Recovery Act funding helps determine the most effective interventions for overweight youth

By Erin Fults

November 23, 2011

Abby Holmes struggled with being overweight. She was only 10 years old, but already she was teased by the kids at school and had a very negative body image. She played some sports at school but remained overweight and unhappy. Although her school offered some healthy options and activities, when Abby went home, it was easy to fall into the habits of watching T.V. and eating the junk food that was easily accessible. Her parents had read some educational materials on childhood obesity from the pediatrician, but they felt unsure of where to go from there.

A Growing Problem
A child like Abby is one of the approximately 32 percent of children and adolescents in the United States struggling with overweight or obesity. Beyond the social problems that often follow an overweight child, such as low self-esteem and social isolation, unhealthy weight also can contribute to cardiovascular disease and type 2 diabetes as well as to future eating disorders. As nationwide attention turns to this growing problem, researchers such as Denise Wilfley, Ph.D., professor of psychiatry, medicine, pediatrics, and psychology at Washington University in St. Louis, are looking for solutions. In collaboration with researchers at Seattle Children’s Research Institute, University of Florida, and University at Buffalo, Wilfley is working to answer a serious question: What are the best ways to help children lose weight and sustain weight loss and healthy behaviors in the long term?

Wilfley’s research looks at children ages 7 through 11. When children are overweight at such young ages, there’s a high likelihood that weight problems will follow them into early adulthood and beyond. “What we’re trying to do is prevent further weight gain and help these children lose weight and also to prevent future illnesses,” Wilfley said.

Wilfley had a strong foundation of data from previous studies that looked at family-based weight interventions compared to standard educational methods. Her previous work had shown that augmenting a family-based weight loss intervention with a weight maintenance intervention consisting of extended contact and duration helped children and families use social support to increase healthy behaviors and maintain their weight loss outcomes in the long term. Wilfley wanted to go deeper to see whether outcomes could be improved further by tailoring and refining the already successful treatment.

ARRA to the Rescue
Wilfley was all set with a competitive renewal of her original grant, which received extremely high scores. But in the current budget climate, her research was at risk of not getting funded. American Recovery and Reinvestment Act (ARRA) funds allowed Wilfley and her team to continue their important research and work toward refining successful interventions for pediatric obesity.

“For us, ARRA funds were a life-saver,” Wilfley said. “They allowed us to accomplish a lot in a very short period of time.”

From previous studies, Wilfley knew that engaging families in the pediatric weight loss process was producing positive results. But she wanted to determine the most effective approach for producing durable changes and the optimal frequency and intensity of treatment. ARRA allowed Wilfley to continue investigating a treatment she calls social facilitation maintenance (SFM), an eight-month program that follows a four-month family-based behavioral weight loss treatment.

Using ARRA funds, Wilfley worked on evaluating the built environment around the children and families in the program. This critical work uses spatial databases and geographic information system (GIS) technologies to objectively assess environmental factors, such as proximity to fast food restaurants versus health food stores, as well as access to parks and open spaces for exercise and play. These elements may determine which families particularly need weight loss maintenance treatment and how much of it. This research brings together a diverse team, including basic and behavioral scientists, public health professionals, and urban design experts, to expand the scope of the program and turn additional scientific discoveries into key intervention points in real-world settings.

Wilfley’s study is able to evaluate the SFM program by making comparisons to a health education control program. “Health education control involves giving families helpful information about activities and diet, but it differs from SFM, which focuses on really going in and trying to make changes in the social environment,” Wilfley said.

Making Healthy the Easy Choice
To determine the most effective weight control strategy, Wilfley’s team must evaluate the contexts in which children and families live and work to both maximize the prompts for healthy behaviors and minimize the prompts for unhealthy ones. Her team uses a novel socio-environmental approach that builds on the “traffic light” plan, color-coding foods and opportunities for physical activities in a user-friendly manner. Families are encouraged to go for healthy GREEN foods and activities, exercise caution around YELLOW foods and activities, and stop and plan how to limit unhealthy RED foods and activities.

The goal of the SFM intervention is to make the healthy choice the easy choice by building social support and routines for healthy behaviors across the home, peer, and community environments. It’s much easier to eat healthy foods when they are well-stocked in the pantry and junk foods are not. Such a change for a child requires that family members are also on board. “We’re trying not to single out the overweight child,” Wilfley said. “Caregivers have to become advocates for healthy choices on the home front so that the whole family can be involved in these life changes.”

And it doesn’t stop at home. The healthy options in school, friends’ houses, and the community as a whole play a crucial role in getting healthy behavior changes to stick. Wilfley employs an innovative socio-environmental model, which includes the inner circle of the individual and extends out to the home, peer, and community contexts. By taking intervention steps at all levels, overweight children will be more exposed to healthy activities and behaviors as they move through the different aspects of their lives.

“Overweight individuals who have repeatedly failed at weight loss feel like failures. We teach them that we all respond to contextual cues. If it’s around, we’re more likely to succumb to it. So, we try to make them aware of the contextual prompts in their environment,” Wilfley said.

Different individuals may respond better to certain amounts of SFM. According to Wilfley, children with serious social problems coming from impoverished environments, such as limited sources of social support or physical structures like parks, may need extended treatment, while less effort may be sufficient in other cases. Augmenting weight loss interventions with specialized treatment to address children’s particular psychological and social profiles could enhance not only their weight loss outcomes but also decrease their risk for developing psychiatric problems down the line.

By making sure the new learning of healthy choices is practiced over and over again, the behaviors become ingrained, leading to durable change and sustained weight loss for kids. The use of this theory is novel to weight loss interventions, representing a cutting-edge aspect of Wilfley’s work.

Looking Ahead
Wilfley already has 5 published papers, 3 papers in press, and 11 national and international presentations on findings supported by the ARRA grant. The ARRA funds also helped to hire and train 32 additional staff members. Because experts in assessment, intervention, and data analysis were required, an expansive research team was critical to the study’s success.

Going forward, Wilfley plans to implement the weight loss treatment in health care settings, increasing the reach of effective treatments to combat this nationwide problem. By embedding this pediatric obesity treatment into routine practice, overweight kids, like Abby, and their families can learn to curb unhealthy behaviors and gain the skills to get healthy for the long-term.