the environment may alter food choices and reduce consumption of food, without conscious cognitive awareness or control. People overestimate the portion size when the food covers more of the area of the plate/bowl/spoon and they underestimate the portion size when the food covers a smaller proportional area. These results suggest that people serve themselves and consume less drinks and food, without being aware of it, when drinking from taller and thinner glasses and when eating from smaller plates, bowls and serving utensils. During home visits the home interventionist helps families select smaller glasses and dinnerware from our samples and catalog. Pilot study data were used to select replacement dishware to produce ≥ 25% reduction in volume and/or surface area compared to families’ existing dishware. Old glasses and dishware are packed into boxes for storage.
Family-Based Behavioral Counseling Intervention
The family-based behavioral counseling intervention consists of three modules: reducing energy intake, increasing physical activity, and reducing screen time. They can be delivered in any order, depending on the order preferences of the family. The content has been adapted from the Stanford Pediatric Weight Control Program (SPWCP) family-based, group, behavioral program, for use with individual families, and prior screen time reduction interventions. The SPWCP was originally adapted from the approaches used by Epstein et al, demonstrating long-term beneficial outcomes. The diet module includes: categorizing foods and self-monitoring intake using traffic light colors (red, yellow, green) defined by energy density; setting goals to reduce red light foods; reciprocal contracting with parents/guardians, and instruction for parents about the appropriate use of praise, constructive criticism and rewards to build intrinsic motivation and methods to foster a growth mindset. Weight is also monitored and followed throughout these modules, with a goal of slowing weight gain, maintaining or slowly decreasing weight relative to height. The screen time reduction module focuses on environmental and behavioral strategies to build skills and self-efficacy for two main screen time reduction strategies, reducing eating while watching screens and reducing total screen time. Reducing screen time is one of the best-documented strategies to reduce weight gain in children. A particular emphasis of the intervention is on eliminating eating while watching television and other screen media. Children consume, on average, 17%-27% of their total daily weekday calories and 26%-32% of their total daily weekend calories while watching television. In our prior trials of reducing screen time, the intervention group significantly reduced the meals eaten while watching TV and/or reduced energy intake. These findings add to a growing body of research implicating effects of television viewing on eating behavior. The problem solving and maintenance intervention module is delivered as the last module during the three-year intervention.
The Role of Healthcare Providers
Pediatricians and other child health professionals rate childhood obesity as a top priority for treatment but identify lack of time, reimbursement, children’s and parents’ motivation, and support services, and limited effectiveness, confidence and self-efficacy in their own skills, as barriers to addressing the problem. Ultimately, providers are left frustrated with few effective tools or resources to help them.
Practical Tips for Weight Management
While clinical interventions and research studies provide valuable insights, individuals can also adopt practical strategies for weight management in their daily lives.
Read also: Transformation and inspiration: Weight loss stories
- Embrace a Balanced Diet: Focus on consuming whole, unprocessed foods, including plenty of fruits, vegetables, lean proteins, and whole grains. Limit intake of sugary drinks, processed snacks, and unhealthy fats.
- Engage in Regular Physical Activity: Aim for at least 150 minutes of moderate-intensity or 75 minutes of vigorous-intensity aerobic exercise per week. Incorporate strength training exercises to build muscle mass and boost metabolism.
- Mindful Eating: Pay attention to hunger and fullness cues, and avoid eating while distracted by screens or other activities.
- Portion Control: Be mindful of portion sizes and use smaller plates and utensils to help regulate food intake.
- Hydration: Drink plenty of water throughout the day to stay hydrated and help control appetite.
- Limit Screen Time: Reduce sedentary behavior by limiting screen time and engaging in more active pursuits.
- Seek Support: Enlist the support of family, friends, or a healthcare professional to stay motivated and accountable on your weight loss journey.
Adapting to Seasonal Changes
During wintertime, it’s essential to adapt our routines to ensure our pets remain healthy and active despite the frequently frigid weather. Regular exercise is key to maintaining your pet’s health, both physically and mentally. Plain-old walking: Bundle up and take your dog for a brisk walk if the temperature will allow. Start out quickly, and only allow pausing and sniffing on the return route. As the ground thaws and spring progresses, you can gradually reintroduce more activities to your pet’s routine. Consult with your veterinarian for advice on appropriate diet modifications and exercise regimens to keep your pet healthy and active throughout the year. Our Small Animal Nutrition team can also work with you to create an individualized diet plan tailored to your pet’s specific needs, promoting optimal health and weight management.