AHA 儿童肥胖治疗声明 2012

Brian Wansink and Judith Wylie-Rosett Carson, Harold A. Franch, John M. Jakicic, Tanja V.E. Kral, Angela Odoms-Young, Myles S. Faith, Linda Van Horn, Lawrence J. Appel, Lora E. Burke, Jo Ann S. Gaps : A Scientific Statement From the American Heart Association Obese Children: Evidence for Parent Behavior Change Strategies and Research Evaluating Parents and Adult Caregivers as ''Agents of Change'' for Treating ISSN: 1524-4539 Copyright © 2012 American Heart Association. All rights reserved. Print ISSN: 0009-7322. Online 72514 Circulation is published by the American Heart Association. 7272 Greenville Avenue, Dallas, TX published online January 23, 2012Circulation http://circ.ahajournals.org/content/early/2012/01/23/CIR.0b013e31824607ee located on the World Wide Web at: The online version of this article, along with updated information and services, is http://www.lww.com/reprints Reprints: Information about reprints can be found online at journalpermissions@lww.com 410-528-8550. E-mail: Fax:Kluwer Health, 351 West Camden Street, Baltimore, MD 21202-2436. Phone: 410-528-4050. Permissions: Permissions & Rights Desk, Lippincott Williams & Wilkins, a division of Wolters http://circ.ahajournals.org//subscriptions/ Subscriptions: Information about subscribing to Circulation is online at by guest on January 23, 2012http://circ.ahajournals.org/Downloaded from AHA Scientific Statement Evaluating Parents and Adult Caregivers as “Agents of Change” for Treating Obese Children: Evidence for Parent Behavior Change Strategies and Research Gaps A Scientific Statement From the American Heart Association Myles S. Faith, PhD, Chair; Linda Van Horn, PhD, RD, FAHA; Lawrence J. Appel, MD, MPH, FAHA; Lora E. Burke, PhD, FAHA; Jo Ann S. Carson, PhD, RD; Harold A. Franch, MD, FAHA; John M. Jakicic, PhD; Tanja V.E. Kral, PhD; Angela Odoms-Young, PhD, MS; Brian Wansink, PhD; Judith Wylie-Rosett, EdD, RD; on behalf of the American Heart Association Nutrition and Obesity Committees of the Council on Nutrition, Physical Activity and Metabolism, Council on Clinical Cardiology, Council on Cardiovascular Disease in the Young, Council on Cardiovascular Nursing, Council on Epidemiology and Prevention, and Council on the Kidney in Cardiovascular Disease Abstract—This scientific statement addresses parents and adult caregivers (PACs) as “agents of change” for obese children, evaluating the strength of evidence that particular parenting strategies can leverage behavior change and reduce positive energy balance in obese youth. The statement has 3 specific aims. The first is to review core behavior change strategies for PACs as used in family-based treatment programs and to provide a resource list. The second is to evaluate the strength of evidence that greater parental “involvement” in treatment is associated with better reductions in child overweight. The third is to identify research gaps and new opportunities for the field. This review yielded limited and inconsistent evidence from randomized controlled clinical trials that greater PAC involvement necessarily is associated with better child outcomes. For example, only 17% of the intervention studies reported differential improvements in child overweight as a function of parental involvement in treatment. On the other hand, greater parental adherence with core behavior change strategies predicted better child weight outcomes after 2 and 5 years in some studies. Thus, the literature lacks conclusive evidence that one particular parenting strategy or approach causally is superior to others in which children have a greater focus in treatment. A number of research gaps were identified, including the assessment of refined parenting phenotypes, cultural tailoring of interventions, examination of family relationships, and incorporation of new technologies. A conceptual model is proposed to stimulate research identifying the determinants of PAC feeding and physical activity parenting practices, the results of which may inform new treatments. The statement addresses the need for innovative research to advance the scope and potency of PAC treatments for childhood obesity. (Circulation. 2012;125:00-00.) Key word word文档格式规范word作业纸小票打印word模板word简历模板免费word简历 s: AHA Scientific Statements � diet � lifestyle � nutrition � obesity � pediatrics � prevention The American Heart Association makes every effort to avoid any actual or potential conflicts of interest that may arise as a result of an outside relationship or a personal, professional, or business interest of a member of the writing panel. Specifically, all members of the writing group are required to complete and submit a Disclosure Questionnaire showing all such relationships that might be perceived as real or potential conflicts of interest. This statement was approved by the American Heart Association Science Advisory and Coordinating Committee on October 10, 2011. A copy of the document is available at http://my.americanheart.org/statements by selecting either the “By Topic” link or the “By Publication Date” link. To purchase additional reprints, call 843-216-2533 or e-mail kelle.ramsay@wolterskluwer.com. The American Heart Association requests that this document be cited as follows: Faith MS, Van Horn L, Appel LJ, Burke LE, Carson JAS, Franch HA, Jakicic JM, Kral TVE, Odoms-Young A, Wansink B, Wylie-Rosett J; on behalf of the American Heart Association Nutrition and Obesity Committees of the Council on Nutrition, Physical Activity and Metabolism, Council on Clinical Cardiology, Council on Cardiovascular Disease in the Young, Council on Cardiovascular Nursing, Council on Epidemiology and Prevention, and Council on the Kidney in Cardiovascular Disease. Evaluating parents and adult caregivers as “agents of change” for treating obese children—evidence for parent behavior change strategies and research gaps: a scientific statement from the American Heart Association. Circulation. 2012;125:●●●–●●●. Expert peer review of AHA Scientific Statements is conducted at the AHA National Center. For more on AHA statements and guidelines development, visit http://my.americanheart.org/statements and select the “Policies and Development” link. Permissions: Multiple copies, modification, alteration, enhancement, and/or distribution of this document are not permitted without the express permission of the American Heart Association. Instructions for obtaining permission are located at http://www.heart.org/HEARTORG/General/ Copyright-Permission-Guidelines_UCM_300404_Article.jsp. A link to the “Copyright Permissions Request Form” appears on the right side of the page. © 2012 American Heart Association, Inc. Circulation is available at http://circ.ahajournals.org DOI: 10.1161/CIR.0b013e31824607ee 1 by guest on January 23, 2012http://circ.ahajournals.org/Downloaded from This statement addresses parents and adult caregivers(PACs) as “agents of change” for treating obese children in the family; that is, to what extent, and in what specific ways, can PACs help obese youth to reduce excess body fat? How can PACs promote sustainable behavior changes to help obese youth restore energy balance? These are critical ques- tions given the global “epidemic” of childhood obesity,1–4 coupled with the fact that most obese youth become obese adults.5 Children are dependent on parents to structure their home environment and daily lifestyles, which includes diet and physical activity; these behaviors, in turn, influence long-term energy balance and weight status. Obesity runs in families, with parental weight status being one of the stron- gest and most robust predictors of a child’s obesity risk.5–7 This familial transmission reflects both genetic and (home) environmental factors,8 and therefore, PACs are in a unique role to leverage behavior change in obese children. There also is a need for healthcare providers to acquire better knowledge of core behavioral change strategies for PACs of obese youth. A national survey of 202 pediatricians, 293 pediatric nurse practitioners, and 444 registered dietitians examined self-perceived skills and competencies for manag- ing pediatric obesity.9 A sizable proportion of respondents perceived themselves as having “low proficiency” in behav- ioral management strategies (39% of pediatricians), parenting management techniques (31% of registered dietitians and 25% of pediatricians), and assessment of family conduct (46% of registered dietitians and 30% of pediatricians). Another report of 87 primary care pediatricians and nurse practitioners found that only 26% knew the definition of childhood obesity and 9% knew its prevalence, whereas only 39% and 44% knew the American Academy of Pediatrics’ guidelines for exercise and juice consumption, respectively.10 More than 35% of the respondents never discussed fast food, television, or candy and 55% never discussed exercise at well child visits in the first year of life. The management of obesity in primary care settings is an emerging area of healthcare research,11–13 and greater information dissemina- tion on core behavior change strategies by health profession- als is needed. Indeed, the importance of this need is under- scored by a recent report of the US Preventive Services Task Force (http://www.uspreventiveservicestaskforce.org/).14 The report recommended that primary care clinicians screen children �6 years of age for obesity and offer or refer for intensive counseling and behavioral interventions those who are obese. The present statement has 3 aims. The first is to review “core” behavior change strategies that have been shown to promote short-term weight loss and, to some extent, longer- term maintenance in obese youth. These strategies have been used extensively in so-called family-based behavioral modi- fication treatment programs that enlist PAC involvement.15 This section reviews pragmatic questions such as, “How can I begin to make changes today with my child or pediatric patient?” and “What concrete steps can I take?” In this statement, we focus on specific strategies for PACs rather than macroenvironmental or policy changes (eg, soft drink taxes), which were addressed in a prior statement.16 The second aim is to review the evidence that greater PAC “involvement” in pediatric obesity treatment leads to better outcomes. Two strategies are undertaken to answer this question. First, 12 randomized clinical trials are reviewed that varied the degree or nature of parental involvement in family-based treatment and examined effects on changes in child overweight status. These studies varied parental in- volvement by virtue of either having PACs be treated together with (versus separately from) their child or having the PAC (versus the youth) be the primary target of interven- tion. Second, we examine whether greater PAC adherence to behavioral strategies is associated with greater improvements in child overweight in family-based treatment studies. Prior reviews have examined whether greater parental involvement in treatment yields better improvements in child weight status. Conclusions have been mixed, with some reviews17–19 but not others20,21 finding that greater involvement leads to better child weight outcomes. These differences could reflect a number of factors, including qualitative versus quantitative data synthesis, different inclusion/exclusion criteria, and the specific studies that were retrieved. The present statement strives to reconcile these differences while identifying critical areas for future research. The final aim of this statement is to identify critical research gaps in this field. Greater research in these domains should advance insights into the ways in which PACs can be more effective agents of change for modifying behaviors in their obese children. What Are Core Behavior Change Strategies for Obese Youth? Core behavior change strategies to treat childhood obesity include specification of target behaviors, self-monitoring, goal setting, stimulus control, positive parenting strategies, and promotion of self-efficacy and self-management skills.22,23 These core strategies, which are taught in the context of basic information on energy balance and daily calorie intake recommendations for youth,24,25 are grounded in strong theoretical models. These models include social cognitive,26,27 operant conditioning,28 behavioral eco- nomic,29,30 and self-determination31 theories. These theories can be linked to specific behavior change strategies, as illustrated in Table 1. Against this background, the “nuts and bolts” of behavior change can be implemented within fami- lies. A basic framework of these strategies is illustrated in Figure 1 and summarized in this section. Empirical support for the particular core behavior change strategies comes from prior reviews of family-based treat- ments for childhood obesity. These strategies provided the foundation for most of these interventions. Quantitative reviews have supported the efficacy of family-based treat- ments compared with no-treatment controls,19,20,32,33 as well as in comparison to education-only controls.32 The 10-year follow-up studies by Epstein et al34 further support the long-term efficacy of family-based behavioral weight control. A comprehensive literature review by the US Preventive The terms “overweight” and “obesity” are used interchangeably throughout this document, particularly when referring to past studies, given changing terminologies in the literature to describe youth with a body mass index (in kg/m2) �85th and �95th percentiles, respectively. 2 Circulation March 6, 2012 by guest on January 23, 2012http://circ.ahajournals.org/Downloaded from Services Task Force assigned an evidence category of grade B in support of screening for pediatric obesity, recommend- ing that clinicians screen children�6 years of age for obesity and offer them or refer them to intensive counseling or behavioral interventions.14 Moreover, these strategies were incorporated for the family-based lifestyle intervention in the Treatment Options for type 2 Diabetes in Adolescents and Youth (TODAY) study, a 15-center clinical trial that com- pared treatments for 10- to 17-year-olds with type 2 diabetes mellitus.35 The TODAY Lifestyle Program used the core behavior change strategies to help youth attempt a weight loss of 7% to 10% of initial body weight, as well as ongoing lifestyle maintenance and contact for up to 28 months. Hence, these strategies can be effective. At the same time, the potency of existing treatments using these strategies needs to be improved, and they need to be made more generalizable to a broader range of families.15 Specifying Target Behaviors Identification of specific behaviors to be changed by obese youth, as well as the PAC, is an initial step for behavior change. Rather than prescribing gross or nonspecific changes Table 1. Theoretical Models Underlying Core Behavior Change Strategies for Pediatric Obesity Treatment and Hypothetical Implications for Parent and Adult Caregivers Behavioral Theory Hypothetical Implications for PACS Social cognitive theory This theory focuses on the interaction of behavior with environmental and personal factors. Strategies for changing behavior emphasize knowledge, motivation, outcome expectancy (eg, what does the parent expect to happen?), and self-efficacy (ie, confidence that change or goal attainment is achievable). See Bandura.26,27 ● Asking PACs to describe what they expect to happen in treatment and to rate confidence in achieving specific behavioral goals can provide valuable insights for treating pediatric obesity. Operant conditioning This theory focuses on modifying behavior though positive or negative reinforcement strategies, based largely on Skinner’s applied research with humans. The likelihood that a specific behavior will occur (or increase/decrease) depends on an individual’s reinforcement history (or changes in reinforcement schedules) when the behavior is exhibited. See Skinner.28 ● Some PACs inadvertently may contribute to excessive weight gain by using energy-dense foods as a reward (eg, rewarding children with cakes or candies for school accomplishments). Teaching PACs to provide hugs, verbal praise, and other nonfood reinforcements is often part of family-based treatment for childhood obesity. Behavioral economics This theory integrates behavioral and social principles in the examination of how people make choices, including decisions about food and physical activity. Behavioral economics provides a framework for assessing health choices that seemingly violate “rational” economic decision making. Factors that are considered in this model include convenience, cost, and perceived value with regard to food and other commodities. The theory considers variables such as time and money, taste (hedonic appeal), context (distraction, social and emotional variables), and cognition and perception. See Epstein.29,30 ● Understanding behavioral economics principles may help PACs in controlling impulse food shopping habits (eg, making unintended purchases of candy that is displayed at the cash register). ● Although “super-sized” value meals pose a challenge to the calorie budget, these options may be perceived as a bargain for families with limited resources. ● Teaching PACs to structure increased choices by children may promote more nutritious food selections and greater physical activity. For example, allowing a child to choose from 2 preferred vegetable options (rather than a vegetable or candy) may increase the probability of habitual vegetable intake. Self-determination This theory provides a broad framework for understanding human motivation and defining intrinsic and extrinsic sources of motivation. This can be examined in relation to cognitive and social development and individual differences. Conditions that support the experience of autonomy, competence, and relatedness are thought to foster motivation. Developing skills to regulate behavior intrinsically (also called self-regulation) fosters autonomy. See Deci and Ryan.31 ● PAC support of the use of age-appropriate behavioral strategies by children (eg, goals that are self-selected by youths) can foster child motivation through increased autonomy and competency. ● Obese children may experience bias and discrimination from peers. Weight management group programs can help obese children experience relatedness to peers, which can help support behavior change. PACs indicates parents and adult caregivers. Figure 1. Core strategies for changing behavior in family-based interventions for pediatric obesity that include parent and adult caregivers. Faith et al Parents and Adult Caregivers as Agents of Change 3 by guest on January 23, 2012http://circ.ahajournals.org/Downloaded from (eg, “Eating healthier” or “Be more active”), identification of specific behaviors is essential. A number of health behaviors have been targeted in family-based intervention studies of pediatric obesity, such as daily intake of particular foods (eg, fruits and vegetables versus energy-dense “red light” foods36,37), time spent in different types of physical activity (eg, lifestyle versus aerobics versus calisthenics34), and sed- entary time.38,39 Recent work has also shown that modifica- tion of home food environments, such as the visibility and convenience of access to certain foods, has been effective in reducing overeating in laboratory studies40,41 and has been correlated with weight loss in short-term field studies.42 Daily caloric intake also is commonly monitored in treatment,43,44 in the broader context of discussions on energy balance and daily energy requirements.16,24,25 Selection of target behaviors can be decided by the PAC or the obese youth, ideally in collaboration. Self-Monitoring Once target behaviors have been identified, self-monitoring of those behaviors is conducted for a speci