Family-based interventions for the treatment of childhood obesity

Abstract

Recognizing obesity as a chronic disease with complex, multifactorial etiologies calls attention to the fact that prevention efforts and comprehensive interventions earlier in childhood are needed ((1)National Institutes of Health, National Heart, Lung and Blood Institute. Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults. The Evidence Report. Washington, DC: US Government Press, 1998.Google Scholar, (2)Barlow S.E. Dietz W.H. Obesity evaluation and treatment Expert Committee Recommendations.Pediatrics. 1998; 102: 1-11Google Scholar, (3)Hill J.O. Peters J.C. Environmental contributions to the obesity epidemic.Science. 1998; 280: 1371-1374Google Scholar). More effective, innovative, long-term interventions are needed beginning in early childhood ((3)Hill J.O. Peters J.C. Environmental contributions to the obesity epidemic.Science. 1998; 280: 1371-1374Google Scholar) to markedly alter the consequences of this serious, worldwide epidemic ((4)World Health Organization. Obesity. Preventing and Managing the Global Epidemic. Report of a WHO Consultation on Obesity. Geneva: World Health Organization; 1998.Google Scholar). The prevalence of overweight in the United States, defined as a body mass index (BMI) of 25 to 29.9kg/m2 in adults ((1)National Institutes of Health, National Heart, Lung and Blood Institute. Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults. The Evidence Report. Washington, DC: US Government Press, 1998.Google Scholar, (5)Kuczmarski R.J. Carrol M.D. Flegal K.M. Troiano R.P. Varying body mass index cut-off points to describe overweight prevalence among US adults NHANES III (1988 to 1994).Obes Res. 1997; 5: 542-548Google Scholar) and the 85th percentile in children ((6)Troiano R.P. Flegal K.M. Kuczmarski R.J. Campbell S.M. Johnson C.L. Overweight prevalence and trends for children and adolescents. The National Health and Nutrition Examination Surveys, 1963 to 1991.Arch Pediatr Adolesc Med. 1995; 149: 1085-1091Google Scholar), has increased markedly since 1960 in all adult race/gender groups and in children 3 years or older ((7)Ogden CL, Troiano RP, Briefel RR, Kuczmarski RJ, Flegal KM, Johnson CL. Prevalence of overweight among preschool children in the United States, 1971-1994. Pediatrics. 1997;99:E1.Google Scholar). The crude prevalence of overweight and obesity (BMI⩾25) for adults aged 20 years or older has been reported as 54.9% ((8)Flegal K.M. Carroll M.D. Kuczmarski, Johnson C.L. Overweight and obesity in the United States prevalence and trends, 1960-1994.Int J Obes Relat Metab Disord. 1998; 22: 39-47Google Scholar). Comparatively, 22% of children are overweight at a BMI greater than the 85th percentile ((6)Troiano R.P. Flegal K.M. Kuczmarski R.J. Campbell S.M. Johnson C.L. Overweight prevalence and trends for children and adolescents. The National Health and Nutrition Examination Surveys, 1963 to 1991.Arch Pediatr Adolesc Med. 1995; 149: 1085-1091Google Scholar). Childhood obesity has become an alarming health problem ((9)Holtz C. Smith T.M. Winters F.D. Childhood obesity.J Am Osteopath Assoc. 1999; 99: 366-371Google Scholar).Weight management issues are challenging; interventions should involve the family and actively engage the child and the parent in adopting healthy eating habits and physical activity ((10)Proimos J. Sawyer S. Obesity in childhood and adolescence.Aust Fam Physician. 2000; 29: 321-327Google Scholar) and reducing sedentary behaviors overall ((11)Crespo C.J. Smit E. Troiano R.P. Bartlett S.J. Macera C.A. Andersen R.E. Television watching, energy intake, and obesity in US children. Results from the Third National Health and Nutrition Examination Survey, 1988-1994.Arch Pediatr Adolesc Med. 2001; 155: 360-365Google Scholar). Indeed, much work is needed if the Healthy People 2010 Objectives of “increasing ⩾60% the prevalence of healthy weight (BMI⩾19 to <25) and reducing to <5% the prevalence of obesity (BMI⩾30) among all people 20 years and older (from the 1988-1994 baseline of 41% and 22%, respectively)”; and, reducing to <5% the prevalence of overweight/obesity at or above the sex- and age-specific 95th percentile from the revised NCHS/CDC growth charts in children (aged 6 to 11) and adolescents (aged 12 to 19) from the 1988-1994 baselines of 11% of children and 10% of adolescents who are overweight or obese” are to be reached ((12)US Department of Health and Human Services, Office of Public Health and Science. Healthy People 2010. Washington, DC: Public Health Service. January 2000. Leading Health Indicators, 24-45; Overweight and Obesity, 28-29.Google Scholar). While the objectives now include weight goals for children aged 6 to 11 years, goals for preschool children (aged 3 to 6 years) are still needed. Indeed, NHANES III data show that the percentage of children between the ages of 2 to 3 and 4 to 5 years with weight-for-stature above the 95th percentile has risen from 2.1% to 5.0% for boys and from 4.8% to 10.8% for girls ((13)Ogden C.L. Troiano R.P. Briefel R.R. Kuczmarski R.J. Flegal K.M. Johnson C.L. Prevalence of overweight among preschool children in the United States 1971 through 1994.Pediatrics. 1997; 99: E1Google Scholar). This highlights the need for prevention efforts to begin as early as preschool years when important habits are formed. Additionally, it is evident that family involvement and support are needed and could be beneficial throughout life.There is a paucity of data regarding weight management of children aged 3 to 5 years, as most studies focus on school-aged children aged 6 years or older. Lessons learned from these older children may not be directly applicable to preschool children who are under more direct parental control. For example, Johnson and Birch ((15)Johnson S. Birch L.L. Parents’ and children's adiposity and eating style.Pediatrics. 1994; 94: 653-661Google Scholar) demonstrated that the best predictor of a preschool child's ability to regulate energy intake was parental control in the feeding situation, which was inversely related to the ability of the child to self-regulate energy intake. They concluded that the optimum situation for the control of energy intake was one in which parents provided healthy food choices, and allowed the children to assume control of how much they consumed. The Framingham Children's Study also demonstrated that parents’ eating patterns have a significant relationship with the nutrient intake of their preschool children, particularly with regards to saturated fat, total fat, and cholesterol ((16)Oliveria S.A. Ellison R.C. Moore L.L. Gillman M.W. Garrahie E.J. Singer M.R. Parent-child relationships in nutrient intake the framingham children's study.Am J Clin Nutr. 1992; 56: 593-598Google Scholar). These studies are among the many that demonstrate the importance of how both the quality and quantity of food intake and activity patterns in preschool children are significantly influenced by parents. Further, studies indicate the need for improved assessments for children at various ages and the development of coordinated intervention strategies for children and families ((17)Klesges R.C. Stein R.J. Eck L.H. Isbell T.R. Klesges L.M. Parental influence on food selection in young children and its relationship to childhood obesity.Am J Clin Nutr. 1991; 53: 859-864Google Scholar, (18)Klesges R.C. Eck L.H. Hanson C.L. Haddock C.K. Klesges L.M. Effects of obesity, social interactions, and physical environment on physical activity in preschoolers.Health Psychol. 1991; 9: 435-449Google Scholar, (19)Klesges R.C. Haddock C.K. Stein R.J. Klesges L.M. Eck L.H. Hanson C.L. Relationship between psychosocial functioning and body fat in preschool children a longitudinal investigation.J Consult Clin Psychol. 1992; 60: 1252-1256Google Scholar, (20)Klesges R.C. Hanson C.L. Eck L.H. Haddock C.K. Durff A.C. Accuracy of self-reports of food intake in obese and normal-weight individuals effects of parental obesity on reports of children's dietary intake.Am J Clin Nutr. 1988; 48: 793-796Google Scholar, (21)Sallis J.F. Patterson T.L. McKenzie T.L. Nader P.R. Family variables and physical activity in preschool children.J Dev Behav Pediatr. 1988; 9: 57-61Google Scholar, (22)Fogelholm M. Nuutinen O. Pasanen M. Myhohanen E. Saatela T. Parent-child relationship of physical activity patterns and obesity.Int J Obes Relat Metab Disord. 1999; 12: 1262-1268Google Scholar, (23)Wilkins S.C. Kendrick O.W. Stitt K.R. Stinett N. Hammarlund V.A. Family functioning is related to overweight in children.J Am Diet Assoc. 1998; 98: 572-574Google Scholar). Thus, it is evident that developmental, environmental, and psychosocial factors contribute to inactivity, poor eating habits, and excessive weight gains that can be reinforced by parents and/or families. These behaviors have been noted to differ by parent and child's sex ((24)Birch L.L. Fisher J.O. Mother's child-feeding practices influence daughters’ eating and weight.Am J Clin Nutr. 2000; 71: 1054-1061Google Scholar, (25)Laitinen J. Power C. Jarvelin M.R. Family social class, maternal body mass index, childhood body mass index, and age at menarche as predictors of adult obesity.Am J Clin Nutr. 2001; 74: 287-294Google Scholar, (26)Cutting T.M. Fisher J.O. Grimm-Thomas K. Birch L.L. Like mother, like daughter familial patterns of overweight are mediated by mothers’ dietary disinhibition.Am J Clin Nutr. 1999; 69: 608-613Google Scholar) and, unfortunately, track into adulthood, remaining refractory to change.1. Family-Based InterventionsAlthough treatment strategies for overweight adults are different than for children (overweight, normal weight, and/or obesity “prone” as occur in families), they both have the goals of increasing physical activity and/or decreasing energy intake, and modifying the common, shared environment and other family variables. Parents and caregivers have an important and lasting influence on the eating and physical activity habits of young children. For children, the parent is the primary mediator of change, and a family-based intervention is appropriate. Thus, when coordinated treatment is provided for both the child and the parent who is motivated to lose weight, good results can generally be anticipated for both, with somewhat greater benefit for the child ((27)Epstein L.H. Family based behavioral intervention for obese children.Intern J Obesity. 1996; 20: S14-S21Google Scholar). Studies of children aged 6 to 11 years where the parents were targeted as the primary mediators of change showed greater weight loss, increased number of behavioral changes and better retention in the study ((28)Golan M. Fainaru M. Weizman A. Role of behavior modification in the treatment of childhood obesity with the parents as the exclusive agents of change.Int J Obesity. 1998; 22: 1217-1224Google Scholar, (29)Golan M. Weizman A. Apter A. Fainaru M. Parents as the exclusive agents of change in the treatment of childhood obesity.Am J Clin Nutr. 1998; 67: 1130-1135Google Scholar). Five basic behavioral interventions are most often used in childhood as well as adult obesity programs: self-monitoring, stimulus control, eating management, contingency management or rewards, and cognitive-behavioral techniques ((30)Foreyt J.P. Cousins J.H. Obesity.in: Mash E. Barkley R. Treatment of Childhood Disorders. Guilford Press, New York1989Google Scholar). The development of parenting skills to facilitate healthy attitudes and interactions around eating and activity will also help increase success. In 5- and 10-year follow-up reports of family based behavioral treatments by Epstein and colleagues ((31)Epstein L.H. Valoski A. Wing R.R. McCurley J. Ten-year follow-up of behavioral, family based treatment for obese children.JAMA. 1990; 264: 2519-2523Google Scholar, (32)Epstein L.H. McCurley J. Wing R.R. Valoski A. Five year follow-up of family-based behavioral treatments for childhood obesity.J Consult Clinic Psychol. 1990; 58: 661-664Google Scholar, (33)Epstein L.H. Valoski A.M. Kalarchian M.A. McCurley J. Do children lose and maintain weight easier than adults a comparison of child and parent weight changes from six months to ten years.Obes Res. 1995; 3: 411-417Google Scholar), predictors of child success included self-monitoring, changes in eating behaviors, praise of child, and change in parent percent overweight, whereas predictors of successful parental outcomes included self-monitoring weight, baseline parent percent overweight, and participation in fewer subsequent weight control programs. Family characteristics are also important, with more success associated with supportive, interactive families demonstrating parental skills to develop responsibility and a positive self-image ((34)Hertzler A.A. Obesity impact of the family.J Am Diet Assoc. 1981; 79: 525-530Google Scholar). Thus, family-based interventions that emphasize reasonable and coordinated goals for both the parent and child and that incorporate positive reinforcement are most likely to succeed.The environment in which children learn eating habits is changing rapidly with national demographic and economic trends that also affect the family. Home eating patterns have changed such that a greater proportion of income is spent on foods prepared outside the home, different members of the family are deciding on their own about what to eat, and there is more frequent use of convenience foods and single-serve items. The role of gatekeeper, wherein the mother traditionally directed food choices has shifted, in part, to child care providers and schools, and there are many competing nutrition messages from the media and from peers. Indeed, the challenges and opportunities for family-based interventions for the prevention and treatment of obesity are many ((35)Booth S.L. Sallis J.F. Ritenbaugh C. Hill J.O. Birch L.L. Frank L.D. Glanz K. Himmelgreen D.A. Mudd M. Popkin B.M. Rickard K.A. St Jeor S. Hays N.P. Environmental and societal factors affect food choice and physical activity Rationale, influences, leverage points.Nutr Rev. 2001; 59: S21-S37Google Scholar).2. Theoretical ModelsThe need for comprehensive, family-based models is evident, and existing behavioral theories give directions to follow. Cognitive-behavioral therapy has an important role in obesity treatment as it provides a methodology for systematically modifying eating, exercise, or other behaviors that are thought to contribute to or maintain obesity ((36)Stunkard A.J. Current views on obesity.Am J Med. 1996; 100: 230-236Google Scholar). Most of the various cognitive behavioral approaches have several factors in common, including the use of self-monitoring and goal setting, stimulus control and modification of eating style and habits, cognitive restructuring strategies that focus on challenging and modifying unrealistic or maladaptive thoughts or expectations, stress reduction/management strategies, and the use of social support ((37)Perri M.G. Fuller P.R. Success and failure in the treatment of obesity where do we go from here?.Med Exerc Nutr Health. 1995; 4: 255-272Google Scholar, (38)Foreyt J.P. Goodrick G.K. Attributes of successful approaches to weight loss and control.Appl Prev Psychol. 1994; 3: 209-215Google Scholar, (39)Foreyt J.P. Goodrick G.K. Promoting long-term weight maintenance.in: Blackburn G.L. Kanders B.S. Obesity: Pathophysiology, psychology, and treatment. Chapman and Hall, New York1994: 300-311Google Scholar). Social learning theory is comprised of both operant conditioning (reinforcement and punishment) and modeling (engaging in behavior which was observed) ((40)Bandura A. Social learning theory. Prentice-Hall, Englewood Cliffs1977Google Scholar, (41)Bandura A. Social foundations of thought and action. Prentice Hall, Englewood Cliffs, NJ1986Google Scholar, (42)Bandura A. Self-efficacy. WH Freeman, New York1997Google Scholar). Children learn behaviors through both experiencing the consequences of their own behavior and through the development of expectations of consequences by observing others incurring the reinforcement/punishment for their behaviors. This conditioning results in behavioral patterns that are continuously developed and shaped over the course of the child's life. Behavioral modeling is more important during the establishment of new behaviors, while operant conditioning becomes more relevant during the maintenance and shaping of these new behaviors. Children are more likely to learn behavioral patterns from those individuals who control the majority of the rewards and punishments and establish the social contexts in which behaviors are learned and established. The use of differential reinforcement (or different responses for different behaviors) and behavioral modeling are believed to lead to the development of “definitions” that provide a script for behavior ((43)Akers R.L. Krohn M.D. Lanza-Kaduce L. Radosevich M. Social learning and deviant behavior a specific test of a general theory.Am Soc Rev. 1979; 44: 636-655Google Scholar). That is, definitions (attitudes/meanings which are associated with a given behavior) act as internal discriminant stimuli and signal which behaviors are appropriate given a certain situation or setting. The learning process begins with differential reinforcement, modeling, and the presentation of definitions by the primary source of the consequences (ie, the parents). The interaction between the definitions and modeling produces the establishment of the behavioral pattern. Finally, after the initiation of the behavior, operant behaviors, including differential reinforcement, become the principal force in the continuation of the behavior.For example, the preschool child sees his mother dancing to some music. The child shakes his hips from side to side (modeling). The mother says, “That a way! Keep shaking those hips!” (positive reinforcement). The child then starts playing a video game. The mother ignores this behavior (differential reinforcement). The child becomes bored, stands up, and shakes his hips again. The mother says, “Yeah, let's get down and boogie!” (positive reinforcement) With repeated incidents, the child learns to prefer dancing over video games and becomes more active.This model of socialization provides an ideal theory on which to develop and build parenting skills that produce desired changes in children's food intake and activity patterns. While there is a paucity of information about parenting styles regarding physical activity, parental feeding styles have been studied ((44)Baumrind D. Rearing competent children.in: Damon W. Child development today and tomorrow. Jossey Bass, San Francisco1989: 349-378Google Scholar). The authoritative, or cooperative, feeding style, in which adults determine which foods are offered, and children determine the amount eaten, is believed to result in optimum outcomes in children ((15)Johnson S. Birch L.L. Parents’ and children's adiposity and eating style.Pediatrics. 1994; 94: 653-661Google Scholar, (45)Koivisto U.K. Sjoden P.O. Reasons for rejecting food items in Swedish families with children aged 2-17.Appetite. 1996; 26: 89-103Google Scholar) due partially to the development of self-control in children ((44)Baumrind D. Rearing competent children.in: Damon W. Child development today and tomorrow. Jossey Bass, San Francisco1989: 349-378Google Scholar, (46)Satter E. Internal regulation and the evolution of normal growth as the basis for prevention of obesity in childhood.J Am Diet Assoc. 1996; 9: 860-864Google Scholar). This feeding style occupies the middle ground between permissive (inconsistent and unbounded) and autocratic (controlling) parenting styles. The underlying assumption is that the more self-control the child has, the better able the child will be to respond to internal controls of hunger and fullness, and attending to these internal cues might increase the child's ability to self-regulate food intake ((47)Johnson S.L. Improving preschoolers’ self-regulation of energy intake.Pediatr. 2000; 106: 1429-1435Google Scholar). The relationships between parental food preferences and those of their children also have received much attention ((15)Johnson S. Birch L.L. Parents’ and children's adiposity and eating style.Pediatrics. 1994; 94: 653-661Google Scholar, (48)Fisher J.O. Birch L.L. Fat preferences and fat consumption of 3- to 5-year-old children are related to parental adiposity.J Am Diet Assoc. 1995; 95: 759-764Google Scholar). Researchers have examined feeding practices such as rewarding with food ((49)Birch L.L. Marlin D.W. Rotter D. Eating as the “means” activity in contingency effects on young children's food preference.Child Devel. 1984; 55: 532-539Google Scholar), having adults eat at the table with their children ((50)Stanek K. Abbott D. Cramer S. Diet quality and the eating environment of preschool children.J Am Diet Assoc. 1990; 90: 1582-1584Google Scholar), encouraging children to eat, and offering a limited variety of foods ((45)Koivisto U.K. Sjoden P.O. Reasons for rejecting food items in Swedish families with children aged 2-17.Appetite. 1996; 26: 89-103Google Scholar, (51)Hobden K. Pliner P. The effects of a model on food neophobia.Appetite. 1995; 25: 101-114Google Scholar), all of which still pose questions. Parallel messages regarding physical activity and feeding need development, testing and study, and will require long-term application and reinforcement.3. A Case In PointHealth Opportunities for Pre-School Children to Optimize Their Cardiovascular Health (HOPSCOTCH), a program developed by the Nutrition Education and Research Program at the University of Nevada School of Medicine, is supported by the National Institutes of Health as one of their Innovative Approaches to Prevention of Obesity. The purpose of the study is to develop and test the feasibility of a family-based, weight management program. Overweight parents with preschool children were enrolled as pairs into either a treatment group, with the parent as the mediator of change, or a control group. The intervention for the child was designed to provide age-specific, healthy eating patterns with increases in daily physical activity in order to enable weight stabilization or small weight gains of no more than 4.5 Ib (2kg) per year. This will allow for a gradual decline in BMI as the children grow and minimize body fatness, thus prolonging the period before normal adiposity rebound occurs. The intervention for the parent (mother as the major caregiver) followed the traditional weight reduction intervention wherein weight loss goals of −500 kcal/day (−1Ib/wk) and prevention of weight regain were targeted. The parent/child pairs attend all sessions together and the child's intervention is combined with those of the parent. After a brief socialization activity, the children are taken to a play/educational group while the parents attend group treatment sessions. At the end of the session, the parent and child groups are combined, and a snack the children helped prepare is provided.As can be seen in the Figure, the class structure in HOPSCOTCH is expected to directly change the mother, child, and environment. Changes in the mother's behaviors are hypothesized to then have an effect on both the child and the environment. Of course, psychosocial and environmental factors are known to impact the mother's ability to change. The change in the child's behavior is also anticipated to influence the mother's behavioral changes. The content of the class structure was guided by four theoretical principles: cognitive behavior theory, social learning theory, ecological theory, and nurturing theory. Initially, two behavioral models were combined to help parents enhance their parenting skills (social learning theory) and develop strategies to better manage their own weight (cognitive behavior therapy). Additionally, the ecological theory-based concepts ((52)Bronfenbrenner U. The ecology of human development. Harvard University Press, Cambridge, MA1979Google Scholar) were incorporated where appropriate throughout both the mother's and child's components. The ecological framework suggests that the child exists within the center of its universe surrounded by its immediate environment (the microenvironment), which in turn is surround by the environment at large (the macroenvironment)— hence, the term “ecological.” Both micro- and macroen-vironments affect a child's eating behavior, growth and development. The development and application of the fourth theory was also derived from ecological theory and research on parenting styles. Parenting styles (ie, indulgent, authoritarian, or uninvolved) have been associated with parental control issues in general ((44)Baumrind D. Rearing competent children.in: Damon W. Child development today and tomorrow. Jossey Bass, San Francisco1989: 349-378Google Scholar, (53)Darling N. Parenting style, its correlates. Available at: http://www:athealth.com/Practitioner/educ/parentingstyles.html. Accessed October 2, 2001.Google Scholar). The evaluation of these parenting styles on the child's weight ((15)Johnson S. Birch L.L. Parents’ and children's adiposity and eating style.Pediatrics. 1994; 94: 653-661Google Scholar, (54)Constanzo W. Domain specific parenting styles and their impact on the child's development of particular deviance the example of obesity proneness.J Soc and Clin Psych. 1985; 3: 425-445Google Scholar) suggests that parenting styles are an important factor when attempting behavior change. Thus, “nurturing” theory principles were included to enhance the mother's component of the intervention. The child's sessions also tap into the social learning theory by providing both male and female role models for physical activity and healthy snack preparation. The participation of the mothers at the end of the children's sessions provides additional practice in role modeling and provides positive reinforcement for their children. The primary influence on the mother is anticipated to be the intervention itself, which is based on the cognitive behavioral concepts used by Brownell and the LEARN Program ((55)Brownell K.D. The LEARN Program for Weight Control. American Health Publishing Co, Dallas, TX1997Google Scholar). A “caboose section” that engages the parent in applying social learning and nurturing constructs and provides innovative at-home follow-ups for reinforcement has been added as part of the intervention.4. Need For New ApproachesInnovative intervention approaches are needed early in childhood to halt the epidemic of obesity in America. Family based interventions offer new hope for improved results by coordinating treatment strategies to maximize results; however, due to the complexity of combined interventions, new strategies are also needed. The importance of building interventions on theoretically based strategies is evident. The challenge lies in making complex interventions simple and successful. The “Childhood Healthy Weight Initiative” ((56)Myers E.F. Johnson G.H. ADAF takes first steps toward childhood healthy weight initiative.J Am Diet Assoc. 2001; 101: 588Google Scholar) sponsored by the American Dietetic Association Foundation to foster collaboration and enhance the skills of dietetics professionals working in family nutrition will certainly help address the growing need for new strategies for preventing and treating childhood obesity.Dietitians will play a key role in the prevention and treatment of childhood obesity. Family-based models where parents and other family members are involved will set the stage. However, because each family unit varies and the needs of the various members are diverse, the challenge will be to find effective interventions that can be generalized across different ages and environments. Promoting healthy eating and active lifestyles overall and preventing obesity will provide a positive start.This work was supported in part by grant numbers HL65133 and HL 34589 from the National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD. Recognizing obesity as a chronic disease with complex, multifactorial etiologies calls attention to the fact that prevention efforts and comprehensive interventions earlier in childhood are needed ((1)National Institutes of Health, National Heart, Lung and Blood Institute. Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults. The Evidence Report. Washington, DC: US Government Press, 1998.Google Scholar, (2)Barlow S.E. Dietz W.H. Obesity evaluation and treatment Expert Committee Recommendations.Pediatrics. 1998; 102: 1-11Google Scholar, (3)Hill J.O. Peters J.C. Environmental contributions to the obesity epidemic.Science. 1998; 280: 1371-1374Google Scholar). More effective, innovative, long-term interventions are needed beginning in early childhood ((3)Hill J.O. Peters J.C. Environmental contributions to the obesity epidemic.Science. 1998; 280: 1371-1374Google Scholar) to markedly alter the consequences of this serious, worldwide epidemic ((4)World Health Organization. Obesity. Preventing and Managing the Global Epidemic. Report of a WHO Consultation on Obesity. Geneva: World Health Organization; 1998.Google Scholar). The prevalence of overweight in the United States, defined as a body mass index (BMI) of 25 to 29.9kg/m2 in adults ((1)National Institutes of Health, National Heart, Lung and Blood Institute. Clinical Guidelines on the Identification, Evaluation, and Treatment of Overweight and Obesity in Adults. The Evidence Report. Washington, DC: US Government Press, 1998.Google Scholar, (5)Kuczmarski R.J. Carrol M.D. Flegal K.M. Troiano R.P. Varying body mass index cut-off points to describe overweight prevalence among US adults NHANES III (1988 to 1994).Obes