Child and Adolescent Obesity: The Nurse Practitioner’s Use of the . SHAPEDOWN Method . Laurel M. Mellin,
MA,
RD, and Lisa Frost, MS, RN, CPNP
The prevalence of obesity in children and adolescents has increased approximately 50% in the last 20 years and now affects more than one in four young people. Although family-based approaches to the problem recently have shown weight losses maintained at S-year and lo-year follow-up, this care is unavailable in many communities because of an insufficient availability of trained providers. Nurse practitioners are uniquely appropriate for providing child and adolescent obesity services yet appear to be underrepresented among pediatric obesity care providers. This article describes a method of preventive and therapeutic care that nurse practitioners can use in clinical practice. J PEDIATR HEALTH CARE. (1992).
6, 187-193.
T
he prevalenceof obesity has increased 54% in children and 39% in adolescentsin the last 20 years (Gortmaker, Dietz, Sobol, & Wehler, 1987). Currently, at least one in four children is obese. Recently, studies have shown that obesity in young people is very treatable. Although diet, exercise,and behavioral strategies previously had proved ineffective in decreasingobesity in children and adolescents (Coates & Thorensen, 1978), using these modalities in a family-based approach has yielded significant and sustained decreases in relative weight. In 1983 researchersBrownell, Kelman, and Stunkard demonstrated the effectivenessof a family-basedpediatric obesity intervention at l-year follow-up. Subsequently,other studies substantiatedthese findings and showed that the maintenance of weight loss persisted (Epstein, Valoski, Wing, & McCurley, 1991; Epstein, Wing, Koeske, &Valoski, 1987; Mellin, Slinkard, & Irwin, 1987) even at lo-year follow-up using this family approach. Despite the advancesin pediatric obesity treatment, this careis unavailablein many communities largely because of an insufficiency of trained providers. Laurel M. Mellin is the Director of the Center for Child and Adolescent Obesity and Assistant Clinical Professor of Family and Community at the School of Medicine, University of California, San Francisco, Calif. Lisa Frost is the Regional Director of Pediatrics at Care Point Nursing Services in the San Francisco Bay Area. Presented at the 1990 Annual NAPNAP Conference, March 28-31, 1990, San Francisco, Calif. For SHAPEDOWN program information: San Anselmo, CA 94960.
Balboa Publishing, 11 Library Place,
Reprint requests: Laurel M. Mellin, MA, RD, Director, Center for Child and Adolescent Obesity, School of Medicine, University of California, San Francisco AC-g, Box 0900, San Francisco, CA 94143. 2511/x2345
JOURNAL
OF PEDIATRIC
HEALTH
CARE
The purposesof this article are to describe a method of care for obesity in children and adolescentsin which nurse practitioners can assume an important role and to suggest that widespread implementation of this method by nurse practitioners may have a significant impact on the prevalenceand severity of obesity in the young. The SHAPEDOWN method (Mellin, 1991), a clinical processdeveloped during the last 12 years at the University of California, San Francisco, and disseminated to health facilities nationwide, is described. This method involves both preventive care by primary care providers and therapeutic services by interdisciplinary pediatric obesity specialist teams. n
THE NURSE PRACTITIONER’S
ROLE
In the SHAPEDOWN method, the nurse practitioner can assumeeither a preventive or a therapeutic role. In a primary-care setting, nurse practitioners identify obesity and deliver preventive care. They also can function in a pediatric obesity specialist team to deliver therapeutic care. Nurse practitioners are uniquely qualified to deliver pediatric obesity services. First, nursing, of all disciplines, has the most comprehensive knowledge base. The nurse practitioner is able to respond to nutrition questions as readily asto parenting issues.Second,nurse practitioners are skilled in the concrete application of behavioral therapies, yet are equally capableof building a nurturing therapeutic relationship and focusing on interactional problems. Third, nurses place a high value on health promotion activities and thus view this service as valuable. Fourth, nurse practitioners can offer both preventive and therapeutic care and be appropriately compensatedwithout necessitatingexcessivelyhigh pa187
188
Mellin
Volume 6, Number 4 July-August 1992
& Frost
%
-12
1
I 6I
3I
I 9
I 12
I 15
(months) I
I I
‘Percent
l
I
I
NO TREATMENT SHAPEDOWN
01 mean wetght for twght,
n FIGURE SHAPEDOWN
(n = 29) GROUP
(n = 34)
age and sex.
validation
graph.
tient fees or external funding. Last, in their primary care role they have the opportunity to screen a multitude of young people for obesity and thereby contribute significantly to problem identification efforts. THE SHAPEDOWN
METHOD
The SHAPEDOWN program began to be developed at the University of California, San Francisco in 1979 as part of a Bureau of Maternal and Child Health interdisciplinary adolescent health training program. It is currently in its fifth edition. It has been standardized (Mellin, 1991) and validated (Mellin, et al., 1987) in a controlled study of 64 families who were followed for 15 months (Figure). Participation in SHAPEDOWN was associatedwith significant improvements in relative weight, weight-related behavior, depression, and knowledge. It has been disseminated to more than 400 clinical sites nationally and recognized by the American Medical Association as an exemplary program (AMA, 1988). Step 1. identification
Nurse practitioners identify children and adolescents with disproportionate weight-for-height percentile ratios, especially those whose weight percentile has increased or who have a family history of obesity. They briefly assessthe weight problem and develop a preventive care plan. The identification of obesity alone can be a major contribution of the nurse practitioner becausea significant barrier to the primary prevention of the condition is the failure to identify the problem. Parental denial of the obesity is common. Health professionals may ignore
the presence of obesity in children for a variety of reasons, most particularly, fear of identifying a problem they perceive as not treatable or anticipation of prompting negative feelings in the child or parent. In addition, clinicians may sense the family’s denial of the problem and may be reluctant to confront it. Now that the longterm effectivenessof family-based approaches has been supported by research and that programs that are delivered by interdisciplinary pediatric obesity teams are more available in the community, concern about identifying an untreatable problem is lessvalid. Confronting a family’s distress or denial about the problem of pediatric obesity is difficult but therapeutic. By doing so, the child who is teased at school about weight is no longer alone with the problem. The family’s confusion, guilt, and fear about the problem can be directed toward acknowledging the child’s experience and mobilizing to support the young person’s weight management.
T
echniques for stimulating are discussed.
parent awareness
Techniques for stimulating the parents’awarenessof the problem include reviewing their child’s height and weight percentile during well child check-ups and regular follow-up appointments and eliciting their reactions to it, such as asking them “Are you concerned about your child’s weight ?” Should the parent of a severely obese child respond negatively, nurse practitioners can express their concerns about the medical and psychosocial significance of the weight and discusswith the child and parent the consequencesof delay in responding effectively to the problem. Negative sequelae of postponing intervention in childhood include less parental influence during adolescence,the entrenchment of unhealthful behaviors, the protraction of peer ridicule, and the rapid proliferation of adipocytes that accompanies puberty. Step 2. Preventive Care
Obesity in children is complex and diverse in cause; however, the nurse practitioner can conduct an initial brief assessmentand develop a preventive care plan. During the review of systems, nurse practitioners can elicit a broad range of psychosocial, biomedical, and behavioral information and begin to uncover the possible origins of the weight problem: genetics, lifestyle, emotional overeating, the too-comfortable child, the too-uncomfortable child, and/or medical factors. The next step is to develop care plans that correspond to these factors (Table). Genetics. Body build and, to some extent, body fatness are inherited. If the weight history of parents or grandparents indicates obesity, particularly childhood obesity, a genetic predisposition to obesity in the young
Journal of Pediatric Health Care
Child and Adolescent Obesity
TABLE Cause of child and adolescent obesity *: A simplified SHAPEDOWN method
n
CONTRlBUTOR
Genetics Lifestyle
model for preventive counseling with the
DESCRII’TION
TREATMENT COAL
A genetic predisposition to fat deposition High caloric density diet Inactivity
Acceptance of one’s genetic body build Improve family food environment Increase physical activity Decrease television viewing Eat in response to hunger and satiety Improve emotive states Improve communication skills Increase physical activity Decrease child’s “comfort” Strengthen parental limit-setting practices
Emotional overeating
Hyperemotional
Too-comfortable
Indulged child Overprotective/permissive parents, Parent/child enmeshment Deprived child, removed parents Parent/child disengagement Conditions that affect obesin/, diet, or activity
Too-uncomfortable
child
child
Medical problems
*Typically
mme than one etiologic characteristic
189
state eating
Increase child’s comfort Strengthen parental nurturing Improve parent/child communication Improve management of medical conditions
is present in a child or adolescent.
person is likely. The goal of treatment, given this factor, is to increasethe child’s and family’s acceptanceof the young person’sgenetic body build. Becauseweight loss in the genetically obese may be biologically refractory, failure to accept one’s genetic body build can result in restrictive dieting, binge eating, psychologic distress, and weight gain. lifestyle. Adipogenic behaviors(a high-fat diet, meal irregularity, and inactivity) can lead to the onset or exacerbation of obesity. Eliciting information about habitual food behaviors,such asthe fat content of the milk consumed and obtaining a 24-hour dietary recall, can provide data on the caloric density of the diet and on meal regularity. Irregular eating patterns, particularly the obese pattern of skipping breakfast, skimping on lunch, and consuming large quantities of food in the afternoon and evening, can be detected. A ‘-/-dayrecall of physical activity and information about the child’s after-school activity is helpful. Treatment goals include decreasingthe caloric density of the diet (for example, increasingconsumption of non-fat milk products, fruits, vegetables,grains, and low fat meats and decreasing high-fat foods and added fat), consuming regular meals, increasing activity levels (for example, structured &erschool sports, household chores, walking, and family physical activities), and decreasingsedentary activities such as television (Dietz & Gortmaker, 1985). Emotional Overeating. Disregarding internal cuesof hunger and satiety can result in excessiveadipogenesis. Eliciting information about the cuesthat trigger a child to eat when not hungry can be helpful in evaluating
emotional overeating. Common cues are boredom, loneliness, sadness,and anger. The therapy for emotional overeating involves improving emotive states through psychologic counseling and physical activity, increasing skills in emotionally expressiveand assertive communication, substituting adaptive responsesto difficult emotions, and learning to initiate and conclude eating in responseto internal signs of hunger and satiety. Improving the quality of the diet and the quantity of food consumedare not primary goals but are expected to improve as the emotional overeating abates. The Too-comfortable Child. The indulged child typically has overprotective, permissive parents. Parental expectationsare low, and the child has too much power in the family. O ften the child has a specialplace in the family, such as that of surrogate spouse. Parent-child enmeshmentis common. The falsenessof the relationship impairs parent-child intimacy, creating a senseof isolation in the child that excessivefood, television, or reading diminish. In addition, the permissivenessis usually associatedwith indulgent food and inactivity behaviors. The treatment is to decreasethe child’s apparent but not actual comfort by altering the functioning of the family (for example, support one parent in separating from the child and the other in becoming more engaged and improving parental limit setting skills). Family therapy may be indicated. The Too-uncomfortable Child. Children who have been neglected or the victims of unusual stressesmay respond to their difficult emotive responseswith compulsive eating or excessiveinactivity (for example, pro-
Volume
190
Mellin
tracted television viewing or reading). The child often has a depressive affect or expressions of anger at one or both parents. The recommended treatment is to increase the child’s comfort by improving family relationships and nurturing. Often psychotherapy or family therapy is required. Medical Problems. A variety of medical problems can trigger the onset of obesity or contribute to its exacerbation. The mechanism most often induces inactivity; such conditions include congenital heart defects, orthopedic problems, and exercise-induced asthma. Various medications, such as insulin and steroids, can stimulate weight gain. Treatment often focuses on improved management of the condition.
F amily
is provided with program material and
direction. After discussing the probable factors with the young person and his or her parent, the nurse practitioner provides them with the program books and directs them to the content that corresponds to the identified contributors to the problem. During the next 3 months, the family implements the intervention program, with or without periodic visits with the nurse practitioner. At the 3-month follow-up visit, if insufficient progress has been made, the family may be referred to a SHAPEDOWN pediatric obesity specialist team. Indications that the guided self-care program is sufficient include an average weight loss of one-half to 1 pound per week for most young people. However, during periods of rapid growth in adolescence or for children or adolescents who had been rapidly gaining weight before the intervention, weight maintenance to a mean of one-half pound per week weight loss is sufficient. If progress with weight management is sufficient and the child or adolescent is satisfied with the guided self-care program and does not express interest in obtaining the services provided by a pediatric obesity specialist team, such as a more in-depth assessment and participating in more intensive individual and group care, then the continuation of the guided self-care program is appropriate. Step 3. Comprehensive
6, Number
July-August
& Frost
Assessment
When primary preventive interventions have not decreased or resolved the obesity, care by an interdisciplinary team specializing in pediatric obesity is indicated. This care involves a comprehensive, biopsychosocial assessment and includes the availability of a broad range of treatment options. Alternatives range from a group or individual application of the SHAPEDOWN program to managing the underlying causes of the obesity, such as medical, psychologic, and family functioning factors before or instead of entering SHAPEDOWN.
4
1992
In addition to the primary care role of nurses described, nurse practitioners function as members of interdisciplinary teams specializing in pediatric obesity care. The minimal disciplines represented on these teams are medicine, nutrition, mental health, and exercise. Often one or two team members deliver direct service, and the remaining disciplines provide consultation. Typically, nurse practitioners provide the direct service and receive consultation from a physician, a registered dietitian, a licensed mental health professional, and an exercise specialist. For example, the nurse practitioner may provide nutrition advice to otherwise healthy obese teens in a group program but refer a hyperlipidemic adolescent in the group to the registered dietitian for additional diet therapy sessions. The SHAPEDOWN method assists the nurse practitioner in delivering truly interdisciplinary assessments without the resources required for all team members to assess each young person and family. This is done through the Youth Evaluation Scale (YES; Mellin, 1987), a computerized assessment instrument for eating disorders and obesity in children and adolescents. YES is composed of questionnaires for the youngsters and their parents that are compilations of standardized measures of a broad range of biopsychosocial variables related to weight and eating. As a result, for example, all children do not require assessment by a psychologist. Instead, YES provides several standardized measures of psychologic functioning, so the nurse can refer only those children whose YES results include abnormal scores on these tests.
Y
ES provides standardized which the nurse practitioner family and child.
measures with can guide the
To administer YES, the nurse practitioner records on the questionnaires certain information obtained during a clinic visit: height, weight, triceps skin fold, fitness test results, blood pressure, waist-hip circumferences, and total serum cholesterol. The young person and parents complete the questionnaires and mail them to a central processing service. Several days later, the nurse practitioner receives by mail from the processing service two YES reports, one for patient education and the other for the provider. The patient education report displays all the testing results including percent overweight, body fat patterning, serum cholesterol, blood pressure, physical fitness, lifestyle, emotional overeating behaviors, depression, self-esteem, anxiety, body image, weight management knowledge, parental attitudes and behaviors, family functioning, and parent-child communication. In addition, it evaluates the extent of the medical and psychosocial risks of the obesity. The provider report summarizes de-
Journal of Pediatric Health Care
Child
mographic, historic, and sensitive information (for example, sexual activity, substance use) for review by the nurse practitioner. On the second visit, the nurse practitioner reviews the YES results with child/adolescent and parents to describe the extent of obesity, its medical and psychosocial risk, and potential contributors to its onset and exacerbation. With this information, the young person and family can identify their healthful characteristics and those characteristics that are not, which may be the focus of obesity intervention. For instance, Jack, a 14-yearold, learned through his YES assessment that his obesity was a medical risk because he was severely obese and had a central fat deposition pattern and family history of hypertension. The psychosocial disadvantage of his weight was significant because his se&esteem about his weight was low; he was ridiculed about his weight by peers. Correlates of his obesity were genetics, inactivity, emotional overeating, anxiety, poor knowledge of weight management, parental limit-setting deficits, an enmeshed relationship with his obese mother, and a disengaged relationship with his father who reportedly drank heavily. These factors were explored as potential contributors to the problem.
T
he family individualized
develops a care plan that leads to treatment.
By the conclusion of the YES assessment, families have developed a care plan that is individualized according to the contributors to the problem and the medical and psychosocial risk of the obesity. Treatment plans range from other therapies (for example, family therapy, psychotherapy, medical treatment) to group obesity treatment. In Jack’s case, the family was reluctant to identify the father’s substance use as a problem. The provider suggested that family factors associated with substance problems can be major contributors to obesity in the child. The family elected to participate in the family-based teen SHAPEDOWN program. During the parent sessions, the father’s substance-related cognitive difficulties were apparent; by the conclusion of the initial lo-week program, the father identified his substance use as a problem, and the family entered Alcoholics Anonymous programs. One of the most important benefits of this assessment and treatment process is that it often identifies problems underlying the obesity, based on standardized, computerized tests results. By doing so, families that could become stuck on the symptom (obesity) and scapegoating the child, often reframe the problem as related to family variables. Many families are surprisingly open to the computerized information and, in response to it, demonstrate a willingness to address the underlying disturbances.
and Adolescent
Obesity
191
3. I let go of weight&m and accept my child’s natural body build. 4. I create a healthy but not depriving food environment at home. 5. I develop a f&ily lifestyle that is physically active. 6. I sm an acrive and enrichin lifestyle for my child that in&J&s daily exercise. 7. I support each fm member in openly and &ectiveiy expressinghis or her f&gs and needs. 8. I give my child direct messagesthat I accept and value him or her. 9. Isetlimitswithmychildandtbllow through consistently. 10. IarnagoodrolemodelbecauseIam improving my own weight, eating, or inactivity problems. Copyright 1991, L. Mellin.
Step 4. Treatment
The orientation of SHAPEDOWN is to view obesity as a symptom with diverse biopsychosocial contributors and consequences. Rather than narrowly focusing on the excess adipose tissue, the program addresses the obesity within the context of the overall development of the child and in relation to the family and social systems as reflected in the parent guidelines (Box 1). Program goals are to normalize the child’s or adolescent’s weight within his or her genetic potential, to develop risk reduction diet and physical activity behaviors, and to facilitate the identification and treatment of psychosocial and biologic contributors to the problem. The program is designed for children and adolescents aged 6 to 18 years and is comprised of workbooks and parent guides that are on four developmental levels (6 through 8 years, 9 through 10 years, 11 through 13 years, and 14 through 18 years), an instructor’s guide, and support materials. The program can be applied in group sessions or in individual counseling. The duration of the initial group program is 10 weeks; it provides introductory training in SHAPEDOWN skills. Continuing care options include individual follow-up counseling and/or entering an ADVANCED SHAPEDOWN support group. The duration of care ranges from 3 months to several years. Criteria that are designed to ensure a high quality of
Volume
192
Mellin
n
BOX 2 THE SWBDOWN
6, Number
July-August
& Frost
TASKS
1. I love and valuemyself. 2. I acceptmy geneticbody build. 3. I createfor myself an activelifestylethat
includesdaily exercise. 4. I fiII my l&e with pleasurefrom interests,activities,and people. 5. I choosea healthybut not depriving diet. 6. I eat when I am hungry and stop when I am satisfied,not frill. 7. I am awareof my feelings,so I know what I need. 8. I recognizemy needsand am committed to filling them. 9. I connectwith others by sharingmy true feelingsand thoughts. 10. I receivefrom others by askingfor what I needfkom them. 11. I try to changethe things I can control and let go of the things I can’t. 12. I take careof today rather man focusing on yesterdayor tomorrow. Copyright 1991, L. MeIIin.
care have been established for becoming a provider. These criteria include (a) delivery by an interdisciplinary team, (b) the completion of introductory (l-day) and advanced (3-day) pediatric obesity training by videotaped self-study course or by on-site course participation, (c) membership in the Center for Child and Adolescent Obesity (CAO) to receive clinical and research updates, and (d) the use of program materials and the avoidanceof combining other treatments with SHAPEDOWN, specifically, restrictive diets or very low-calorie diet formulas. All costs are low. Program and training information can be obtained from the first author.
C riteria
are designed to ensure high quality provided care.
The following casestudy shows the four components of the SHAPEDOWN method. Rebecca,a 14-year-old, visited the nurse practitioner with the complaint of a persistent upper respiratory infection. The nurse practitioner evaluated Rebecca’sweight, which was above the 95th percentile, and her height, which was at the 25th percentile, and identified the obesity (step 1). The nurse practitioner began to provide preventive care with a brief assessment(step 2). Rebeccawas asked if her weight was a concern. Rebecca responded that she hated her weight and burst into tears. At the conclusion of the interview, the nurse practitioner con-
4
1992
eluded that this adolescent’sobesity appearedto be related to emotional overeating and genetic factors. She described her impressions to Rebecca, and they identified the goals of accepting her genetic body build, eating when she was hungry and participating in an exercise program to decreasestress. Rebecca returned monthly for counseling with the support of program materials. Her parents did not participate in the sessions, although they received program materials. At the 3-month follow-up visit, Rebecca had increasedher physical activity but still engaged regularly in emotional overeating. She expressedan interest in a more intensive, group approach. The nurse practitioner had become increasingly concerned that Rebecca may have a subclinical eating disorder. She referred the adolescent to the SHAPEDOWN interdisciplinary pediatric obesity specialist team. The program to which Rebecca was referred was conducted by a nurse practitioner, with support from other disciplines. Rebecca and her parents completed a YES assessment(step 3), which showed a middle adolescent with a pattern of emotional overeating and a genetic predisposition to obesity. Rebecca resembled her paternal grandmother, who was portly and largeframed. Rebecca’sdepression, anxiety, and self-esteem scoreswere normal, and her family was functional. The obesity appeared to be secondary to genetic factors, conflict about body type, emotional overeating, inactivity, and lack of parenteral acceptanceof the adolescent’s weight. Rebecca was not bulimic. The care plan involved a group program because Rebecca was in middle adolescence,a time when peer samenessis important. A group would allow her opportunities to be the same as others who were also struggling with accepting their body type. Moreover, it would provide structured parental support. Rebeccaenrolled in the group program (step 4) and learned to use stimulus control techniques (identifying the cuessheused to start and stop eating and developing strategies for managing those cues) and binge prevention strategies (emotionally expressivecommunication, stressreduction techniques, physical activity) to control her eating. With support from her peers, she addressed the 12 SHAPEDOWN tasks of Adolescence (Box 2). Rebeccabegan exercising, a combination of walking to school, cheer leading, and aerobic classes.Slowly, she moved toward accepting her body build. In the parent group, Rebecca’sparents began to express their sadnessabout their daughter’s body build and to come to terms with the possibility that Rebecca’s body may always be somewhat rounded. This freed them to stop trying to control Rebecca’s eating and weight, which, in turn, resulted in marked improvement in Rebecca’semotional overeating. After the lo-week group, Rebeccacame to individual
lournal of Pediatric Health Care
Child
sessionsbi-weekly for 5 months and achieved a moderate weight loss. Her emotional overeating subsided, and she becameactive in school sports. Rebecca’sbody image improved significantly. She had the option of participating in an ADVANCED SHAPEDOWN support group but did not feel the need for frequent sessions becauseweight and eating had recededas issues. n
SUMMARY
Nurse practitioners are uniquely qualified to take a leadership role in providing this pediatric obesity care, which not only addressesthe symptom of excessivebody fat but also supports the strength of the family and the well-being of the child. Although developing liaisons with other team members and acquiring additional training require effort, should nurse practitioners take up the challenge and focus a portion of their clinical efforts on pediatric obesity care, the benefits to the health and well-being of the obese young could be highly significant. REFERENCES American Medical Association. (1988). Proceedingsof the National ConFesson Adolescent Health. Chicago: author.
and Adolescent
Obesity
193
Brownell, K. D., Kelrnan, J. H., & Stunkard, A. J. (1983). Treatment of obese children with and without their mothers: Changes in weight and blood pressure.Pediatrics, 71, 515-523. Coates, T., & Thorenson, C. (1978). Treating obesity in children and adolescents:A review. A nzerhn Journal of Public Health, 68: 143148. Dietz, W. H., & Gortmaker, S. L. (1985). Do we fatten our children at the television set? Obesity and television viewing in children and adolescents.Pediutrics, 75, 807-812. Epstein, L. H., Valoski, A., Wing, R. R., & McCurley, J. (1990). Ten-year follow-up of behavior, family-based treatment for obese children. Journal of the American Medical Association, 265, 25 19. 2523. Epstein, L. H., Wing, R. R., Koeske, R., & Valoski, A. (1987). Long-term effectsof family-based treatment of childhood obesity. Journal of Cons&in- and Clinical Psycholog 55, 91-95. Gortmaker, S. L., Diem, W. H., Sobol, A. N., & Wehler, C. A. (1987). Increasing pediatric obesity in the United States.American Journal ofDiseases of Children, 141, 205-215. MeBin, L. M., Shnkard, L. A., & Irwin, C. E. (1987). Adolescent obesity intervention: Validation of the SHAPEDOWN program. Journal ofthe American Dietetic Associahn, 87, 333-337.
Melhn, L. M. (1987). The Young Evahation Scale (2nd ed.) San Anselmo, Calif: Balboa Publishing. Mellin, L. M. (1991). SHAPEDOWN We&h Management ProFam of Children and Adolescents (5th ed.) San Ansehw, Calt$ Balboa Publishing.
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Bound volumes of the JOURNALOF PEDIATRIC HEALTH CARE are available to subscribers(only) for the 1992 issuesfrom the Publisher, at a cost of $28.00 ($35.96 for Canadian and $34.00 for international) for Vol. 6 (January-December).Shipping chargesare included. Each bound volume contains a subject and author index and all advertising is removed. Copies are shipped within 60 days after publication of the last issue of the volume. The binding is durable buckram with the JOURNAL name, volume number, and year stamped in gold on the spine. Payment must acwmpany all W&X. Contact Mosby-Year Book Inc., Subscription Services, 11830 Westline Industrial Drive, St. Louis, M O 63146-3318, USA; phone (800)325-4177, ext. 4351, (314)453-4351. Subscriptions must be in force to qualify. Bound volumes are not available in place of a regular JOURNAL subscription.
MA,
RD, and Lisa Frost, MS, RN, CPNP
The prevalence of obesity in children and adolescents has increased approximately 50% in the last 20 years and now affects more than one in four young people. Although family-based approaches to the problem recently have shown weight losses maintained at S-year and lo-year follow-up, this care is unavailable in many communities because of an insufficient availability of trained providers. Nurse practitioners are uniquely appropriate for providing child and adolescent obesity services yet appear to be underrepresented among pediatric obesity care providers. This article describes a method of preventive and therapeutic care that nurse practitioners can use in clinical practice. J PEDIATR HEALTH CARE. (1992).
6, 187-193.
T
he prevalenceof obesity has increased 54% in children and 39% in adolescentsin the last 20 years (Gortmaker, Dietz, Sobol, & Wehler, 1987). Currently, at least one in four children is obese. Recently, studies have shown that obesity in young people is very treatable. Although diet, exercise,and behavioral strategies previously had proved ineffective in decreasingobesity in children and adolescents (Coates & Thorensen, 1978), using these modalities in a family-based approach has yielded significant and sustained decreases in relative weight. In 1983 researchersBrownell, Kelman, and Stunkard demonstrated the effectivenessof a family-basedpediatric obesity intervention at l-year follow-up. Subsequently,other studies substantiatedthese findings and showed that the maintenance of weight loss persisted (Epstein, Valoski, Wing, & McCurley, 1991; Epstein, Wing, Koeske, &Valoski, 1987; Mellin, Slinkard, & Irwin, 1987) even at lo-year follow-up using this family approach. Despite the advancesin pediatric obesity treatment, this careis unavailablein many communities largely because of an insufficiency of trained providers. Laurel M. Mellin is the Director of the Center for Child and Adolescent Obesity and Assistant Clinical Professor of Family and Community at the School of Medicine, University of California, San Francisco, Calif. Lisa Frost is the Regional Director of Pediatrics at Care Point Nursing Services in the San Francisco Bay Area. Presented at the 1990 Annual NAPNAP Conference, March 28-31, 1990, San Francisco, Calif. For SHAPEDOWN program information: San Anselmo, CA 94960.
Balboa Publishing, 11 Library Place,
Reprint requests: Laurel M. Mellin, MA, RD, Director, Center for Child and Adolescent Obesity, School of Medicine, University of California, San Francisco AC-g, Box 0900, San Francisco, CA 94143. 2511/x2345
JOURNAL
OF PEDIATRIC
HEALTH
CARE
The purposesof this article are to describe a method of care for obesity in children and adolescentsin which nurse practitioners can assume an important role and to suggest that widespread implementation of this method by nurse practitioners may have a significant impact on the prevalenceand severity of obesity in the young. The SHAPEDOWN method (Mellin, 1991), a clinical processdeveloped during the last 12 years at the University of California, San Francisco, and disseminated to health facilities nationwide, is described. This method involves both preventive care by primary care providers and therapeutic services by interdisciplinary pediatric obesity specialist teams. n
THE NURSE PRACTITIONER’S
ROLE
In the SHAPEDOWN method, the nurse practitioner can assumeeither a preventive or a therapeutic role. In a primary-care setting, nurse practitioners identify obesity and deliver preventive care. They also can function in a pediatric obesity specialist team to deliver therapeutic care. Nurse practitioners are uniquely qualified to deliver pediatric obesity services. First, nursing, of all disciplines, has the most comprehensive knowledge base. The nurse practitioner is able to respond to nutrition questions as readily asto parenting issues.Second,nurse practitioners are skilled in the concrete application of behavioral therapies, yet are equally capableof building a nurturing therapeutic relationship and focusing on interactional problems. Third, nurses place a high value on health promotion activities and thus view this service as valuable. Fourth, nurse practitioners can offer both preventive and therapeutic care and be appropriately compensatedwithout necessitatingexcessivelyhigh pa187
188
Mellin
Volume 6, Number 4 July-August 1992
& Frost
%
-12
1
I 6I
3I
I 9
I 12
I 15
(months) I
I I
‘Percent
l
I
I
NO TREATMENT SHAPEDOWN
01 mean wetght for twght,
n FIGURE SHAPEDOWN
(n = 29) GROUP
(n = 34)
age and sex.
validation
graph.
tient fees or external funding. Last, in their primary care role they have the opportunity to screen a multitude of young people for obesity and thereby contribute significantly to problem identification efforts. THE SHAPEDOWN
METHOD
The SHAPEDOWN program began to be developed at the University of California, San Francisco in 1979 as part of a Bureau of Maternal and Child Health interdisciplinary adolescent health training program. It is currently in its fifth edition. It has been standardized (Mellin, 1991) and validated (Mellin, et al., 1987) in a controlled study of 64 families who were followed for 15 months (Figure). Participation in SHAPEDOWN was associatedwith significant improvements in relative weight, weight-related behavior, depression, and knowledge. It has been disseminated to more than 400 clinical sites nationally and recognized by the American Medical Association as an exemplary program (AMA, 1988). Step 1. identification
Nurse practitioners identify children and adolescents with disproportionate weight-for-height percentile ratios, especially those whose weight percentile has increased or who have a family history of obesity. They briefly assessthe weight problem and develop a preventive care plan. The identification of obesity alone can be a major contribution of the nurse practitioner becausea significant barrier to the primary prevention of the condition is the failure to identify the problem. Parental denial of the obesity is common. Health professionals may ignore
the presence of obesity in children for a variety of reasons, most particularly, fear of identifying a problem they perceive as not treatable or anticipation of prompting negative feelings in the child or parent. In addition, clinicians may sense the family’s denial of the problem and may be reluctant to confront it. Now that the longterm effectivenessof family-based approaches has been supported by research and that programs that are delivered by interdisciplinary pediatric obesity teams are more available in the community, concern about identifying an untreatable problem is lessvalid. Confronting a family’s distress or denial about the problem of pediatric obesity is difficult but therapeutic. By doing so, the child who is teased at school about weight is no longer alone with the problem. The family’s confusion, guilt, and fear about the problem can be directed toward acknowledging the child’s experience and mobilizing to support the young person’s weight management.
T
echniques for stimulating are discussed.
parent awareness
Techniques for stimulating the parents’awarenessof the problem include reviewing their child’s height and weight percentile during well child check-ups and regular follow-up appointments and eliciting their reactions to it, such as asking them “Are you concerned about your child’s weight ?” Should the parent of a severely obese child respond negatively, nurse practitioners can express their concerns about the medical and psychosocial significance of the weight and discusswith the child and parent the consequencesof delay in responding effectively to the problem. Negative sequelae of postponing intervention in childhood include less parental influence during adolescence,the entrenchment of unhealthful behaviors, the protraction of peer ridicule, and the rapid proliferation of adipocytes that accompanies puberty. Step 2. Preventive Care
Obesity in children is complex and diverse in cause; however, the nurse practitioner can conduct an initial brief assessmentand develop a preventive care plan. During the review of systems, nurse practitioners can elicit a broad range of psychosocial, biomedical, and behavioral information and begin to uncover the possible origins of the weight problem: genetics, lifestyle, emotional overeating, the too-comfortable child, the too-uncomfortable child, and/or medical factors. The next step is to develop care plans that correspond to these factors (Table). Genetics. Body build and, to some extent, body fatness are inherited. If the weight history of parents or grandparents indicates obesity, particularly childhood obesity, a genetic predisposition to obesity in the young
Journal of Pediatric Health Care
Child and Adolescent Obesity
TABLE Cause of child and adolescent obesity *: A simplified SHAPEDOWN method
n
CONTRlBUTOR
Genetics Lifestyle
model for preventive counseling with the
DESCRII’TION
TREATMENT COAL
A genetic predisposition to fat deposition High caloric density diet Inactivity
Acceptance of one’s genetic body build Improve family food environment Increase physical activity Decrease television viewing Eat in response to hunger and satiety Improve emotive states Improve communication skills Increase physical activity Decrease child’s “comfort” Strengthen parental limit-setting practices
Emotional overeating
Hyperemotional
Too-comfortable
Indulged child Overprotective/permissive parents, Parent/child enmeshment Deprived child, removed parents Parent/child disengagement Conditions that affect obesin/, diet, or activity
Too-uncomfortable
child
child
Medical problems
*Typically
mme than one etiologic characteristic
189
state eating
Increase child’s comfort Strengthen parental nurturing Improve parent/child communication Improve management of medical conditions
is present in a child or adolescent.
person is likely. The goal of treatment, given this factor, is to increasethe child’s and family’s acceptanceof the young person’sgenetic body build. Becauseweight loss in the genetically obese may be biologically refractory, failure to accept one’s genetic body build can result in restrictive dieting, binge eating, psychologic distress, and weight gain. lifestyle. Adipogenic behaviors(a high-fat diet, meal irregularity, and inactivity) can lead to the onset or exacerbation of obesity. Eliciting information about habitual food behaviors,such asthe fat content of the milk consumed and obtaining a 24-hour dietary recall, can provide data on the caloric density of the diet and on meal regularity. Irregular eating patterns, particularly the obese pattern of skipping breakfast, skimping on lunch, and consuming large quantities of food in the afternoon and evening, can be detected. A ‘-/-dayrecall of physical activity and information about the child’s after-school activity is helpful. Treatment goals include decreasingthe caloric density of the diet (for example, increasingconsumption of non-fat milk products, fruits, vegetables,grains, and low fat meats and decreasing high-fat foods and added fat), consuming regular meals, increasing activity levels (for example, structured &erschool sports, household chores, walking, and family physical activities), and decreasingsedentary activities such as television (Dietz & Gortmaker, 1985). Emotional Overeating. Disregarding internal cuesof hunger and satiety can result in excessiveadipogenesis. Eliciting information about the cuesthat trigger a child to eat when not hungry can be helpful in evaluating
emotional overeating. Common cues are boredom, loneliness, sadness,and anger. The therapy for emotional overeating involves improving emotive states through psychologic counseling and physical activity, increasing skills in emotionally expressiveand assertive communication, substituting adaptive responsesto difficult emotions, and learning to initiate and conclude eating in responseto internal signs of hunger and satiety. Improving the quality of the diet and the quantity of food consumedare not primary goals but are expected to improve as the emotional overeating abates. The Too-comfortable Child. The indulged child typically has overprotective, permissive parents. Parental expectationsare low, and the child has too much power in the family. O ften the child has a specialplace in the family, such as that of surrogate spouse. Parent-child enmeshmentis common. The falsenessof the relationship impairs parent-child intimacy, creating a senseof isolation in the child that excessivefood, television, or reading diminish. In addition, the permissivenessis usually associatedwith indulgent food and inactivity behaviors. The treatment is to decreasethe child’s apparent but not actual comfort by altering the functioning of the family (for example, support one parent in separating from the child and the other in becoming more engaged and improving parental limit setting skills). Family therapy may be indicated. The Too-uncomfortable Child. Children who have been neglected or the victims of unusual stressesmay respond to their difficult emotive responseswith compulsive eating or excessiveinactivity (for example, pro-
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tracted television viewing or reading). The child often has a depressive affect or expressions of anger at one or both parents. The recommended treatment is to increase the child’s comfort by improving family relationships and nurturing. Often psychotherapy or family therapy is required. Medical Problems. A variety of medical problems can trigger the onset of obesity or contribute to its exacerbation. The mechanism most often induces inactivity; such conditions include congenital heart defects, orthopedic problems, and exercise-induced asthma. Various medications, such as insulin and steroids, can stimulate weight gain. Treatment often focuses on improved management of the condition.
F amily
is provided with program material and
direction. After discussing the probable factors with the young person and his or her parent, the nurse practitioner provides them with the program books and directs them to the content that corresponds to the identified contributors to the problem. During the next 3 months, the family implements the intervention program, with or without periodic visits with the nurse practitioner. At the 3-month follow-up visit, if insufficient progress has been made, the family may be referred to a SHAPEDOWN pediatric obesity specialist team. Indications that the guided self-care program is sufficient include an average weight loss of one-half to 1 pound per week for most young people. However, during periods of rapid growth in adolescence or for children or adolescents who had been rapidly gaining weight before the intervention, weight maintenance to a mean of one-half pound per week weight loss is sufficient. If progress with weight management is sufficient and the child or adolescent is satisfied with the guided self-care program and does not express interest in obtaining the services provided by a pediatric obesity specialist team, such as a more in-depth assessment and participating in more intensive individual and group care, then the continuation of the guided self-care program is appropriate. Step 3. Comprehensive
6, Number
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Assessment
When primary preventive interventions have not decreased or resolved the obesity, care by an interdisciplinary team specializing in pediatric obesity is indicated. This care involves a comprehensive, biopsychosocial assessment and includes the availability of a broad range of treatment options. Alternatives range from a group or individual application of the SHAPEDOWN program to managing the underlying causes of the obesity, such as medical, psychologic, and family functioning factors before or instead of entering SHAPEDOWN.
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In addition to the primary care role of nurses described, nurse practitioners function as members of interdisciplinary teams specializing in pediatric obesity care. The minimal disciplines represented on these teams are medicine, nutrition, mental health, and exercise. Often one or two team members deliver direct service, and the remaining disciplines provide consultation. Typically, nurse practitioners provide the direct service and receive consultation from a physician, a registered dietitian, a licensed mental health professional, and an exercise specialist. For example, the nurse practitioner may provide nutrition advice to otherwise healthy obese teens in a group program but refer a hyperlipidemic adolescent in the group to the registered dietitian for additional diet therapy sessions. The SHAPEDOWN method assists the nurse practitioner in delivering truly interdisciplinary assessments without the resources required for all team members to assess each young person and family. This is done through the Youth Evaluation Scale (YES; Mellin, 1987), a computerized assessment instrument for eating disorders and obesity in children and adolescents. YES is composed of questionnaires for the youngsters and their parents that are compilations of standardized measures of a broad range of biopsychosocial variables related to weight and eating. As a result, for example, all children do not require assessment by a psychologist. Instead, YES provides several standardized measures of psychologic functioning, so the nurse can refer only those children whose YES results include abnormal scores on these tests.
Y
ES provides standardized which the nurse practitioner family and child.
measures with can guide the
To administer YES, the nurse practitioner records on the questionnaires certain information obtained during a clinic visit: height, weight, triceps skin fold, fitness test results, blood pressure, waist-hip circumferences, and total serum cholesterol. The young person and parents complete the questionnaires and mail them to a central processing service. Several days later, the nurse practitioner receives by mail from the processing service two YES reports, one for patient education and the other for the provider. The patient education report displays all the testing results including percent overweight, body fat patterning, serum cholesterol, blood pressure, physical fitness, lifestyle, emotional overeating behaviors, depression, self-esteem, anxiety, body image, weight management knowledge, parental attitudes and behaviors, family functioning, and parent-child communication. In addition, it evaluates the extent of the medical and psychosocial risks of the obesity. The provider report summarizes de-
Journal of Pediatric Health Care
Child
mographic, historic, and sensitive information (for example, sexual activity, substance use) for review by the nurse practitioner. On the second visit, the nurse practitioner reviews the YES results with child/adolescent and parents to describe the extent of obesity, its medical and psychosocial risk, and potential contributors to its onset and exacerbation. With this information, the young person and family can identify their healthful characteristics and those characteristics that are not, which may be the focus of obesity intervention. For instance, Jack, a 14-yearold, learned through his YES assessment that his obesity was a medical risk because he was severely obese and had a central fat deposition pattern and family history of hypertension. The psychosocial disadvantage of his weight was significant because his se&esteem about his weight was low; he was ridiculed about his weight by peers. Correlates of his obesity were genetics, inactivity, emotional overeating, anxiety, poor knowledge of weight management, parental limit-setting deficits, an enmeshed relationship with his obese mother, and a disengaged relationship with his father who reportedly drank heavily. These factors were explored as potential contributors to the problem.
T
he family individualized
develops a care plan that leads to treatment.
By the conclusion of the YES assessment, families have developed a care plan that is individualized according to the contributors to the problem and the medical and psychosocial risk of the obesity. Treatment plans range from other therapies (for example, family therapy, psychotherapy, medical treatment) to group obesity treatment. In Jack’s case, the family was reluctant to identify the father’s substance use as a problem. The provider suggested that family factors associated with substance problems can be major contributors to obesity in the child. The family elected to participate in the family-based teen SHAPEDOWN program. During the parent sessions, the father’s substance-related cognitive difficulties were apparent; by the conclusion of the initial lo-week program, the father identified his substance use as a problem, and the family entered Alcoholics Anonymous programs. One of the most important benefits of this assessment and treatment process is that it often identifies problems underlying the obesity, based on standardized, computerized tests results. By doing so, families that could become stuck on the symptom (obesity) and scapegoating the child, often reframe the problem as related to family variables. Many families are surprisingly open to the computerized information and, in response to it, demonstrate a willingness to address the underlying disturbances.
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3. I let go of weight&m and accept my child’s natural body build. 4. I create a healthy but not depriving food environment at home. 5. I develop a f&ily lifestyle that is physically active. 6. I sm an acrive and enrichin lifestyle for my child that in&J&s daily exercise. 7. I support each fm member in openly and &ectiveiy expressinghis or her f&gs and needs. 8. I give my child direct messagesthat I accept and value him or her. 9. Isetlimitswithmychildandtbllow through consistently. 10. IarnagoodrolemodelbecauseIam improving my own weight, eating, or inactivity problems. Copyright 1991, L. Mellin.
Step 4. Treatment
The orientation of SHAPEDOWN is to view obesity as a symptom with diverse biopsychosocial contributors and consequences. Rather than narrowly focusing on the excess adipose tissue, the program addresses the obesity within the context of the overall development of the child and in relation to the family and social systems as reflected in the parent guidelines (Box 1). Program goals are to normalize the child’s or adolescent’s weight within his or her genetic potential, to develop risk reduction diet and physical activity behaviors, and to facilitate the identification and treatment of psychosocial and biologic contributors to the problem. The program is designed for children and adolescents aged 6 to 18 years and is comprised of workbooks and parent guides that are on four developmental levels (6 through 8 years, 9 through 10 years, 11 through 13 years, and 14 through 18 years), an instructor’s guide, and support materials. The program can be applied in group sessions or in individual counseling. The duration of the initial group program is 10 weeks; it provides introductory training in SHAPEDOWN skills. Continuing care options include individual follow-up counseling and/or entering an ADVANCED SHAPEDOWN support group. The duration of care ranges from 3 months to several years. Criteria that are designed to ensure a high quality of
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n
BOX 2 THE SWBDOWN
6, Number
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& Frost
TASKS
1. I love and valuemyself. 2. I acceptmy geneticbody build. 3. I createfor myself an activelifestylethat
includesdaily exercise. 4. I fiII my l&e with pleasurefrom interests,activities,and people. 5. I choosea healthybut not depriving diet. 6. I eat when I am hungry and stop when I am satisfied,not frill. 7. I am awareof my feelings,so I know what I need. 8. I recognizemy needsand am committed to filling them. 9. I connectwith others by sharingmy true feelingsand thoughts. 10. I receivefrom others by askingfor what I needfkom them. 11. I try to changethe things I can control and let go of the things I can’t. 12. I take careof today rather man focusing on yesterdayor tomorrow. Copyright 1991, L. MeIIin.
care have been established for becoming a provider. These criteria include (a) delivery by an interdisciplinary team, (b) the completion of introductory (l-day) and advanced (3-day) pediatric obesity training by videotaped self-study course or by on-site course participation, (c) membership in the Center for Child and Adolescent Obesity (CAO) to receive clinical and research updates, and (d) the use of program materials and the avoidanceof combining other treatments with SHAPEDOWN, specifically, restrictive diets or very low-calorie diet formulas. All costs are low. Program and training information can be obtained from the first author.
C riteria
are designed to ensure high quality provided care.
The following casestudy shows the four components of the SHAPEDOWN method. Rebecca,a 14-year-old, visited the nurse practitioner with the complaint of a persistent upper respiratory infection. The nurse practitioner evaluated Rebecca’sweight, which was above the 95th percentile, and her height, which was at the 25th percentile, and identified the obesity (step 1). The nurse practitioner began to provide preventive care with a brief assessment(step 2). Rebeccawas asked if her weight was a concern. Rebecca responded that she hated her weight and burst into tears. At the conclusion of the interview, the nurse practitioner con-
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1992
eluded that this adolescent’sobesity appearedto be related to emotional overeating and genetic factors. She described her impressions to Rebecca, and they identified the goals of accepting her genetic body build, eating when she was hungry and participating in an exercise program to decreasestress. Rebecca returned monthly for counseling with the support of program materials. Her parents did not participate in the sessions, although they received program materials. At the 3-month follow-up visit, Rebecca had increasedher physical activity but still engaged regularly in emotional overeating. She expressedan interest in a more intensive, group approach. The nurse practitioner had become increasingly concerned that Rebecca may have a subclinical eating disorder. She referred the adolescent to the SHAPEDOWN interdisciplinary pediatric obesity specialist team. The program to which Rebecca was referred was conducted by a nurse practitioner, with support from other disciplines. Rebecca and her parents completed a YES assessment(step 3), which showed a middle adolescent with a pattern of emotional overeating and a genetic predisposition to obesity. Rebecca resembled her paternal grandmother, who was portly and largeframed. Rebecca’sdepression, anxiety, and self-esteem scoreswere normal, and her family was functional. The obesity appeared to be secondary to genetic factors, conflict about body type, emotional overeating, inactivity, and lack of parenteral acceptanceof the adolescent’s weight. Rebecca was not bulimic. The care plan involved a group program because Rebecca was in middle adolescence,a time when peer samenessis important. A group would allow her opportunities to be the same as others who were also struggling with accepting their body type. Moreover, it would provide structured parental support. Rebeccaenrolled in the group program (step 4) and learned to use stimulus control techniques (identifying the cuessheused to start and stop eating and developing strategies for managing those cues) and binge prevention strategies (emotionally expressivecommunication, stressreduction techniques, physical activity) to control her eating. With support from her peers, she addressed the 12 SHAPEDOWN tasks of Adolescence (Box 2). Rebeccabegan exercising, a combination of walking to school, cheer leading, and aerobic classes.Slowly, she moved toward accepting her body build. In the parent group, Rebecca’sparents began to express their sadnessabout their daughter’s body build and to come to terms with the possibility that Rebecca’s body may always be somewhat rounded. This freed them to stop trying to control Rebecca’s eating and weight, which, in turn, resulted in marked improvement in Rebecca’semotional overeating. After the lo-week group, Rebeccacame to individual
lournal of Pediatric Health Care
Child
sessionsbi-weekly for 5 months and achieved a moderate weight loss. Her emotional overeating subsided, and she becameactive in school sports. Rebecca’sbody image improved significantly. She had the option of participating in an ADVANCED SHAPEDOWN support group but did not feel the need for frequent sessions becauseweight and eating had recededas issues. n
SUMMARY
Nurse practitioners are uniquely qualified to take a leadership role in providing this pediatric obesity care, which not only addressesthe symptom of excessivebody fat but also supports the strength of the family and the well-being of the child. Although developing liaisons with other team members and acquiring additional training require effort, should nurse practitioners take up the challenge and focus a portion of their clinical efforts on pediatric obesity care, the benefits to the health and well-being of the obese young could be highly significant. REFERENCES American Medical Association. (1988). Proceedingsof the National ConFesson Adolescent Health. Chicago: author.
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Brownell, K. D., Kelrnan, J. H., & Stunkard, A. J. (1983). Treatment of obese children with and without their mothers: Changes in weight and blood pressure.Pediatrics, 71, 515-523. Coates, T., & Thorenson, C. (1978). Treating obesity in children and adolescents:A review. A nzerhn Journal of Public Health, 68: 143148. Dietz, W. H., & Gortmaker, S. L. (1985). Do we fatten our children at the television set? Obesity and television viewing in children and adolescents.Pediutrics, 75, 807-812. Epstein, L. H., Valoski, A., Wing, R. R., & McCurley, J. (1990). Ten-year follow-up of behavior, family-based treatment for obese children. Journal of the American Medical Association, 265, 25 19. 2523. Epstein, L. H., Wing, R. R., Koeske, R., & Valoski, A. (1987). Long-term effectsof family-based treatment of childhood obesity. Journal of Cons&in- and Clinical Psycholog 55, 91-95. Gortmaker, S. L., Diem, W. H., Sobol, A. N., & Wehler, C. A. (1987). Increasing pediatric obesity in the United States.American Journal ofDiseases of Children, 141, 205-215. MeBin, L. M., Shnkard, L. A., & Irwin, C. E. (1987). Adolescent obesity intervention: Validation of the SHAPEDOWN program. Journal ofthe American Dietetic Associahn, 87, 333-337.
Melhn, L. M. (1987). The Young Evahation Scale (2nd ed.) San Anselmo, Calif: Balboa Publishing. Mellin, L. M. (1991). SHAPEDOWN We&h Management ProFam of Children and Adolescents (5th ed.) San Ansehw, Calt$ Balboa Publishing.
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