Treating Obesity in Children and Adolescents: A Review THOMAS J. COATES, PHD, AND CARL E. THORESEN, PHD

Abstract: Researchers and health practitioners are becoming increasingly concerned with the problems associated with obesity among children and adolescents. Obesity tends to persist into adulthood and to be associated with a variety of physical and psychological problems. Treatment approaches used to date are generally impotent, but some promising short-term results have been achieved with some forms of dietary counseling, exercise programs, total environmental management, and behavior therapy. But even with

these strategies, clinically significant weight loss is rare and advances during treatment are rarely maintained. Radical departures from current treatment strategies are needed in the form of more structured and intensive treatments, family involvement, and training in problem solving. Closer adherence to sound scientific methodology might at least provide a foundation from which more effective treatments might be developed. (Am. J. Public Health 68:143-151, 1978)

Obesity among children and adolescents is a current health problem of considerable magnitude in terms of both prevalence and effects.1 For example, the Ten State Nutritional Survey,2 using an arbitrary triceps skinfold value to determine obesity (18.6 mm for boys and 25.1 mm for girls) reported the following percentages of obesity among 12 and 13 year olds: white males, 17 per cent; black males, 9 per cent; white females, 12 per cent; black females, 11 per cent. Larger percentages of children in older age groups exceeded this criterion for obesity. During adolescence, lower income adolescent females continue to gain while more middle and upper income females become lean during this time.3 Overweight infants tend to become overweight children and adolescents,4 who in turn tend to become overweight adults.5-8 In the Haggerstown prospective study, Abraham, Nordsieck, and Collins9 found that 86 per cent of overweight boys and 80 per cent of overweight girls became overweight adults as compared to 42 per cent of average weight boys and 18 per cent of average weight girls. Stunkard and Burt10 estimated that the odds against an overweight adolescent becoming an average weight adult are 28 to 1. Obesity among children and adolescents is associated

with increased risk of a variety of physical and psychological problems, such as depressed growth hormone release, hyperinsulemia, carbohydrate intolerance, and elevated blood pressure."-15 In the Muscatine study of 4,829 Iowa school children, elevated weight and triceps skinfold was associated with an increase in coronary risk factors16 (elevated blood pressure and lipoprotein levels). These relationships are modest but have been replicated in several studies and suggest that obesity can contribute independently to increased risk even among children.12' 17 Females who were obese as teenagers are more likely to develop cancer of the uterus than females who were not obese as teenagers; the comparative rates are 3.4 per 1,000 and 2.1 per 1,000.19 Obese children and adolescents experience a broad range of social and psychological problems which often carry on into adulthood. Given the social stigma associated with being obese, it is not surprising that obese youth show less acceptance from peers,19 experience discrimination from significant adults,20 21 greater body image disturbances,22 poorer self-concepts, and greater evidence of disturbed personality characteristics than their normal weight peers.23 Effective interventions to help the overweight child and adolescent lose weight and maintain a suitable and healthy weight seem imperative. Treatment early in life seems especially crucial because young children might learn and use appropriate eating and exercise habits more easily when they are young; obesity with its concomitant physical and psychological problems might also be reduced and/or prevented. In this review, we examine critically the current status of interventions for this age group.

From the Center for Educational Research, Stanford University. Address reprint requests to Dr. Thomas J. Coates, Research Associate, Center for Educational Research at Stanford, School of Education, Stanford University, Stanford, CA 94305. Dr. Thoresen is Professor of Education and Psychology at Stanford. This paper, submitted to the Journal November 10, 1976, was revised and accepted for publication June 14, 1977.

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Current Approaches * Treatments evaluated to date with obese children and adolescents can be classified into one or a combination of six basic approaches: 1) caloric restriction, 2) anorectic drugs, 3) physical exercise, 4) therapeutic starvation, 5) bypass surgery, and 6) habit pattern changes based on social learning theory. Following Stunkard,24 25 we used three criteria in surveying this body of research and in evaluating treatment approaches. First, sole reliance on group summary statistics, e.g., means and standard deviations, were considered inadequate for evaluating a treatment because they provide little basis for determining the range of effects of that treatment. Because a few extreme values can affect scores considerably, an adequate evaluation strategy demands that the data for individual subjects be reported along with group summary statistics. Second, it was important that the treatment demonstrated clinically significant changes in weight and other body dimensions, e.g., reductions in adipose tissue, rather than just statistically significant values. Finally, it was essential that some evidence of maintained changes and continued weight losses be documented. In general, strategies have been limited in number, have produced very modest outcomes, and have remained so poorly defined that systematic replication has been difficult. In terns of the adequacy of evaluations designs, weight loss or the percentage of weight loss for a total group are typically reported without recognizing major differences among subjects and specifying amounts of weight change or overweight lost for each subject. Further, the difference between being overweight and overfat (total body weight and proportions of adipose tissue compared to norms) has not been recognized. In the few studies reporting individual data, the results suggest that clinically significant changes for obese children are rare. Follow-up data, although seldom available, show consistently that subjects fail to continue losing weight or even maintain weight loses experienced during treatment.

Dietary Approaches From one perspective the treatment of obesity should be simple: reduce caloric intake below energy expenditure by inhibiting food intake, increasing physical exercise, or some combination of the two. In this process, the body will draw the balance of needed calories from its fat deposits causing a reduction in fat and weight. Unfortunately, the application of this knowledge is rarely effective either with adults or children. Standard clinical practice usually involves some form of dietary counseling at irregular intervals for varying amounts *We attempted to locate and examine all available controlled examinations of treatments for obesity among children and adolescents. Two minimal criteria for inclusion in our analysis were employed: 1) Some description of a treatment program had to be provided; and 2) Some evaluative data were presented. The studies were identified and form the basis for the analysis presented here. These studies have been summarized in tabular form which is available upon request from the authors. 144

of time. For example, Asher26 reported that only 26 per cent of a sample of 269 five to 14 year old obese British school children, seen in a clinic on a monthly basis, were able to reduce weights to 25 per cent above appropriate weight (a criterion still leaving them obese). None reached an appropriate weight. Hoffman27 used dietary restrictions and a variety of anorectic drugs over a treatment period which averaged four months to produce average weight losses of 20 pounds (the mean excess weight at the beginning of the study was 43.6 pounds). Individual and/or follow-up data were not reported. Hammar, et al,28 reported that 44.6 per cent of a sample of 65 obese adolescents showed minimal weight loss (10-15 pounds) while 24.6 per cent gained weight and 30.7 per cent maintained their beginning weight. More encouraging results have been obtained with more frequent contact and more intensive treatments. Heyden, et al,29 reported interesting results with eight subjects using individual counseling, restricted caloric intake, daily selfmonitoring of calories, and fasting for two days per week. Treatment time varied from three to nine months. One subject lost ten pounds, four subjects lost between ten and 20 pounds, and two lost more than 20 pounds. Most subjects were within a close range of weight loss goals at the end of treatment. Attempts to replicate these results in a group-administered treatment using subjects from the individually administered treatment as group leaders were less successful, but results of the individual treatment program were replicated successfully in a third study. Unfortunately, follow-up data were not reported in any of the studies. Stanley, Glaser, Levin, et al,30 also reported encouraging results using a combination of inpatient followed by outpatient treatment. The adolescents remained in a hospital setting for six weeks, were placed on a restricted diet, and met bi-weekly for group discussions and counseling. Their parents also attended separate weekly group meetings. Once released, the patients and parents continued meeting for 13 months. Ten of the I1 patients lost more than ten pounds. At 15 months following release, three subjects continued to lose, three had maintained losses, and five had gained weight. However, all were still overweight at the end of the follow-up period. Unfortunately, the content and structure of the counseling sessions in these two studies were described so sketchily that controlled replication is impossible. Results from the long-term follow-up studies are discouraging. Lloyd, et al,31 nine years following treatment, reported that 80 per cent of their subjects had relapsed. Hammar, et al,28 found (time not specified) that 70.7 per cent of those responding were still obese at follow-up, and only 17 per cent (11 subjects) had maintained initial weight loss. Thirty-five (53.8 per cent) of the subjects reported several periods of gain and loss. These data are even more discouraging given that they represent self-reports from a biased sample: a 30 per cent response to a mail questionnaire.

Three conclusions can be drawn. First, it is probable that any promising results represent an overly optimistic estimate of the potential of this form of treatment. Second, dietary counseling, as practiced, is ineffective in the long run, although if given intensively, it may work in the short AJPH February 1978, Vol. 68, No. 2

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run. Third, it seems obvious that dietary counseling, by itself, is an inefficient use of patient and professional time.

Anorectic Drugs Amphetamines, presumably depressing the appetite through some form of central nervous system stimulation, are generally of little effect in the treatment ofjuvenile obesity and carry with them the dangers of abuse and dependence.32 Lorber and Rendleshort33 found no weight loss that could be attributed to the effects of phenmetrazine and amphetamine rezinate above those achieved by placebo and diet. Lorber34 reported extremely discouraging long-term results (I to 3-½6 years) for each of these three treatments. New non-amphetamine drugs include chlortermine and fenfluramine, believed to affect the appetite control centers of the hypothalamus, and mazindol which presumably exerts its influence by facilitating electrical activity in the septal area of the brain. In general, four problems are encountered in the controlled evaluations of these drugs. First, dropout rates are high.35-37 Second, the short term efficacy of the drugs are minimal,35' 38, 39 and typically show no advantage beyond results produced by placebo and diet. Lorber34 reported that the first treatment used (whether placebo, diet, or drug) produced the greatest weight losses. Mazindol may be an exception to this rule. Bauta37 found an average of 13.8 pound weight loss with this drug, as compared to a mean 3.8 pound reduction with placebo over a 12-week treatment. The drug, however, did not show similar advantages in reducing subcutaneous fat (triceps and subscalpular skinfold measurements). Third, follow-up data, when reported, indicate complete relapse.40 Finally, considerable data suggest that adherence to medical regimens remains a serious problem.41' 42 None of these studies have reported controlled data on the degree to which experimental subjects actually adhered to drug or diet regimens. It might be argued that drugs are meant to work only in combination with dietary restriction, but the combination of the two approaches is no more effective than using either alone. Seemingly, these drugs are moderately useful in the short-term arrest of weight gain. Rivlin43 recently completed a review of hormonal treatment for childhood obesity, concluding that they have little place in its treatment. Controlled studies with chorionic gonadotropin are inconclusive while human growth hormone may be suitable only for those who show deficiencies in it. Thyroid treatment produces minimal weight loss while it is being taken, but its effects on cardiovascular health and skeletal growth render its use somewhat risky.

Exercise It has been reported that obese adolescents eat no more than their non-obese peers44-47 but that increases in body fat are accounted for by decreases in exercise as children grow older.48 Much of this research, however, is based on selfreport data, e.g., retrospective reports and food diaries. The results may be of questionable validity because obese adoAJPH February 1978, Vol. 68, No. 2

lescents may be reluctant to report food intake accurately or perhaps are less aware of actual food intake.49 In addition, any kind of systematic self-monitoring may temporarily reduce the amounts of food eaten. Conflicting data have also been reported on the relative activity levels of obese and normal weight adolescents. Using a pedometer, Stunkard and Pestka50 found that obese and non-obese girls were equally active both during and after a summer camp experience. Bullen, Reed, and Mayer51 collected motion picture samples of obese and non-obese girls in a camp setting while they were engaged in tennis, swimming, and volleyball. The girls were rated for the per cent of time spent motionless and estimated caloric expenditures. Normal weight adolescent girls were 2-1/2 times more active and tended to expend more calories than their overweight peers. The overweight girls managed to be sedentary even when engaged in active sports such as tennis. Based on the findings in this latter study, some programs have emphasized increases in physical activity as a method for decreasing body fat and food intake in adolescents. Moody, et al,52 engaged 28 obese girls in a 29-week daily exercise program of walking, jogging, and running within the context of a high school physical exercise program. Neither the obese girls nor the 40 normal weight controls lost much weight (mean loss was 2.2 and 1.2 pounds respectively). But the obese girls showed an average triceps skinfold reduction of 52.5 mm while the normal weight girls showed a reduction of 23.9 mm. Apparently the program was somewhat beneficial for both groups. Seltzer and Mayer53 54 evaluated the efficacy of the 10-month program (nutrition education, physical exercise, psychological support) with 350 obese elementary and secondary students. Overall, treatment subjects showed no changes in weight or triceps skinfold measures at the end of the program. Obese treatment subjects tended to show slower growth rates in triceps skinfold and body weight, but these differences were statistically significant only in male elementary students. Christakis, et al,55 using nutrition education and daily exercise with 90 obese high school students, reported an average of 10.9 per cent reduction (41.1 to 30.2) in per cent overweight for the treatment group, while control subjects decreased only by 2.3 per cent (39.6 to 37.3). These programs appear to have some value. Although minimal weight reduction occurs, there is evidence that reductions in body fat do occur with normal and obese subjects, and the potential of reaching larger numbers of persons is increased because the programs can be applied within the context of the school setting. But subjects at the end of treatment are still considerably overweight, and participants do not continue exercising once the structured programs are terminated. Mayer54 recently reported follow-up data relative to the program reported by Seltzer and Mayer. Results were maintained as long as subjects were engaged in the program. Funding cutbacks forced its cessation, and any effects due to the program were eliminated when groups were compared three years following its termination. Evidence for both continued weight loss and maintenance in exercise regimens would appear necessary if such programs are going to have significant and lasting impact. 145

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Therapeutic Starvation Short-term or prolonged fasting by means of hospitalization has been advocated as a possible treatment for the grossly obese for several reasons: 1) severely obese persons do not respond to usual reduction treatments requiring selfcontrol; 2) dramatic reductions within a short period of time are possible; 3) the amount of food eaten can be controlled; and 4) the person can be shown that weight reduction is possible. Predictably, fasting produces short-term losses in adults and in adolescents56' 57 but recidivism prevails in the long-term follow-up with fasting with adolescents. Nathan and Pisula,58 in working with 15 adolescents ranging in age from 12 to 16 years, found that all but two regained weight after eight to 24 months. In fact, all but four equaled or excelled their admission weight. These four at follow-up were 9, 45, 72, and 75 per cent overweight. Fasting has some potentially deleterious side effects such as B-12 malabsorption, electrolyte disorders, and normochromic anemia. Although evaluations with adolescents have been rare, some evidence indicates that adrenal function may be lowered59 and growth retarded during starvation therapy.60 One currently popular approach involves placing the obese child or adolescent in a special camp setting for a period of time and using a variety of procedures to promote weight loss. The summer camp is designed as a controlled and presumably ideal eating environment. Low calorie, balanced, and nutritious meals are complemented with nutrition counseling and exercise. Although these camps have proliferated recently, controlled evaluations are sparse. Those reported generally show favorable short-term results.61-63 Predictably, long-term follow-up data show weights at or exceeding baseline, and are similar to gains reported following starvation therapy.61 63 Strategies employing structured physical and social environments (exercise programs, camps, hospitals) can be effective as long as the person remains in this controlled setting. The potential of these forms of treatment for maintained weight loss remains to be demonstrated. The regimens in use provide no basis for continued decrease in food intake as the individual moves from the hospital or camp back into his everyday environment; the person has not learned how to alter eating behavior in the natural environment where food may be readily available. In addition, psychological reactions experienced during "enforced treatment" may lead to a rebound effect and thus predispose the person to avoid further attempts at weight loss altogether.58 Indeed, the extreme of hospitalization or encampment may reinforce the belief and attribution that change under normal circumstances is clearly impossible and the person is predestined to remain obese.1I

Bypass Surgery Bypass surgery represents an extreme attempt to effect reductions in grossly obese patients not responding to other forms of therapy by reducing the length of the absorptive surface of the small intestine. Assessments with adults have 146

been extensive; the procedure typically produces weight losses plateauing at 20 per cent above ideal weight within 12 to 18 months. Further, clinically significant reductions in triglyceride, serum cholesterol, and blood pressure have been recorded66 and eating patterns may become more normalized.67

The procedure has not been used often with adolescents. Of major concern with this age group are the possible adverse reactions on body functioning and growth. Bypass surgery in adults can result in moderate to severe diarrhea, B- 12 malabsorption, hypocalcemia, episodic polyarthritis, fatty liver, and some psychiatric difficulties.68' 69 Randolph, Weintraub, and Rigg70' 71 reported that few adolescents experienced problems with the procedure, but White, Cheek, and Haller72 indicated that subjects experienced mild hepatic

dysfunctioning, protein to carbohydrate malnutrition, and significant depletion of six essential amino acids. Bypass surgery, if shown to be safe for adolescents, may provide one extreme alternative after all other resources have been exhausted. Certainly, it should never be employed without careful preparation and follow-up. Perhaps the need for such extreme procedures in adults might be diminished if it could be demonstrated that, given appropriate weight reduction strategies, children and adolescents could be asisted in the loss of excess fat and maintenance of appropriate weight.

Behavior Therapy Approaches In recent years, treatments coming under the heading of behavior modification have become increasingly popular in treating obesity among adults. These procedures recognize that from a behavioral or social learning perspective eating and exercise behaviors are related to events in the immediate environment: physical and social situations (advertisements, parties, displays of food, persons offering food), cognitions (thoughts about particular foods, self-talk, feelings of frustration, depression), and other actions (watching television, sitting in the kitchen). Behavioral approaches are designed to alter specific food intake and energy expenditure actions by modifying those variables believed to influence a person's food selection and activity patterns in their everyday natural environment. Persons are instructed in methods for changing specific features of their personal, social, and physical environment as a means of altering their eating and exercise behaviors.73 Treatment techniques include recording the quality and circumstances of eating, restricting the range of cues associated with eating (eating at only certain times and places, not eating when doing other activities), altering the act of eating (eating more slowly, eating bulk foods first), changing physical and social cues associated with eating (food storage, stressful interactions with family members at meal time), and using rewarding consequences on a systematic basis.74-76 Studies evaluating behavioral procedures for treating obesity among children and adolescents are few in number, but show promising short-term results. Rivinus, Drummond and Combrinck-Graham77' 78 treated ten black lower soAJPH February 1978, Vol. 68, No. 2

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cioeconomic children in ten two-hour weekly group meetings which included a weigh-in, a group meeting with parents and children, group suppers in which appropriate eating habits were modeled and discussed, and material reinforcement for habit change. Subjects self-monitored the application of these procedures in their homes and were rewarded for meeting pre-selected goals. Although the magnitude of the weight changes was small (only two subjects lost more than ten pounds), nine subjects did report weight loss, a significant finding given the racial and socioeconomic characteristics of the sample employed. Aragona, et al,79 reported promising short-term results with five- to ten-year-old females. Parents were trained in nutrition, exercise, and ways to alter the physical and social environment. A money deposit was refunded for attending weekly group meetings, completing homework assignments, and when their children met weight loss goals. One group of parents was also trained to reinforce habit changes in their children, while a third group served as a no-contact control. Both experimental procedures produced clinically significant short-term losses over the 12 weeks of treatment (average losses of 11.3 and 9.5 pounds in the two treatment groups as compared to an average gain of 0.9 pounds in the control group). At the 46week follow-up evaluation, most subjects returned to or exceeded baseline weights and this could not be attributed to normal growth patterns. Wheeler and Hess80 reported the results of clinical trials of an individually tailored behaviorally oriented program with two- to ten-year-old children. Notable in this program were three factors: 1) mothers and children were treated in pairs; 2) programs were tailored to the needs of the individual child based on a careful behavior analysis; and 3) the program emphasized gradual changes and long-term involvement. After seven months of treatment, treatment subjects (N = 14) showed an average 4.1 per cent reduction in percentage overweight, while dropouts (N = 12) gained an average of 3.0 per cent and no-treatment controls (N = 14) gained an average 6.3 per cent overweight. Variances unfortunately were not reported, and long-term follow-up are not available. Gross, Wheeler and Hess8" treated ten obese adolescent girls in ten weekly sessions which included self-monitoring, rearranging the physical and social environment, nutritional information, and individual problem-solving. At the end of ten weeks, four subjects had gained or maintained, three subjects had lost from two to eight pounds, and three lost more than 15 pounds. At a 27-week follow-up, the following results were documented: 1) of those maintaining or gaining immediately following treatment, three continued to gain, while one lost ten pounds; 2) the losses of those losing two to eight pounds ranged from six to 14-1/4 pounds; and 3) of those losing 15 or more pounds, the losses now ranged from 21 to 40 pounds. In general, continued success could be predicted from weight losses during the program. Average per cent overweight at the beginning of treatment was 39.2; at the end of treatment it was 34.5; and at follow-up it was 31.5. Behavior therapies have been heralded for the hope they have brought to the treatment of obesity in adults,73 but application with children and adolescents do not portend any AJPH February 1978, Vol. 68, No. 2

breakthroughs yet. Some beneficial results are achieved with some subjects, but maintenance of changes or continued losses may still be the rare exception rather than the rule. This approach, however, does offer two advantages not typically employed by other treatments: treatment programs are defined explicitly; and the treatment results are documented carefully on an individual basis. The first advantage permits other researchers and therapists to replicate and build upon previous attempts, while the second affords the entire community the luxury of examining research results in

detail. The possibilities for treating obesity among adults were viewed pessimistically until the behavior therapies ushered in an era of hope for this seemingly intractable problem. However, two unresolved issues remain: individual response to treatment is variable82 and when reported, followup evaluations show that most subjects return to baseline within two years.73 7 Initial evaluations suggest that the same problems may occur when these strategies are applied for children and adolescents.

Is Obesity Biologically Inevitable? (The Hypercellularity Hypothesis) Once overweight occurs it tends to persist and even worsen despite our best attempts to alter its course. Despite these outcomes, clinical practice still operates on the assumption that obesity, is a learned disorder, and poor results are attributed to poor treatments. Recently it has been proposed that this intractability may, in fact, be biologically inevitable. Persons vary in adipose cell composition. Hypertrophic obese persons have a normal number of over-filled adipose cells, while hyperplastic obese persons possess, in addition, an excess number of adipose cells.83-85 Hypertrophy is thought to be related to adult-onset obesity, while hyperplasia is thought to be related to genetic structure, early feeding experiences, and, most important, to the onset of obesity in childhood. It is hypothesized that the excessive number of adipose cells, once generated, remains constant. Depleting these excess adipose cells of lipid, which is required if the person is to achieve and maintain a normal weight, forces the organism to remain in a biologically abnormal state. Because these cells pressure the organism to be filled, they drive the organism to regain and/or maintain the obese state. In effect, the obese state is the normal state for the hyperplastic obese person. Because the treatment implications of this hypothesis (and it is just a hypothesis and not a proven fact) are far reaching, it is important to have a clear notion of the degree and quality of the data available at present to support it. First, although there tends to be some association between the age of onset of obesity, severity of obesity, and cell number in humans,84 these data are merely suggestive and not confirmatory.86 A frequently confounding piece of evidence is the obese human who by medical history became obese as an adult and yet has an excessive number of adipocytes.87 Second, there has been a great deal of speculation about biological B-set points" and the relationship between adipose 147

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cell number, cell size, and appetite. It appears certain that cell number is fixed; once generated, even dieting will reduce only the size of adipose cells and not their number. If the lipid content of some of these excessive cells becomes depleted, they supposedly signal the central nervous sytem to alter feeding behavior so that the set point can be maintained. Unfortunately, this means maintenance at an obese state for the person with an excessive number of fat cells. Models of food intake control based on these speculations have been elaborated.83 But it is important to note that they remain hypothetical. Adipose tissue signals have not been identified, and without any evidence of their existence (or, if identified, of their function), the physiological significance of excessive cellularity remains an interesting finding with unclear clinical import.87 The adipose tissue hypothesis is intriguing and challenging. But those in clinical practice must be careful not to regard it as true, confirmed, or even partially suipported. As a hypothesis, it deserves careful study. But at the same time it needs to be challenged scientifically, as do all hypotheses. Nor can we afford to let it permit us to become paralyzed in our attempts to treat a problem which seems intractable. It remains an equally plausible hypothesis that our interventions are impotent, not because we are battling the biologically inevitable, but because we have not yet developed maximally powerful treatment procedures, the means for teaching them, and the methods for insuring their careful application over time.88 At the very least, because of the magnitude and importance of the problem, these alternative hypotheses and others deserve careful consideration and evaluation.

Developing Alternatives Our conclusions and recommendations will necessarily have to be modest and tentative. While our review is generally gloomy, there are some bright possibilities. It seems reasonable to suggest that we should stop repeating the same mistakes in attempting to treat obesity among children and adolescents. Perhaps some of the suggestions which emerge will lead to advances in the methods used to investigate these important clinical and research questions. l. At the very least, it is imperative that we discontinue the routine application of treatments already proven impotent. It makes little sense, for example, to prescribe low calorie diets and anorectic drugs, presume that they will be followed, and expect that weight loss will occur. The loss in professional time is obvious, but subjecting the obese child or adolescent to failure experiences may have serious repercussions. The obese child is often labeled as unhealthy by family and physician, told that changes are needed, and started on a treatment program that is not likely to be successful. In all probability, he or she will be left with another failure to deflate self-esteem and reinforce the notion that he or she is a "fat person" for whom weight loss is impossible. We may be fostering a deepening despair and discouragement among our patients in inadvertently encouraging failure by using ineffective techniques. 148

2. Interventions marked by a high degree of structure and supervision usually produce better short-term treatment results. The most extreme example involves inpatient starvation treatment. But other programs with some promise have employed methods for insuring consistent application of a particular technique. Examples include the exercise programs conducted in the schools and programs conducted in residential camps. Similar results are apparently possible when subjects are not physically confined but given intensive and frequent individual counseling.2" It seems very unreasonable to expect to change a long lasting and complex pattern of behavior so intimately associated with multiple and diverse environmental, physiological, and cognitive factors without intense and sustained time and efforts. Treatment may need to extend for a year or more and may need to be conducted more frequently to insure success. Indeed, for some persons some form of treatment may always be re-

quired.

3. Family involvement, at some level, seems critical to program success for two reasons. First, obesity in parents and children tends to be positively correlated. When the various parental mating combinations are compared (both parents lean vs. one parent lean, one parent obese vs. both parents obese), their children become increasingly obese.2 80 While it might be argued that this indicates a strong genetic component,1111- " these relationships hold for adopted as well as biological children.1'2 It may be that fat parents have fat children for the same behavioral reasons that fat pet owners tend to have fat pets. '3 Second, programs which attempt to involve family members directly in treatment sessions have been more successful. 77' 29. 80 Although family support was not dealt with explicitly in their study, Gross, et al.,81 reported that that degree of family support was important in influencing the degree of immediate and continued weight loss. 4. Strategies based on a behavioral rationale produced results slightly superior to other treatment programs. These treatments are based on the hypothesis that changes in food intake and energy expenditure require persons to alter those variables influencing those actions. These strategies may be stymied, however, if the range of variables considered important are conceptualized too narrowly. A perspective is needed which will encompass and attempt to modify a wider variety of variables (environmental, cognitive, affective, physiological, motivational) and study their influence on energy intake and expenditure patterns. 5. Strategies designed to support and encourage applications of beneficial eating and exercise habits ouitside of regular treatment sessions also appear influential in determining treatment outcomes. For example, Heyden, et al,2' used several short but intensive treatment sessions per week and Aragona, et al,7" used monetary incentives to encourage adherence. Other strategies, not yet tried, might include telephone calls, postcards reporting progress, or a "buddy'" system for encouraging peer support. In summary, those strategies showing some evidence of maintained or continued losses have: 1) continued to follow and treat subjects in some systematic way during the followup period;29' 30 and/or 2) provided additional family inAJPH February 1978, Vol. 68, No. 2

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volvement to support and facilitate maintenance30' 77, 80 and/ or 3) employed a problem-solving format to teach subjects strategies for managing eating in problem situations.81 If, as we believe, the variables influencing obesity are learned and maintained early in life and at the level of the family and the culture, its management must become more complicated.94 An analogy can be drawn from research on the treatment of children with aggressive and out-of-control behavior. When children with these problems are referred to mental health clinics on an outpatient basis, only a few are offered treatment, only a very few of those improve.95 Residential treatment programs produce little long-term change in behavior96 and those not treated tend not to change as they grow older.97 Patterson98 and his colleagues found, in carefully conducted programmatic research, that alternative treatment methods could revise this discouraging history of results. Required, however, was direct, intensive and prolonged intervention with family and school in the natural environment over time. While we might explain continued poor treatment results by our limited understanding of obesity and treatment processes, there can be no excuse for using poor scientific research methods. Serious methodological problems exist at present, such as poor defining of the treatment regimens, unreliable measurement procedures, lack of data on individual subjects, and systematic follow-ups. A rigorous scientific perspective can facilitate the advancement of knowledge by requiring careful specification of operations and the systematic collection of data relevant to treatment outcomes.

ACKNOWLEDGMENTS

The preparation of this manuscript was supported in part by a grant from the Spencer Foundation and by The Boys Town Center for the Study of Youth Development at Stanford University. The opinions expressed or the policies advocated herein do not necessarily reflect those of the Spencer Foundation or of Boys Town. Gratitude is extended to Robert Jeffery, Rena Wing, Julianna Rogers and Elizabeth Gong-Guy for helpful suggestions on earlier versions of this manuscript.

REFERENCES

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Postdoctoral Fellowships Available to Cardiovascular Researchers The need for fully trained, independent investigators and teachers continues to be a matter of great concern to the Division of Heart and Vascular Diseases, National Heart, Lung, and Blood Institute. Approximately one-fourth the number required to meet conservatively estimated needs are currently in training. In order to increase current support levels, the Division of Heart and Vascular Diseases is vigorously encouraging research training programs. Individual Postdoctoral Fellowships are available to support research training of cardiovascular investigators in a variety of disciplines to promote multidisciplinary research capability. The research training may be in fundamental studies of basic processes and functions or clinical investigations, behavioral studies, including risk factor modification (e.g. diet, smoking), genetics (including studies of populations) and primary or secondary prevention. They should aim toward long-term involvement in research toward increasing knowledge and understanding in cardiovascular areas. Individual Postdoctoral Fellowships are available to United States citizens or non-citizens who have been admitted for permanent residence. Research training should be in the above or other disciplines related to heart and vascular diseases or fundamental cardiovascular processes. Applicants must be sponsored by an investigator at a domestic or foreign nonprofit public institution that has the staff and facilities to provide the desired training. Applications for training outside the United States require a detailed justification of the need to study abroad based on the unique facilities and/or training opportunities. Stipends range between $10,000 and $13,200 for the first year of postdoctoral research training depending on the years of relevant postdoctoral experience, and may be supplemented from non-federal funds. Usual payback activity requires research or teaching for a period equal to the duration of training support. Alternative payback requires 20 months service for each 12 months of training support. Deadlines for the receipt of applications are: February I with announcement of results in September June I with announcement of results in February October I with announcement of results in May Further information or applications may be obtained from: Dr. Max A. Heinrich, Jr., Manpower Branch, Division of Heart and Vascular Diseases, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD 20014, (301) 496-1724.

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