Childhood Obesity: Targeted Dietary Interventions
Childhood obesity is a global concern, and dietary interventions have shown varying effectiveness in reducing BMI in children and adolescents. However, there is little guidance on targeted dietary approaches and energy reduction, leading to inconsistent recommendations. This excellent systematic review aimed to assess the effectiveness of nutritional interventions with varying energy content in managing weight for children and adolescents with obesity and related comorbidities in the short term, providing evidence-based strategies for pediatric obesity management.
The background of the study
Childhood obesity has emerged as a critical public health challenge worldwide, with an estimated 158 million children between the ages of 5 and 19 years being affected [1]. If current trends continue, childhood obesity numbers will reach 206 million by 2030. The implications of childhood obesity are far-reaching and may lead to many physical and psychological health complications, including cardiovascular diseases, type 2 diabetes, and low self-esteem [2]. While several therapies may address this pressing issue, dietary interventions have been widely employed as a primary approach to managing and reducing childhood obesity. Also, these nutritional interventions are often supplemented with physical activity initiatives and behavioral modifications to enhance effectiveness [3].
Although dietary interventions have shown promise in the short-term management of pediatric obesity, the outcomes vary significantly among individuals, and there is a lack of clear guidelines regarding targeted dietary approaches [3, 4]. One standard recommendation for adults is an energy deficit of 500–1000 kcal/day, resulting in a gradual weight loss of 0.5–1.0 kg/week. However, translating this recommendation to children and adolescents is challenging, as their energy requirements, growth patterns, and nutritional needs differ from adults [3]. Despite the recommendation of moderately reduced energy diets as a first-line treatment for childhood obesity, there is a lack of consensus on the definition of “moderate” energy reduction and its application across different age groups and disease severities [1, 5].
For children and adolescents with severe obesity or obesity-related comorbidities, more intensive dietary approaches have been proposed, including very low-energy diets, low-carbohydrate diets, and protein-sparing modified fasts (2). These approaches have shown promising results in improving BMI, cardiometabolic profiles, and overall well-being over the short to medium term. However, implementing such intensive strategies raises concerns about potential nutrient deficiencies, growth stunting, and long-term sustainability (5). Therefore, a gap exists in the literature between conventional dietary treatments and the more intensive approaches, necessitating a deeper understanding of the role of energy targets in pediatric obesity management [3].
In light of the existing ambiguities and inconsistencies in dietary interventions for childhood obesity, this systematic review aimed to investigate the effectiveness of various dietary approaches with different energy content in managing excessive weight gain and related comorbidities in children and adolescents. By synthesizing the available evidence, this study seeks to provide comprehensive and evidence-based guidelines for tailored dietary management in this vulnerable population [1, 2]. It is hoped that the findings of this review will not only shed light on the most effective dietary strategies but also contribute to the development of targeted and individualized interventions that can be sustained over the long term to combat the growing epidemic of childhood obesity [4].
The study method
The researchers conducted a systematic review following PRISMA (Preferred Reporting for Systematic Reviews and Meta-Analysis) recommendations. They registered the review protocol with PROSPERO. This review aimed to find relevant studies published between 2000 and 2021, focusing on dietary interventions for childhood obesity treatment.
The researchers searched various electronic databases to gather information about childhood obesity and reviewed reference lists and relevant papers’ citations. They included studies that met specific criteria: participants were children and adolescents aged 2–18 years with obesity or related conditions, the interventions were targeted dietary approaches, and the outcomes included objective measurements of weight and BMI.
The full-text screening was done in duplicate to ensure accuracy and consistency. Data extraction was conducted based on predefined criteria, including participant characteristics, details of dietary interventions, energy targets, and anthropometric measures.
One reviewer evaluated the studies to assess the risk of bias, and a second reviewer checked for accuracy. All discrepancies were resolved through discussion with a third reviewer. The researchers used statistical methods to analyze the data and determine the effectiveness of different dietary interventions. They grouped the interventions into categories based on the type of diet and energy targets. They also assessed the heterogeneity, or variation, among the studies’ results.
Overall, the researchers followed rigorous procedures to identify and evaluate relevant studies, ensuring the reliability of their systematic review findings for childhood obesity.
Analysis
The research analyzed the effectiveness of various dietary interventions for children and adolescents with obesity and severe obesity. Based on current practices, the researchers categorized the childhood obesity interventions into ten groups and conducted statistical analyses using RevMan 5.0. The results were visualized using forest plots, revealing the combined effect sizes for different dietary and energy categories, including interventions targeting severe obesity. The study offers valuable insights into dietary management for addressing obesity in young populations, contributing to better weight management strategies.
Results
This review analyzed data from 125 studies, which included 7003 participants across different age groups and geographic locations. Out of the 125 studies, sixty (60) were randomized controlled trials (RCTs), sixty-one (61) were prospective cohort studies, and four (4) belonged to other study designs. The overall bias risk in the studies was high, with only three( 3) studies having low risk and nine (9) studies having moderate bias risk. Also, these researches were conducted in Europe (38.4%) and North America (26.4%).
The dietary interventions included 142 approaches across the 125 studies. Analysis of these studies revealed the following findings;
- The most common type of intervention involved a prescribed energy target (28.2% of interventions), followed by national reference diets (19.0%), and targeted macronutrient consumption (12.7%).
- The interventions varied in duration, with some lasting as short as 0-4 weeks and others lasting over 12 months. Collectively, all dietary approaches effectively achieved weight loss, resulting in a BMI reduction of 1.57 kg/m2.
- Hypocaloric dietary interventions (with the most significant energy deficit) demonstrated the greatest BMI reduction of 2.32 kg/m2. Nutritional interventions with normocaloric energy targets showed a BMI reduction of 1.72 kg/m2.
- There was a high degree of heterogeneity in the results, indicating variations in the effectiveness of different dietary approaches. After excluding studies with an increased risk of bias, the overall efficacy remained similar.
- The study also examined the intervention effects by age and found that dietary interventions in high school-aged children showed a BMI reduction of 2.27 kg/m2. In comparison, interventions in primary school-aged children showed a 2.11 kg/m2 reduction.
- The study’s findings suggest that various dietary approaches can effectively manage obesity in children and adolescents. However, the efficacy may differ depending on elements like the energy target and the participants’ ages. Further research is needed to determine the most suitable dietary interventions for specific age groups and risk profiles.
Discussion
The discussion presented in this systematic review offers a thorough assessment of the effects of diets with various energy contents on weight management for kids and teenagers with obesity and associated comorbidities. The researchers conducted a meta-analysis of 125 studies to investigate the relationship between dietary energy deficit and BMI reduction in this population. They found a clear association between a decrease in BMI and the extent of dietary energy deficit. As the energy deficit increased, the nutritional interventions were more effective in reducing BMI, mainly when measured immediately after the treatment (1).
The review identified three main types of dietary interventions for childhood obesity: hypocaloric, basal metabolic rate (BMR), and normal-caloric interventions. Hypocaloric diets (very low-energy diets (VLEDs), low-carbohydrate diets, and protein-sparing modified fasts) showed the most substantial reduction in BMI. However, even less intense hypocaloric diets were more effective than BMR or normocaloric interventions (1).
It is important to note that the energy restriction across the different dietary interventions exhibited high heterogeneity, especially for hypocaloric diets, which showed varying BMI reduction rates. Additionally, the review highlighted the need for more clinical trials testing intensive dietary interventions, with limited evidence available for their use in younger children (1).
While ad libitum diets and conventional interventions failed to achieve clinically significant BMI reductions, early weight loss success within the first month of treatment initiation predicted meaningful BMI changes at six months and one year. Thus, the researchers recommend offering effective treatment options for childhood obesity at the start of care and considering alternative interventions for individuals not showing treatment effects within the initial three months (1).
The review acknowledged that a 5-7% BMI reduction is commonly recommended as clinically significant. However, it also pointed out that smaller BMI reductions can improve obesity-related comorbidities. To fully realize health improvements in children and adolescents, the review calls for varying intensity levels of dietary interventions over the short and long term (1).
This systematic review and meta-analysis emphasize the importance of considering dietary energy deficits in weight treatment for patients with childhood obesity. It highlights the effectiveness of hypocaloric diets but also encourages further research on less intensive hypocaloric approaches and the development of standardized definitions for energy restriction concerning baseline BMI, age, and gender (1).
Limitations
There are caveats to this study that need to be considered. They include;
- Limited Representation of Severe Obesity: The study lacked sufficient data on childhood obesity defined as severe obesity, affecting the generalizability of the findings.
- Exclusion of Certain Comorbidities: Some interventions excluded specific obesity-related and developmental comorbidities, limiting the understanding of intervention effectiveness in these subgroups.
- Lack of Focus on Developing Countries: The study had a geographical bias, with limited research on dietary interventions in developing countries.
- Limitation in Outcome Measure (BMI): Using BMI as the primary outcome measure may only partially account for natural growth effects, impacting the interpretation of results.
- Heterogeneity in Dietary Energy Targets: Different interventions had varied energy targets, making direct comparisons challenging.
- Age Representation and Lack of Evidence for Younger Children: There was a lack of data on interventions for younger children, particularly preschool-aged children.
- Absence of Detailed Treatment Component Analysis: Some interventions had multiple components, but the study didn’t analyze their influence on outcomes.
- Insufficient Evidence for Intensive Dietary Approaches: Limited evidence supported intensive dietary approaches in younger children.
- Lack of Consistent Definitions for Energy Restriction: Standardized definitions for energy restriction were lacking, affecting the evidence base.
- Potential Influence of Other Factors: Some interventions didn’t consider starting BMI, potentially impacting the outcomes.
These limitations should be considered while interpreting the study’s findings and planning future research in pediatric obesity and dietary interventions.
Conclusion
This fantastic systematic review establishes a strong link between dietary interventions’ energy deficit and BMI reduction in children and adolescents with obesity and related comorbidities. Hypocaloric, BMR, and normocaloric interventions showed promising results in achieving clinically substantial BMI reductions. Conversely, general nutrition education in childhood obesity patients without a specified energy target yielded increased BMI levels, suggesting that it is crucial to differentiate between population-level interventions and targeted weight management approaches to ensure effective treatment for all affected children and adolescents. These findings emphasize the need for tailored and efficacious therapies to address the challenges of childhood obesity.
References
- [1] Southcombe, E., Gerner, B., Allman-Farinelli, M., & Greenwood, C. (2023). Targeted dietary approaches for the management of obesity and severe obesity in children and adolescents: a systematic review and meta-analysis. International Journal of Obesity, 47(3), 439-452. https://onlinelibrary.wiley.com/doi/epdf/10.1111/cob.1256
- [2] World Health Organization. (2023). Childhood overweight and obesity. Retrieved from https://www.who.int/dietphysicalactivity/childhood/en/
- [3] Chen, L., Appel, L. J., Loria, C., Lin, P. H., Champagne, C. M., Elmer, P. J., … & Harsha, D. W. (2009). Reduction in consumption of sugar-sweetened beverages is associated with weight loss: the PREMIER trial. The American journal of clinical nutrition, 89(5), 1299-1306. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2676995/
- [4] Daniels, S. R. (2006). The consequences of childhood overweight and obesity. The Future of Children, 16(1), 47-67. https://pubmed.ncbi.nlm.nih.gov/16532658/
- [5] Hu, F. B., Li, T. Y., Colditz, G. A., Willett, W. C., & Manson, J. E. (2003). Television watching and other sedentary behaviors in relation to risk of obesity and type 2 diabetes mellitus in women. Jama, 289(14), 1785-1791. https://pubmed.ncbi.nlm.nih.gov/12684356/
- [6] Lu, W., McKyer, E. L., Lee, C., Goodson, P., Ory, M. G., & Wang, S. (2013). Perceived barriers to children’s active commuting to school: a systematic review of empirical, methodological and theoretical evidence. International journal of behavioral nutrition and physical activity, 10(1), 140. https://ijbnpa.biomedcentral.com/articles/10.1186/s12966-014-0140-x
- [7] Olds, T., Ridley, K., Dollman, J., & Maher, C. (2010). The validity of a brief measure of sedentary time within adolescents’ school hours. The Journal of Science and Medicine in Sport, 13(4), 403-407. https://ijbnpa.biomedcentral.com/articles/10.1186/1479-5868-7-92
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