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Denise E. Wilfley, Anna Vannucci, Juliette Iacovino

Continuing Education Information

The Public Health Problem of Childhood Obesity

Over the past few decades, pediatric obesity has emerged as a significant public health threat. Recent prevalence estimates indicate that over one-third of children in the United States are overweight (body mass index; kg/m2; BMI > 85th percentile) or obese (BMI > 95th percentile) (Ogden, Carroll, Curtin, Lamb, & Flegal, 2010). Further, rates of extreme pediatric obesity (> 99th BMI percentile) are increasing disproportionately faster than overweight or moderate levels of obesity (Freedman, Kettel Khan, Serdula, Ogden, & Dietz, 2006; Koebnick et al., 2010). Not only are there more obese children now than in the past, but the severity of overweight among these children is also much greater.

Pediatric obesity is associated with increased medical and psychosocial problems. At the highest levels of obesity, life expectancy may be reduced as much as 9 years (Wardle, 2005). Medical conditions associated with obesity include type II diabetes, high blood pressure, heart problems, metabolic syndrome, sleep apnea, and orthopedic complications (M. Tanofsky-Kraff et al., 2003). Deleterious psychological and social effects related to overweight and obese status include depression, anxiety, disordered eating, poor body image, discrimination and social exclusion, low self-esteem, and a reduced overall quality of life (Hayden-Wade et al., 2005a; Wardle & Cooke, 2005).

Despite the popular idea that children will simply outgrow their overweight status, the reality is that childhood obesity does not resolve spontaneously with age. That is, overweight children are much more likely to continue to gain weight and be overweight as adolescents and adults compared to normal weight children (Nader et al., 2006). Further, this risk increases progressively with child age and increased BMI (Nader, et al., 2006). The tendency for children to track obesity into adolescence and adulthood, along with the dramatic rise in pediatric obesity, has created a mounting need for health care providers to play a significant role in the assessment and treatment of pediatric obesity and related issues (D. E. Wilfley, A. Vannucci, & E. K. White, 2010).

The Role of Mental Health Providers

Mental health providers have the potential to play a crucial role in the early identification of and intervention with eating- and weight-related problems in youth. Overweight and obese children have higher rates of health care utilization (Hampl, Carroll, Simon, & Sharma, 2007), meaning that they tend to seek treatment more often than their non-overweight peers. This increases the likelihood that mental health care providers will see youth with eating- and weight-related problems, especially those who already have greater physical and psychological problems. Therefore, they are uniquely suited to assess for a broad range of physical and mental problems and to recommend appropriate treatment and referrals.

Unfortunately, the identification of eating and weight problems is complicated by the fact that most individuals are more likely to seek treatment for psychological and medical complications associated with obesity, rather than for an eating or weight problem. Further, studies have shown that a large proportion of parents of overweight children do not recognize that their child is in fact overweight (Huang et al., 2007). This underscores the importance of conducting a comprehensive assessment of potential eating- and weight-related problems in youth presenting with a wide variety of symptoms. Many mental health providers are concerned that overweight individuals feel uncomfortable discussing their weight, but research actually shows that people want their providers to discuss these issues (Cohen, Tanofsky-Kraff, Young-Hyman, & Yanovski, 2005). Although effective intervention strategies have been identified for a wide variety of eating and weight problems, the translation of these practices to routine use by providers in real-word settings has been extremely limited. Therefore, it is crucial for mental health providers to be aware of the causes and consequences of pediatric obesity and to be familiar with evidence-based assessment and intervention strategies.

Factors that Contribute to the Development of Childhood Obesity

Obesity develops when energy intake (the amount of calories taken in through dietary consumption) regularly exceeds energy expenditure (the amount of calories burned through activity). Overall, it is likely that weight status is determined by a complex interaction between environmental and individual factors (Carnell & Wardle, 2008a). For example, individuals with a genetic susceptibility for a high motivation to eat may seek out environments with easy access to unhealthy foods, increasing the risk of excess weight gain. Even minor changes in overall energy intake as compared with energy expenditure can have a lasting and cumulative effect on weight status and adiposity; an excess of only 150 calories per day (equivalent to one can of soda) could cause a child to gain up to 12 pounds of fat tissue in one year (Rosenbaum, Leibel, & Hirsch,
1997).

Biological factors alone are unable to account for the startling increases in rates of obesity in recent decades, as genes are unable to mutate quickly enough to produce such changes. This notion highlights the incredible influence of the modern, obesity-promoting environment on eating and weight problems (Sallis & Glanz, 2006). Individual changes in dietary patterns and environmental changes in access to and pricing of food have shifted drastically in recent decades, making the consumption of high fat, high calorie foods the default for many individuals (Jahns, Siega-Riz, & Popkin, 2001; Lin & Frazao, 1999; Wang, Bleich, & Gortmaker, 2008; Wardle, 2005) . Americans also eat more meals away from home, larger portion sizes, and more unhealthy snacks. Additionally, reduced access to physical activity and the convenience of sedentary behaviors have contributed to increases in obesity-promoting behaviors (Dietz & Gortmaker, 2001; Epstein, Roemmich, Paluch, & Raynor, 2005; Sallis & Glanz, 2006; Taveras et al., 2006) . Children now increasingly choose to watch television, to use the computer, or to play videogames over more active pursuits. Aspects of the surrounding environment, such as a access to parks, neighborhood safety, and the frequency of recess and physical education at schools, also impact children’s ability to engage in physical activity.

Although the pervasive obesity-promoting environment has contributed to striking increases in rates of obesity in youth and adults, weight within populations and among individuals remains highly variable (Hedley et al., 2004). There is strong evidence for the influence of genetic factors on weight differences between individuals (Wardle, Carnell, Haworth, & Plomin, 2008). While genes have been shown to influence metabolic and physiological aspects of obesity directly (Carnell & Wardle, 2008a), there is an increasing recognition that certain behaviors related to eating are also genetically influenced and contribute to individual differences (Carnell & Wardle, 2007; D.E. Wilfley, A. Vannucci, & E.K. White, 2010). These behavioral subtypes are called appetitive traits, which are defined as stable underlying characteristics that contribute to observable dysregulated eating behaviors that promote a positive energy balance and thereby overweight in youth.

Assessment and Treatment of Key Appetitive Traits

Research has identified key appetitive traits that may represent distinct behavioral subtypes of individuals either at risk for obesity or among the obese population (D. E. Wilfley, A. Vannucci, et al., 2010). Although several appetitive traits have been identified, there are four key appetitive traits for which there is more consistent evidence: binge and loss of control eating, satiety responsiveness, motivation to eat, and impulsivity. Research has shown that each is heritable, is associated with overweight in youth, and is related to either the types of foods consumed (e.g., high-fat, high-calorie foods) or to increases in energy consumption (D. E. Wilfley, A. Vannucci, et al., 2010). If these appetitive traits can be identified at an early age, then it is possible that targeted prevention efforts designed to modify appetitive traits can reduce their impact on weight before they become more resistant to change.

Mental health providers, in particular, have the potential to play an important role in the early identification and intervention of appetitive traits in youth at risk for obesity. Physicians may not always have the time to assess for appetitive traits and may not possess adequate training in effective behavior change strategies. Therefore, mental health providers are advised to assess for appetitive traits frequently and to adapt treatment approaches as needed, in addition to screening for weight status and common psychological comorbidities. Recommended assessment and general intervention strategies will be reviewed, which are also described more fully elsewhere (D. E. Wilfley, A. Vannucci, et al., 2010). It is also notable that there may be considerable overlap among appetitive traits (D. E. Wilfley, A. Vannucci, et al., 2010), and therefore the treatment approaches should be adapted to fit the specific behavioral profile with which youth present. Table 1 presents the basic definition for each appetitive trait, along with the estimated prevalence rates and typical age of emergence.

Binge Eating and Loss of Control Eating

Binge eating is defined as the consumption of an unambiguously large amount of food while experiencing a loss of control over what or how much one is eating (APA, 2000). Loss of control (LOC) eating refers to episodes in which the amount of food consumed is not unambiguously large, but loss of control is still present (M. Tanofsky-Kraff, Faden, Yanovski, Wilfley, & Yanovski, 2005).

Assessment of binge eating and LOC eating in youth can be challenging because it relies on a subjective experience (i.e., sense of LOC) and the ability of children to remember the type of food and amounted consumed. The concept of LOC can be difficult for children and adolescents to understand, but they typically understand the analogy “like a car without brakes or a ball rolling down a hill, going faster and faster” (Goldschmidt et al., 2008). It is also useful to ask youth whether they have ever felt like they ate a really big amount of food and also felt like they just could not stop eating (even if only for a part of the time they were eating). Determining whether an episode is unambiguously large can also be difficult, so it is important for providers to obtain detailed descriptions of the youth’s typical episodes in order to establish their clinical significance. Several interview-based and self-report assessment methods, namely the Eating Disorder Examination, have been well validated in older children and adolescents(Bryant-Waugh, Cooper, Taylor, & Lask, 1996; Goldschmidt, et al., 2008) . However, research is needed to test the utility of these approaches in children younger than 10 years.

See Table 1.

There is limited research on binge and LOC interventions among youth. However, both cognitive behavior therapy (CBT) and interpersonal psychotherapy (IPT) are promising approaches. Both CBT and IPT are considered “gold standard” approaches for the treatment of Binge Eating Disorder in adults (D. Wilfley, Welch, & Stein, 2003; Wilson, Wilfley, Agras, & Bryson, 2010) , and preliminary data suggests that both modalities may be effective for adolescents (Jones et al., 2008; Stewart & Chambless, 2009; Marian Tanofsky-Kraff et al., 2010) . The primary treatment targets for CBT include establishing regular, healthy eating patterns using self-monitoring, self-control strategies, and problem-solving, as well as using relapse prevention strategies to promote maintenance of behavior changes. The main goals of IPT include drawing connections between interpersonal triggers, negative affect, and LOC eating, so that these patterns can be modified through the use of social skills training.

Satiety Responsiveness

Satiety responsiveness refers to an individual’s ability to perceive internal hunger and fullness signals. Observable eating behaviors thought to signal problems with satiety responsiveness include eating in the absence of hunger (EAH, intake of palatable foods following the consumptions of a meal until satiety) and impaired compensation (lack of ability to reduce amount eaten at a meal after consuming a snack right beforehand).

Satiety responsiveness, EAH, and compensation are measured through several objective (Fisher & Birch, 2002; Jansen et al., 2003) and self-report methods (M. Tanofsky-Kraff et al., 2008; Wardle, Guthrie, Sanderson, & Rapoport, 2001). Although laboratory methods are the most accurate measures, they require many resources and are not suitable for clinical practice. Rather, it is recommended that mental health providers ask parents or children (depending on age) whether they get full easily, how often they leave food on their plate after eating a meal, or how frequently they can eat a full meal if they have a snack right beforehand. The satiety responsiveness subscale of the Child Eating Behavior Questionnaire (full copy at: http://www.ucl.ac.uk/hbrc/diet/) has been validated in children between 3 and 11 years old (Wardle, et al., 2001), while the EAH Questionnaire may be suitable for older children and adolescents (M. Tanofsky-Kraff, et al., 2008).

Several intervention strategies have been suggested to promote improvement in youth’s satiety responsiveness (Carnell & Wardle, 2008b; D. E. Wilfley, A. Vannucci, et al., 2010) . Although it may be possible to use pharmaceutical methods to regulate children’s appetites, behavioral interventions are much more likely to be sustainable in the long-term. One study found that a 6-week intervention using dolls to teach pre-school children how to pay more attention to internal satiety cues was associated with improvements in the regulation of their food intake (Johnson, 2000). Appetite awareness training, which encourages children to focus on their hunger and fullness to guide food consumption rather than other external triggers (e.g., emotional), has been associated with reductions in BMI (Bloom, Wynne, & Chaudhri, 2005; Jones, et al., 2008). Providers can also teach parents to not use overly restricting feeding practices (e.g., giving children the choice of a variety of health foods, rather than cutting out a lot of foods) and to make environmental changes in the home (e.g., offering portion sizes appropriate to child’s needs).

Motivation to Eat

Motivation to eat is conceptualized as the reinforcing nature of food as relative to non-food alternatives for an individual, such as spending time with friends or engaging in preferred activities. This construct refers to an individual’s anticipation of how rewarding they believe food will be, as a proxy of “wanting,” rather than how rewarding the food actually is when consumed, or “liking.” A child’s motivation to eat can be assessed by measured how hard he or she will work (e.g., points played for in a videogame) for food when given a choice between two alternatives (e.g., two types of food, food and an alternative activity) (Goldfield, Epstein, Davidson, & Saadd, 2005). Both laboratory paradigms and a self-report questionnaire assessing motivation to eat have been used successfully in older children (8-12 years) (Epstein, Dearing, Temple, & Cavanaugh, 2008; Temple, Legierski, Giacomelli, Salvy, & Epstein, 2008). Providers can also ask parents questions related to how much their child asks for food, how often their child be eating if given the choice, and the likelihood that their child would choose food over various alternatives (e.g., time with friends, watching television, soccer).

The primary intervention strategy for high motivation to eat should encourage parents to shift the relative reinforcing value of food by increasing access to healthy foods and activities while simultaneously decreasing the availability of unhealthy foods in the home (Epstein et al., 2001). It can be difficult for healthful alternatives to compete with highly reinforcing, high-fat foods, so it may be especially helpful to also substitute unhealthy foods with social interactions (Epstein, Dearing, & Roba, 2010; D.E. Wilfley et al., 2007). Another method to help reduce food consumption among children with a high motivation to eat is to decrease activities that are compatible with eating, such as watching television (Epstein, et al., 2010).

Impulsivity

Impulsivity refers to an individual’s impaired ability to resist immediate needs or desires in favor of long-term goals. For youth with eating and weight problems, this is often behaviorally observed as a child’s inability to delay gratification for certain types of food.

Impulsivity is a multi-dimensional construct and therefore can be measured in a variety of ways. Delay of gratification has been most commonly measured in the laboratory, where children choose between a small, immediate reward (e.g., one marshmallow) and a larger, delayed reward (e.g., 3 marshmallows in 15 minutes) (Mischel, Shoda, & Rodriguez, 1989). While this method may not be practical for everyday use, it may be possible to query children about this concept (e.g., would you rather have one cookie right now, or two cookies in 15 minutes?). Reward sensitivity, a key aspect of impulsivity in obese individuals, can also be briefly assessed by questionnaire. The reward sensitivity subscale of the Barratt Impulsivity Scale (Patton, Stanford, & Barratt, 1995) suggests that it is useful to ask children whether they think before they act or act before they think, find it difficult to sit still for long period of time, or have difficulty concentrating on tasks. This questionnaire has been validated in adolescents, though more work is needed to determine its validity in younger children.

Impulsivity is often manifested as frequent cravings for food coupled with an inability to resist those cravings (Epstein, et al., 2010). Interventions that teach general self-regulation skills, such as focusing attention and following instructions, are promising (Israel, Stolmaker, Sharp, Silverman, & Simon, 1984). A more targeted approach could focus on training children food-specific self-control skills, such as planning ahead of time what to do when cravings occur. It is also recommended that parents help their children delay gratification by limiting access to unhealthy foods to decrease temptation and learning to distract their children’s attention away from food with rewarding, alternative activities (e.g., playing active games together) (D. E. Wilfley, A. Vannucci, et al., 2010).

Lifestyle Interventions for the Treatment of Pediatric Obesity

Beyond the contribution of individual differences in appetitive traits to eating and weight problems, the broader environment is a major culprit in promoting unhealthy eating and a sedentary lifestyle. Therefore, effective interventions must help individuals create a healthy eating and activity “zone” that makes healthy choices the default (Ashcroft, Semmler, Carnell, van Jaarsveld, & Wardle, 2008).

Lifestyle interventions, defined as active interventions that modify daily weight-related behaviors, are the most well-established and effective treatments for pediatric obesity (Epstein, Valoski, Wing, & McCurley, 1994; McGovern et al., 2008; D.E. Wilfley, et al., 2007) . Such interventions strive to integrate changes into daily life, enabling a more sustainable lifestyle. A recent quantitative review of the research indicated that lifestyle interventions were associated with an 8.9% decrease in percent overweight, while youth receiving either no-treatment or education-only exhibited a 2.7% increase in percent overweight immediately following treatment, which persisted 3-5 months later (D.E. Wilfley, et al., 2007). Usual care, which typically consists of an individual’s usual healthcare routine such as check-ups with a pediatrician, has shown no efficacy in treating pediatric obesity (D.E. Wilfley, et al., 2007). These findings should encourage providers to seek training in and to offer lifestyle interventions to treat overweight and obesity in youth, or to become familiar with local resources for such treatment.

The primary goal of all lifestyle interventions is either to promote weight loss or to prevent excess weight gain (i.e., weight maintenance). Providers can work with families to determine when weight maintenance versus weight loss is indicated. In general, weight loss, achieved through a negative energy balance, would be indicated for older children with a higher degree of obesity, particularly above the 95th percentile (Spear et al., 2007). Weight maintenance, achieved through stable energy balance, would be indicated for younger children who are overweight but not obese (Spear, et al., 2007). Furthermore, weight maintenance is strongly suggested once an adult has reached a BMI of 22 and a child has reached the 50th BMI percentile for their age and height (Spear, et al., 2007).

Components of Family-based Behavioral Interventions

Family-based behavioral lifestyle interventions are considered a first line of treatment for pediatric obesity, as they have demonstrated efficacy in reducing percent overweight and are safer than other treatment options (i.e., pharmacotherapy and bariatric surgery) (L.H. Epstein, M.D. Myers, H.A. Raynor, & B.E. Saelens, 1998b; D. E. Wilfley, A. Vannucci, et al., 2010) .

In family-based interventions, parents are regarded as key agents of change because a greater degree of parental involvement in behavior change is associated with better child weight outcomes (Kirschenbaum, Harris, & Tomarken, 1984; White et al., 2004). Studies have shown that targeting both the parent and the child is more effective than targeting the child alone (Wrotniak, Epstein, Paluch, & Roemmich, 2005; Wrotniak, Epstein, Paluch, & Roemmich, 2004). Parental use of healthy behaviors increases the likelihood that their children will also develop healthy habits, as parents can create an environment in which healthy behaviors are the norm (D. E. Wilfley, A. Vannucci, et al., 2010), and can model healthy eating and activity behaviors and attitudes for their children (Golan & Crow, 2004; Wrotniak, Epstein, Roemmich, Paluch, & Pak, 2005). A primary role of mental health providers is to set goals with families, to evaluate progress and problem-solve barriers, to teach behavior change techniques, and to provide education about healthy eating and activity.

Early on in the intervention process, both parents and children are introduced to the energy balance equation, which posits that weight loss is achieved by decreasing energy consumption and increasing energy expenditure. This negative energy balance is achieved by modifying dietary intake and increasing moderate to vigorous physical activity. For families who wish to maintain weight, stable energy balance, when caloric intake equals energy expenditure, is discussed. Weight loss and maintenance is most effectively achieved by implementing small, successive changes at home.

See Table 2

Behavior Change Techniques

A number of evidence-based behavior change techniques are implemented with families from the start of treatment (D.E. Wilfley, Vannucci, & White, in press). Goal setting is addressed during each treatment session. Goals target specific eating and activity behaviors that promote weight loss or maintenance, such as decreasing caloric intake, increasing physical activity, and achieving a weekly weight change goal (typically a loss of 0.5-1lb per week or weight maintenance, depending on the age and weight status of the child) (L.H. Epstein, M.D. Myers, H.A. Raynor, & B.E. Saelens, 1998a; D.E. Wilfley, et al., in press). Goals should be specific, measurable, attainable, realistic, and timely (SMART) in order to insure that families will be able to achieve their goals and that providers will be able to hold families accountable for their work outside of sessions. For example, a goal such as “eat more fruits and vegetables” is vague and difficult to measure. A goal such as “eat at least 5 fruits or vegetables on at least 5 out of 7 days this week” is much more specific because the expectations for the family are clear; the goal can be measured and therefore achieved. Goals can be changed throughout treatment to accommodate progress (i.e., gradually increasing physical activity; increasing calorie goal to transition from weight loss to maintenance).

Self-monitoring is also crucial to the success of family-based interventions and long-term weight management (D.E. Wilfley & Saelens, 2001). Families are asked to monitor their food and drink intake (i.e., foods, amounts, and calories) and physical and sedentary activity (i.e., type and length of activity). Monitoring is useful because it increases awareness of behavioral patterns, and enables families to monitor their attainment of daily goals (D.E. Wilfley & Saelens, 2001). Families can monitor with the use of a written or computer-based food log (though written logs are more portable). Online food logs are also available. The chosen method of monitoring should be decided upon collaboratively in order to minimize barriers to monitoring, as it can be one of the most challenging activities for families. Monitoring can be included as a goal for the first few sessions in order increase motivation for completion. It is recommended that providers encourage families to use a reward system for children. Basic behavioral research demonstrates that contingency management (i.e., rewarding desirable behavior) is an effective strategy for promoting behavior change in children (Petry et al., 2001). Such a system should include activities agreed on by both parent and child, should be affordable, and should be given as soon as possible. The most effective rewards are those that parents are willing to withhold if their child does not earn it (e.g., a family vacation should not be a reward). Each reward should be given a point value, and as goals are achieved, points are given. Providers can encourage families to avoid food-related rewards and to reward themselves with healthy, active events. Families can be provided with a list of suggested rewards or can formulate a list of rewards, themselves. These can include spending time together as a family, visiting a museum or park, playing a board game, or attending a sporting event.

Parents are also encouraged to facilitate healthy behaviors by providing consistent meal and snack times, as well as planning ahead for busy weeks and high-risk situations (i.e., parties, holidays). In addition, parents are encouraged to use positive reinforcement by praising positive behaviors while minimizing attention to negative behaviors. Furthermore, parents are encouraged to practice stimulus control (Epstein, Paluch, Kilanowski, & Raynor, 2004). Stimulus control refers to the modification of environmental cues that promote undesirable behaviors. In the case of pediatric obesity treatment, parents are asked to restructure the home environment to increase the likelihood of healthy eating and activity. Parents are instrumental to the implementation of this technique as they can control access to healthy and unhealthy foods, can encourage green activity through increasing access (i.e., transportation), and can reduce sedentary activities by setting time limits on TV and video games.

Dietary Modification

Regardless of whether the primary treatment goal is to lose weight or to prevent weight gain, it will likely be necessary to encourage children to decrease their energy intake. In order to decrease energy intake, families are encouraged to increase consumption of low energy density (LED) foods and to decrease consumption of high energy density (HED) foods. LED foods are highly nutritious, low-calorie-dense foods (e.g., vegetables, fruits) while HED foods are high fat, high sugar foods (e.g., fast food, chips) (Epstein, et al., 1998a; Katan, 2009; Sacks et al., 2009) . Reduction of sugar-sweetened beverages (i.e., juices, sodas) is also targeted, as these tend to be one of the biggest “offenders” in promoting excess calorie consumption. In order to assist families in learning how to think about the health value of food, it is useful to introduce families to an easy way to classify foods. The Traffic Light Diet (Epstein & Squires, 1988) is a widely studied classification system for foods, and classifies foods based on fat and sugar content. LED foods are GREEN or GO! (foods with <2g of fat; most fruits and vegetables); nutrient-dense but HED foods are YELLOW or CAUTION! (foods with >2 but ≤5 grams of fat per serving), and HED foods are RED or STOP (foods with >5g of fat). Additional sugar cutoffs based on serving size can be utilized for relevant foods, such as yogurts, juices, and cereals.

In compliance with the CDC food guide recommendations, families are instructed to consume at least 5 servings of fruits or vegetables per day and less than 10-15 RED food servings per week, which can be gradually reduced. Furthermore, increasing consumption of healthy fats (i.e., fish and nuts) and high-fiber foods (i.e., whole grains) can positively influence weight outcomes. Families are also encouraged to remain within a specified calorie goal (1,000-1,200 kCal/day for children for weight loss; 1,200-1,400 kCal/day for adults for weight loss). Calorie goals can be gradually increased as families transition from weight loss to weight maintenance. It is important to note that under-recording of foods and caloric intake is common, even among dieticians. Thus, individuals may appear to be in their calorie range based on their food log, but may still gain weight. This is an opportunity for providers to explore potential strategies for improving the accuracy of monitoring (e.g., writing foods down immediately after eating).

In order to facilitate dietary modification for families, they are taught skills such as limiting portion sizes and using healthier cooking methods (i.e., baking and steaming foods; using broth instead of oil/butter). Additionally, families are encouraged to reduce RED snacking and to have fewer meals outside of the home. Families are also encouraged to replace common YELLOW and RED foods in their diet with GREEN alternatives (i.e., pretzels instead of chips) instead of simply adding GREEN foods. Another strategy for replacing HED with LED foods is to begin packing lunches at home, as lunches provided by schools are notoriously high in calories and fat.

Physical Activity

Increasing physical activity (PA) augments energy expenditure and aids in achieving an overall negative or stable energy balance. Changes in activity should include both increasing PA (i.e., walking, running, sports) and decreasing time spent in sedentary activities (i.e., TV, video and computer games, phone use) (Epstein, et al., 1998a; D.E. Wilfley, et al., in press).

Current ADA guidelines (Physical activity guidelines advisory committee report, 2008) indicate that children should get 60 minutes per day of moderate to vigorous intensity activity for weight maintenance, and 90 minutes of PA per day is suggested for weight loss. For adults, 30 minutes (weight maintenance) to 60 minutes (weight loss) of PA is suggested. Children and parents who come to treatment largely inactive should have their level of activity gradually increased to prevent injuries, and in some instances a doctor’s approval would be appropriate, such as in the case of extreme obesity or medical contraindications. Parents should be encouraged to provide their children with access to PA equipment and transportation, and to find enjoyable, age-appropriate, and eclectic activities. Furthermore, families are encouraged to participate in at least some PA together, in order to promote family cohesion in healthy behavior change and to increase positive role modeling.

In addition to planned physical activities, families are encouraged to increase the amount lifestyle activity they engage in (i.e., using the stairs instead of the elevator; getting off the bus a stop early and walking). One study suggested that flexible, unstructured lifestyle activity was more effective for long-term weight maintenance than structured and high-intensity exercise (Epstein, et al., 1998a; Epstein et al., 1985). While structured PA is important for weight loss and maintenance, lifestyle activity is also critical as it increases overall activity and energy expenditure.

Providers can also instruct parents to reduce sedentary activity time to less than 2 hours per day outside of school, as reducing television and computer use by as little as 50% has been shown to result in significant z-BMI reductions in youth (Epstein et al., 2008) . In family-based behavioral programs, sedentary activity refers to “screen time,” that is, watching TV, using computer and video games, and talking on the phone or texting, as these particular activities have been strongly linked to obesity in children (Epstein, Paluch, Consalvi, Riordan, & Scholl, 2002; L. H. Epstein, et al., 2008) . This enables children to reallocate time to PA and to other activities that are incompatible with snacking.

Weight Maintenance Treatment: A Multilevel Approach

Though family-based behavioral weight loss interventions are largely successful, weight regain is not uncommon for children and parents. Importantly, the skills needed to sustain an individual’s weight goals over a long period of time are distinct. Not only is behavior change crucial for effective weight maintenance, but adherence to healthy behaviors across multiple environmental contexts is also integral (D. E. Wilfley, A. Vannucci, et al., 2010; D.E. Wilfley, et al., in press) .

Learning theory suggests that relapse occurs because old behaviors are never “erased”, but rather coexist with the new behaviors that individuals learn. Unfortunately, old, unhealthy behaviors can be cued by contextual stimuli, especially during ambiguous or stressful situations (D. E. Wilfley et al., 2010) . The problem of weight regain may occur following weight loss interventions because the myriad contexts in which old behaviors can be cued are not modified (D. E. Wilfley, D. J. Van Buren, et al., 2010) . Research suggests that a broader scope and longer duration of treatment is associated with better weight outcomes, as families are able to practice and master behavioral skills in a variety of contexts (Bennett, 1986). The socio-ecological model is a framework that structures maintenance approaches for pediatric obesity, and is composed of four levels: individual, family, peer/social, and community (D.E. Wilfley et al., 2007).

To impact weight maintenance at the individual and family levels, families are asked to begin to weigh at home weekly and to keep a weight graph in order to begin to monitor their own progress and adherence to healthy behaviors. If weight regain occurs, families are instructed to return to their weight loss goals until they have returned to their maintenance weight. In addition, families continue to create action plans for dealing with high-risk situations, and continue to seek the support of other family members. For example, families can institute a plan for birthday parties in which they eat beforehand and only eat a maximum of 2 RED foods at the party. During the holidays, parents may instruct visiting family members to bring a healthy dish, and may even provide recipes. Overall, the individual/family level focuses on sustaining and continuing to practice healthy behaviors within the home environment.

The skills addressed in the peer/social level strive to expand the contexts that support and reward healthy behaviors. This includes developing skills for eliciting social support of healthy behaviors, such as increasing the number of supportive peers, and organizing healthy play-dates with friends. Research has shown that children tend to make healthier choices when their peers do and that social connectedness is associated with more physical activity and healthy eating. Teasing is also addressed, an aspect of the peer/social environment that can make it more difficult to sustain healthy behaviors. Children are taught to “tease the tease, not the teaser,” (i.e., “that insult is as old as the Queen of England!”) as well as to make teasing less fun by ignoring insults.

The community/environmental level of the model addresses the need to modify stimuli that support unhealthy behaviors within the broader community environment. The proximity of parks, fast food restaurants, and supermarkets, as well as the safety and walkability of a neighborhood, are all aspects of the community that can impact maintenance of healthy behavior patterns. Parents are encouraged to practice self-regulation skills in high-risk environmental contexts (i.e., take a route home that does not pass fast food restaurants), while also identifying opportunities in their community for healthy eating and activity. Providers can work with families to identify opportunities in their community, such as farmer’s markets, free fitness classes, and community walks or runs. Overall, mental health professionals should provide families with support as they develop a lifestyle that capitalizes on opportunities for healthy behavior.

A recent study by Wilfley and colleagues (2007) compared Social Facilitation Maintenance (SFM) treatment, which follows the socio-ecological model, with Behavioral Skills Maintenance (BSM) treatment, which focuses solely on the individual context, and a no-further-contact control. Results indicated that SFM and BSM were both associated with greater weight maintenance in the short-term; however, only SFM was superior to the control condition in the long-term (D.E. Wilfley, et al., 2007). These results suggest that attention to multiple contexts, particularly a child’s social and peer context, is crucial to successful long-term weight maintenance. Indeed, a computer simulation model indicated that an enhanced version that addressed multiple contexts would lead to even better weight maintenance (D. E. Wilfley, D. J. Van Buren, et al., 2010) .

See figure1 and figure2.

Additional Treatment Considerations

A number of factors can influence treatment outcome. First, genetically susceptible individuals, such as those who evidence significant appetitive traits, may find behavior change to be particularly challenging and may be more prone to relapse (M. Tanofsky-Kraff et al., 2009; D. E. Wilfley, A. Vannucci, et al., 2010) . In addition to implementing individualized intervention approaches described earlier, it is crucial to focus on altering the environment in such a way as to reduce the phenotypic expression of appetitive traits (i.e., increase satiety responses by making high-fiber foods widely available; use of stress management techniques to reduce loss of control and emotional eating).

Despite the prevalence of obesity in the US, overweight individuals are often discriminated against, and therefore face a number of practical problems. Such individuals may thus experience discomfort in seeking help for a weight or eating problem. Thus, providers must ensure that individuals can be treated in an environment that is free of stigma. Providers can undergo training to learn how to assess and treat overweight families in a sensitive and non-stigmatizing manner, and clinics can seek to ensure that the physical and space needs of overweight clients are addressed (D. E. Wilfley, A. Vannucci, et al., 2010). Maximizing comfort within the treatment setting can enhance success in intervention programs.

Overweight youth who present with co-morbid psychosocial symptoms are especially likely to struggle with weight management. Overweight and obesity is associated with higher levels of anxiety, depression, conduct problems, and eating disorder symptoms (M. Tanofsky-Kraff et al., 2004; Wildes et al., 2010), which may impact treatment success and therefore should be assessed. Furthermore, childhood obesity is a prominent risk factor for eating disorders (Stice, 2002; Stice, Presnell, & Spangler, 2002) ; thus, overly restrictive eating behaviors or excessive amounts of exercise should be monitored. Both cognitive-behavioral therapy and interpersonal psychotherapy have proven efficacy for the treatment of anxiety, depression, and binge-eating (Cuijpers et al., 2011; Moreau, Mufson, Weissman, & Klerman, 1991; Reinecke, Ryan, & DuBois, 1998; Stewart & Chambless, 2009; Marian Tanofsky-Kraff, et al., 2010; D. Wilfley, et al., 2003) . Additional or concurrent psychological treatment may enhance the effectiveness of lifestyle interventions for a subset of individuals.

In addition to psychological co-morbidities, many overweight and obese children experience social difficulties, such as teasing, poor body-image, and weaker and less healthy social networks (Banis et al., 1988; Hayden-Wade et al., 2005b) . These social problems may pose barriers to implementing healthy behaviors, as children with social problems may be less likely to seek out social support for healthy activities and may be less likely to participate in physical activities (Hayden-Wade, et al., 2005b). In Wilfley and colleagues’ (2007) randomized trial of maintenance interventions, children with greater social problems were found to do more poorly in SFM than those with lower social problems. This finding suggests that children with significant social problems may benefit from additional social skills training. Such children may also need more time and space to discuss issues related to bullying, stigma, and body image concerns.

Medical co-morbidities (e.g., Type II Diabetes, Metabolic Syndrome, Asthma) may also influence treatment adherence and success among overweight youth. Lifestyle interventions may be modified to address medical issues by including information about the link between obesity and the condition in question, as well as encouraging medical management and adherence to medications (Faith, Saelens, Wilfley, & Allison, 2001; M. Tanofsky-Kraff, Hayden, Cavazos, & Wilfley, 2003). It is also crucial that providers ensure that youth diagnosed with medical co-morbidities are referred to relevant experts. In this case, a multi-disciplinary treatment team and communication between all providers will likely enhance the results and increase the safety of the child.

Increasing access to effective lifestyle interventions, particularly within low-income and minority populations, is another important consideration. One study found that for low-income families, adherence to treatment was enhanced by a combination of in-person and telephone sessions, along with materials modified for low literacy(Cluss, Ewing, Long, Krieger, & Lovelace, 2010). Family-based behavioral interventions are particularly amenable for use in families from diverse backgrounds, as they take a flexible approach to taste preferences and cultural norms. Indeed, one study found that significant weight loss was maintained over 12 months in an ethnically diverse sample of children with high degrees of obesity (Savoye et al., 2011). Mental health providers are key providers of lifestyle interventions for pediatric obesity. While obesity is often associated with the medical arena, mental health providers specialize in fostering motivation for change and in supporting and promoting the difficult process of behavior change. Training mental health providers in a primary care setting is crucial, as this is often the first point of contact for children and parents with weight and eating problems. Knowledge of resources for pediatric obesity treatment among pediatricians and family physicians is also of utmost importance, as adequate referral is a central component of access to effective treatment. Furthermore, an interdisciplinary approach to pediatric obesity treatment may be most effective. Mental health and medical providers should set up a system for active and frequent communication so that the treatment of the psychological, behavioral, and physical sequelae of obesity can be integrated in order to maximize health.

Authors

Dr. Denise Wilfley is a Professor of Psychiatry, Medicine, Pediatrics and Psychology at Washington University in St. Louis. She is an internationally recognized expert on the etiology, prevention, and treatment of obesity and eating disorders across the age spectrum. She has received more than $25 million in funding from the National Institutes for Mental Health to conduct multi-site randomized clinical trials of lifestyle interventions for the treatment of adult and pediatric obesity.

Anna Vannucci is a first year student in the Medical and Clinical Psychology dual-track program at the Uniformed Services University of the Health Sciences. Anna was the recipient of a Fulbright Scholarship and worked as a research assistant for Dr. Denise Wilfley and her team at Washington University in St. Louis School of Medicine before beginning graduate school.

Juliette Iacovino is currently a graduate student and Chancellor's Graduate Fellow working with Dr. Denise Wilfley in the Weight Management and Eating Disorders Program at Washington University School of Medicine. Her research interests include the dissemination and implementation of empirically-supported treatments for eating disorders and obesity into community settings.

Notes
The opinions and assertions expressed herein are those of the authors and are not to be construed as reflecting the views of USUHS or the U.S. Department of Defense.

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