SEARCH

SEARCH BY CITATION

Keywords:

  • Anti-Obesity Agents [therapeutic use];
  • Diet, Reducing;
  • Life Style;
  • Motor Activity;
  • Obesity [*therapy];
  • Randomized Controlled Trials as Topic;
  • Child;
  • Humans

Abstract

  1. Top of page
  2. Abstract
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Implications for research
  10. Acknowledgements
  11. Characteristics of studies
  12. Data and analyses
  13. Appendices
  14. What's new
  15. History
  16. Contributions of authors
  17. Declarations of interest
  18. Sources of support
  19. REFERENCES

Background

Child and adolescent obesity is increasingly prevalent, and can be associated with significant short- and long-term health consequences.

Objectives

To assess the efficacy of lifestyle, drug and surgical interventions for treating obesity in childhood.

Search strategy

We searched CENTRAL on The Cochrane Library Issue 2 2008, MEDLINE, EMBASE, CINAHL, PsycINFO, ISI Web of Science, DARE and NHS EED. Searches were undertaken from 1985 to May 2008. References were checked. No language restrictions were applied.

Selection criteria

We selected randomised controlled trials (RCTs) of lifestyle (i.e. dietary, physical activity and/or behavioural therapy), drug and surgical interventions for treating obesity in children (mean age under 18 years) with or without the support of family members, with a minimum of six months follow up (three months for actual drug therapy). Interventions that specifically dealt with the treatment of eating disorders or type 2 diabetes, or included participants with a secondary or syndromic cause of obesity were excluded.

Data collection and analysis

Two reviewers independently assessed trial quality and extracted data following the Cochrane Handbook. Where necessary authors were contacted for additional information.

Main results

We included 64 RCTs (5230 participants). Lifestyle interventions focused on physical activity and sedentary behaviour in 12 studies, diet in 6 studies, and 36 concentrated on behaviorally orientated treatment programs. Three types of drug interventions (metformin, orlistat and sibutramine) were found in 10 studies. No surgical intervention was eligible for inclusion. The studies included varied greatly in intervention design, outcome measurements and methodological quality.

Meta-analyses indicated a reduction in overweight at 6 and 12 months follow up in: i) lifestyle interventions involving children; and ii) lifestyle interventions in adolescents with or without the addition of orlistat or sibutramine. A range of adverse effects was noted in drug RCTs.

Authors' conclusions

While there is limited quality data to recommend one treatment program to be favoured over another, this review shows that combined behavioural lifestyle interventions compared to standard care or self-help can produce a significant and clinically meaningful reduction in overweight in children and adolescents. In obese adolescents, consideration should be given to the use of either orlistat or sibutramine, as an adjunct to lifestyle interventions, although this approach needs to be carefully weighed up against the potential for adverse effects. Furthermore, high quality research that considers psychosocial determinants for behaviour change, strategies to improve clinician-family interaction, and cost-effective programs for primary and community care is required.

Plain Language Summary

Treating obesity in children

Childhood obesity affects both the physical and psychosocial health of children and may put them at risk of ill health as adults. More information is needed about the best way to treat obesity in children and adolescents. In this review, 64 studies were examined including 54 studies on lifestyle treatments (with a focus on diet, physical activity or behaviour change) and 10 studies on drug treatment to help overweight and obese children and their families with weight control. No surgical treatment studies were suitable to include in this review. This review showed that lifestyle programs can reduce the level of overweight in child and adolescent obesity 6 and 12 months after the beginning of the program. In moderate to severely obese adolescents, a reduction in overweight was found when either the drug orlistat, or the drug sibutramine were given in addition to a lifestyle program, although a range of adverse effects was also noted. Information on the long-term outcome of obesity treatment in children and adolescents was limited and needs to be examined in some high quality studies.


Background

  1. Top of page
  2. Abstract
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Implications for research
  10. Acknowledgements
  11. Characteristics of studies
  12. Data and analyses
  13. Appendices
  14. What's new
  15. History
  16. Contributions of authors
  17. Declarations of interest
  18. Sources of support
  19. REFERENCES

The prevalence of obesity and overweight is increasing in both adult and child populations throughout the world (Lobstein 2004; Wang 2006; WHO 2000). The 2004 report from the International Obesity Taskforce (IOTF) on worldwide prevalence rates, and a subsequent update, show that the paediatric obesity epidemic has spread globally, with some countries in economic transition having prevalence rates higher than those in the United States (Lobstein 2004; Wang 2006). Using the IOTF standard definition of paediatric overweight and obesity, the worldwide prevalence of overweight (including obesity) in children and young people aged 5–17 years is approximately 10%, with that of obesity alone being 2-3%. Certain regions and countries have particularly high rates of paediatric obesity: more than 30% of children and adolescents in the Americas, and approximately 20% of those in Europe, are overweight or obese, with lower prevalence rates being seen in sub-Saharan Africa and Asia (Lobstein 2004).

Within countries socio-demographic gradients in overweight have been observed. Overweight tends to be more prevalent among socio-economically disadvantaged children in developed countries (Shrewsbury 2008) and children of higher socio-economic status in developing countries (Lobstein 2004; Wang 2002). Among countries in economic transition obesity is more prevalent among higher income groups and in urban, compared with rural, communities (Hong 2007; Wang 2002), but there are indications that this burden may be shifting towards the poor, in adults at least (Popkin 2004) . With regards to ethnicity, data from the United States indicate that differences in prevalence of obesity exist among Hispanic (21.8%), African American (21.5%) and white children (12.3%), with the sharpest increases occurring among African American and Hispanic children (Strauss 2001).

Overweight and obesity in childhood are known to have significant impact on both physical and psychosocial health. For example, hyperlipidaemia, hypertension, insulin resistance and abnormal glucose tolerance occur with increased frequency in obese children and adolescents (Freedman 1999; Reilly 2003; Weiss 2004). In addition, childhood obesity is associated with a range of medical conditions, including poor pulmonary function, advanced growth and early maturity, hepatic steatosis and cholelithiasis asthma, low grade systemic inflammation, sleep apnoea, polycystic ovary disease and orthopaedic complications (Dietz 1998; Ebbeling 2002; Lobstein 2004; Reilly 2003 ). Overweight children are known to become targets of early discrimination (Dietz 1998; Puhl 2007; Tang-Peronard 2008). In addition, obesity in childhood is an independent risk factor for adult obesity (Parsons 1999; Singh 2008; Whitaker 1997). A systematic review by Singh 2008 found that in high quality studies the risk of overweight children remaining so in adulthood was at least twice that for normal weight children, with the risk generally higher for adolescents and those who were obese during childhood. Furthermore, there is evidence of an association between adolescent obesity and increased risks for health in adult life (Must 1992; Must 1999; Power 1997). For example, Must and colleagues, in considering long-term morbidity and mortality of overweight adolescents, found that adolescent overweight predicted a broad range of adverse health effects, independently of adult BMI (Must 1992). The relative risks among men aged 68 to 73 were 1.8 (95% CI: 1.2 to 2.7; P = 0.004), for mortality from all causes and 2.3 (95% CI: 1.4 to 4.1; P = 0.002), for mortality from coronary heart disease. It is noteworthy that being overweight in adolescence was a more powerful predictor of risk than being overweight in adulthood. Metabolic and inflammatory markers are risk markers of future cardiovascular and endocrinological disease an can therefore be helpful in monitoring treatment success in terms of reducing complications.

Treatment of childhood overweight and obesity is important, given the significant health and social consequences both in the short- and long-term. Ultimately treatment shares the same fundamental principles as treatment in adults i.e. to decrease caloric intake and increase energy expenditure. However, the primary goal of treatment (i.e. weight reduction or deceleration of weight gain) and the recommended mode of intervention is variable and dependent on the child's age and initial level of overweight, among other considerations. In order to support clinicians in determining the most appropriate form of treatment, paediatric weight management guidelines exist in many countries to promote best practice, but at present many of these recommendations are based on low grade scientific evidence.

The first version of this systematic review was published in 2003 (Summerbell 2003) and included analysis of childhood obesity treatment studies published up until July 2001. Many of the studies included in the review had small sample sizes, high drop-out rates, unreliable or limited outcome measurements or sampling problems, raising concerns about validity and generalisability of the findings. Furthermore, the wide range of interventions tested made comparison of studies difficult. No direct conclusions could be drawn from the review. 

The aim of this current review was to update the previous 2003 review. A new feature of this review is the consideration of drug trials and surgical interventions for the treatment of obesity in children and adolescents, reflecting both the increasing use of such therapies in clinical management and the emergence of published studies. Since the Review was first published there have been a number of trials of drug therapy in children, and especially adolescents, who are obese. In addition there have been several case reports and retrospective case series of bariatric surgery in adolescents.

This review complements the systematic review of long-term outcomes for the treatment of adult obesity (Avenell 2004) and includes studies that were part of a 2006 Cochrane review of dietetic interventions in child obesity (Collins 2006). The results of the current review and other systematic reviews will provide information on which to underpin clinical guidelines and health policy on the treatment of childhood obesity.

Objectives

  1. Top of page
  2. Abstract
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Implications for research
  10. Acknowledgements
  11. Characteristics of studies
  12. Data and analyses
  13. Appendices
  14. What's new
  15. History
  16. Contributions of authors
  17. Declarations of interest
  18. Sources of support
  19. REFERENCES

To assess the efficacy of a range of interventions designed to treat obesity in children and adolescents, specifically the evaluation of any combination of lifestyle (dietary, physical activity, behavioral therapy), drug or surgical interventions, compared with any other combination of these interventions or no treatment.

Methods

  1. Top of page
  2. Abstract
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Implications for research
  10. Acknowledgements
  11. Characteristics of studies
  12. Data and analyses
  13. Appendices
  14. What's new
  15. History
  16. Contributions of authors
  17. Declarations of interest
  18. Sources of support
  19. REFERENCES

Criteria for considering studies for this review

Types of studies

Randomised controlled trials (RCTs). The value and appropriateness of RCTs in assessing the efficacy of lifestyle interventions is a contentious issue. However, there is strong evidence that RCTs provide the least biased estimate of effect size (Stephenson 1998).

For lifestyle interventions, only RCTs that were specifically designed to treat obesity in children and observed participants for a minimum of six months were included. The rationale for introducing this criterion arose from the belief that many interventions appear to be effective in the short term (up to three months), but not in the long term (Glenny 1997). It seemed to be more important to evaluate the longer term effects of treatments, as this would provide a more valuable indication of effectiveness, given the chronic nature of obesity. For drug trials, we included trials that had at least three months of drug therapy and follow up at six months. Data were extracted for outcomes at 6, 9, 12 and 24 months where possible, and other time points where appropriate. This timeframe refers to the intervention itself or to a combination of the intervention with a follow-up phase.

Types of participants

Participants in study groups with a mean age less than 18 years at the commencement of the intervention were included, recognising that some interventions may target families inclusive of all children and some studies in adolescents include participants aged up to 21 years of age. Pregnant females and the critically ill were excluded, as were children with obesity due to a secondary or syndromic cause (for example Prader-Willi syndrome).

Types of interventions

Strategies: Lifestyle (dietary, physical activity and/or behavioral therapy interventions), drug (orlistat, metformin, sibutramine, rimonabant) and surgical interventions. Drug therapy had to be provided for at least 3 months. Alternative therapies were not considered in this review.

Topics: Diet and nutrition, exercise and physical activity, lifestyle and social support, involving children themselves with or without associated family members. Interventions that dealt with the treatment of eating disorders such as anorexia nervosa and bulimia nervosa were excluded, as were interventions that dealt with the treatment of type 2 diabetes in youth.

Settings: Interventions could be community, school or clinic-based.

Delivery: There was no restriction on who delivered the interventions. These may have included researchers, primary health physicians, nutrition/diet professionals, teachers, physical activity professionals, health promotion agencies, health departments or specialist doctors.

Types of outcome measures

To be included, studies had to report one or more of the following primary outcomes, presenting a baseline and a post-intervention measurement. Self-reported measurements of height and weight were not included.

Primary outcomes

The primary outcome measures for this review were measured (not self-reported) height and weight. If conducted by the same, trained operator, these measures are reasonably reliable. To account for sex- and age-related changes over time, we chose body mass index standard deviation score (BMI-SDS or BMI-Z-score) and percentage overweight to compare studies in the results section of this review. Studies were also included if they reported measures of body fatness (in percent or kilograms) by dual energy X-ray absorptiometry (DXA) or bioelectrical impedance analysis (BIA).

Secondary outcomes
  • Measures of body fat distribution, like abdominal (visceral) or subcutaneous adiposity (measured by DXA or BIA) or waist and hip circumference.

  • Measures of metabolic changes (or markers of future cardiovascular and endocrinological disease), for example, lipid profile, glucose and insulin metabolism, leptin, adipocytokines and other obesity or inflammatory markers.

  • Behaviour change - for example, changes in weekly activity levels or energy intake.

  • Participants views of the intervention.

  • Measures of self-esteem, health status and well being, quality of life.

  • Measures of harm associated with the process or outcomes of the intervention.

  • Cost effectiveness/costs of the intervention.

Search methods for identification of studies

For the original version of this review published in 2003, the search strategy developed by Glenny 1997 was used. This involved extensive consultation with identified experts in the field in conjunction with information scientists in the NHS Centre for Reviews and Dissemination (NHS CRD). A range of databases were searched from 1985 to 2001. These search strategies are shown in Appendix 1 and Appendix 2.  In addition, the reference lists of two reviews (Glenny 1997; SIGN 2003) were screened to identify any additional  papers. A full description of this process was published in the original version of this review (Summerbell 2003). 

For this current update in 2008, we used similar search strategies making some necessary changes because of changes in database indexing terms. Alternative therapies were not considered in this review, therefore terms in the original search describing alternative therapies were removed. As only RCTs were eligible for inclusion, filter terms for identifying RCTs in MEDLINE (Higgins 2006) were used.

The following electronic databases were searched in May 2008 (full search strategies can be found in Appendix 3).

  • 1.
    Cochrane CENTRAL Register of Controlled Trials Register (CENTRAL) on The Cochrane Library Issue 2, 2008;
  • 2.
    MEDLINE (Ovid) (2001 to May 2008);
  • 3.
    EMBASE (Ovid) (2001 to May 2008, week 21);
  • 4.
    CINAHL ARC Service (WinSPIRS online) (2001 to May 2008);
  • 5.
    PsycINFO Silver Platter (WebSPIRS) (2001 to May 2008);
  • 6.
    ISI Web of Science (2001 to May 2008); and
  • 7.
    DARE (Database of Abstracts of Reviews of Effects), NHS EED (National Health Service Economic Evaluation Database), and Health Technology Assessment database on The Cochrane Library Issue 2, 2008.

In addition, the reference list of a systematic review on effectiveness of weight management programs in children and adolescents (Whitlock 2008) was scanned for relevant references. No new studies for inclusion were identified from this report; however three surgical studies were identified which were not eligible for inclusion because they were not randomised controlled trials (Lawson 2006, Sugerman 2003, Tsai 2007). 

Data collection and analysis

Methods described in the Cochrane Handbook were used (Higgins 2008). Assessment of search strategy data was undertaken independently by two reviewers (HOL screened all, the second review was performed by all other authors by dividing all titles and abstracts into equal batches). Study data extraction and information on a number of measures of methodological quality of the included studies was assessed independently by two reviewers; study design, statistical power, method of allocation concealment, blinding of outcome assessment, comparability of participants baseline variables, and drop out rates between study arms. Where there was uncertainty, authors were contacted to clarify aspects of study design. Differences between reviewers were resolved by discussion. In cases where the two reviewers did not reach consensus, the study was presented to a third independent reviewer for a final decision.

Most of the included studies were too small to have the power to detect efficacy. In an attempt to overcome this problem, we compared studies that included children in the same age group, dealt with comparable interventions, and had a similar duration of intervention at the follow up moment for meta-analysis. Data needed to be reported at 6, 9, 12 or 24 months for the same outcome measurements (BMI-SDS or percentage overweight). Since few data on BMI-SDS were available in adolescents, we chose absolute changes in BMI as a second measure of fatness to compare results obtained in adolescents. Only studies providing similar analyses based on intention-to-treat principles (for example with baseline- or last-observation-carried-forward or imputed data by mixed model analysis) were considered. Studies fulfilling all these criteria were pooled in meta-analyses. Results were reported independently if studies were not pooled. Where key details or data were missing authors were contacted, or data were imputed based on methods described in the Cochrane Handbook (Higgins 2008).

Results

  1. Top of page
  2. Abstract
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Implications for research
  10. Acknowledgements
  11. Characteristics of studies
  12. Data and analyses
  13. Appendices
  14. What's new
  15. History
  16. Contributions of authors
  17. Declarations of interest
  18. Sources of support
  19. REFERENCES

Description of studies

See: Characteristics of included studies; Characteristics of excluded studies; Characteristics of ongoing studies.

Results of the search

The updated search of electronic databases performed in 2008 found 6496 abstracts. From these the full text of 206 papers were assessed. The results of the 2008 searches are detailed in Figure 1.

thumbnail image

Figure 1. 2008 Quorom statement flow diagram [revised 29/08/08] Interventions for Treating Obesity in Childhood

Download figure to PowerPoint

All papers for which hard copies were obtained but which failed to meet the inclusion criteria (n=136 papers) were excluded from this review (see Characteristics of excluded studies). Nineteen papers were clearly not relevant to the aim of this review (nine papers were on treatment of other conditions like PCOS, type 2 diabetes, fatty liver disease, eating disorders and precocious puberty, six papers on predictors of success or failure after weight loss-intervention, two on alternative therapies, one laparoscopy technique description and one paper on a functional meal test). In four papers the aim was other than to treat childhood obesity and 22 papers focused on the prevention of childhood obesity or preventative health. Fifty-six papers were excluded because they were not randomised controlled studies. These included all studies on surgical interventions (n=23). Two papers were identified that were interventions in participants other than children. In 13 papers the participants were followed less than six months. Six review type papers and 11 meeting abstracts were excluded. These include three studies that were pending assessment in the original review (Ball 2000; Coates 1982; Taitano 1998). For another study pending assessment in the original review, a published paper was found and included (Jelalian 2006). Three studies were excluded because they considered maintenance treatment after an obesity intervention (Deforche 2005; Van Egmond-Frohlich 2006; Wilfley 2007). The remaining 70 papers (55 on lifestyle interventions, 15 on drug interventions) reported 49 different studies (39 on lifestyle interventions, 10 on drug interventions). One lifestyle intervention paper was an additional report of an existing included study (Golan 1998).

Brief details of the results of the searches for the previous version of the review can be found in Figure 2.

thumbnail image

Figure 2. 2002 Quorom statement flow diagram [revised 20/08/02] Interventions for Treating Obesity in Childhood

Download figure to PowerPoint

Included studies

Eighteen studies were included in the first version of the review (Duffy 1993; Epstein 1985a; Epstein 1985b; Epstein 1985c; Epstein 1994a; Epstein 1995; Epstein 2000a; Epstein 2000b; Flodmark 1993; Golan 1998; Graves 1988; Israel 1985; Israel 1994; Mellin 1987; Schwingshandl 1999; Senediak 1985; Wadden 1990; Warschburger 2001). They all involved lifestyle interventions to treat obesity in children or adolescents (Figure 2). An additional 46 studies that met the inclusion criteria were found in 2008. Therefore a total 64 studies are included in the current review. Two additional papers were ongoing trials, both involving lifestyle interventions, but these studies could not be included in the present review because outcomes measures were not yet available (Brennan 2008; Janicke 2008, see Characteristics of included studies).

Overall, 54 studies reported on lifestyle interventions, ten on drug interventions (with or without combination with lifestyle intervention) i.e. sibutramine (n=5), orlistat (n=3) and metformin (n=2). None of the surgical intervention studies met the inclusion criteria. No randomised controlled trials of bariatric surgery have been reported in adolescents. Neither have there been any published reports of a controlled clinical trial, a controlled before and after study or an interrupted time series study (as defined by Cochrane EPOC criteria). Hence, surgical interventions are not further considered in this review.

The total number of participants in the 64 included studies with outcome data was 5230, of which 3806 participated in the lifestyle studies and 1424 in the drug trials. Ages ranged from 3 to 21 years. Thirty-four lifestyle studies included children with a mean age below 12 years. All but one drug trial involved adolescents aged 12 to 19 years. One study included children aged 9 to 18 years, but the mean age of children was 12.5 years (Srinivasan 2006).

Of the lifestyle intervention studies, 12 focused on exercise, physical activity or the reduction of sedentary behaviours, 6 focused on diet and 36 concentrated on behaviorally orientated treatment programs. The lifestyle interventions ranged in duration from 1 month to 24 months, with 14 having a duration less than 6 months. Forty interventions lasted 6 months or longer, 6 of which continued for one year. Four interventions lasted at least two years.

Thirty of the 54 lifestyle studies took place in the USA and Canada (29 in the USA, one in Canada). Twelve studies were conducted in Europe (three in Germany, two in United Kingdom, one each in Austria, Belgium, Finland, France, Italy, Sweden and Switzerland). Seven studies took place in Australia and Asia (four in Australia, two in China and one in Japan). The other five studies were conducted in South America (one in Brazil) or the Middle-East (all four in Israel).

Two studies on sibutramine were conducted in the USA, two in Central America (both in Mexico) and the other one in Europe (the Netherlands). One of the studies with orlistat took place in the USA and one was a multicenter trial in the USA and Canada, the third study took place in Central Eurasia (Turkey). The two metformin trials were conducted in the USA or Australia.

A wide range of behavioural approaches have been examined. These include family therapy, cognitive-behavioural treatment, problem-solving approaches and multicomponent behavioural programs which incorporate a variety of behavioral techniques. The specific details of the behavioral programs vary widely between the studies. The target of intervention was the child in nine studies (all but one in adolescents).Two studies did not clearly report their target of intervention but it appeared to be the child (Schwingshandl 1999; Warschburger 2001). Six studies examined the effects of the level of parent and/or child participation (Golan 1998; Israel 1985; Israel 1994; Golan 2006; Munsch 2008; Wadden 1990). In one study the target of intervention was the parent (McCallum 2007). However, in most studies (n=40) the target of intervention was the family or the child with a parent. In the drug trials the drugs were only administered to the child. Two drug trials reported the family as the target of the lifestyle intervention component (Berkowitz 2003; Berkowitz 2006).

For details of included studies, see the Characteristics of included studies table.

Risk of bias in included studies

All 64 included studies were RCTs. All studies included in this review had some methodological weaknesses according to the criteria set out in the Cochrane Handbook (Higgins 2008), and thus did not fulfil all quality criteria.

Allocation

Allocation to the intervention or control group was reported to be concealed in 14 of 54 lifestyle studies. However, allocation concealment was unclear in 38 of 54 studies and two studies reported that allocation was not concealed (i.e. chosen by lot, Graf 2005a; i.e. coin toss, Grey 2004). In all but two drug intervention studies, allocation to intervention or control was concealed; in one sibutramine study allocation concealment was unclear (Godoy-Matos 2005) and one orlistat study reported an unconcealed allocation to intervention or control (i.e. alternating patients were randomised to intervention or control, Ozkan 2004).

Of the 54 lifestyle studies with useful outcome data, the unit of allocation was the child in 38 and family in 13 studies. One study randomised family physicians to intervention and control (Nova 2001) and two studies randomised schools to intervention and control (Berry 2007; Graf 2005a). In all ten drug interventions the unit of allocation was the child.

Blinding

Blinded outcome assessment was reported in five of the 54 lifestyle intervention studies. Outcome assessment was not blinded in seven studies and unclear in the other 42 studies. Outcome assessment was blinded in seven of the drug trials. In the other three it was unclear (Garcia-Morales 2006; Godoy-Matos 2005; Ozkan 2004).

Follow up and exclusions

One study reported that no participants were lost to follow-up (Weintraub 2008). Drop-out rates reported at the end of intervention ranged from 0 to 42%. Lost-to-follow-up rates at 6 months ranged from 1 to 42%, at 9 months from 8 to 34% and at 12 months from 7 to 43%. Dropout rates after 12 months of follow up ranged from 12 to 52%. Twenty-seven studies reported a completion of intervention rate of more than 80%. Four other studies did not adequately describe attrition (Grey 2004; Rooney 2005; Warschburger 2001; Woo 2004).Twenty-one lifestyle intervention studies reported analysis based on intention-to-treat principles to account for missing data. In general, drop-out rates in drug intervention trials were higher; at the end of intervention they ranged from 4 to 35%, but in only four of the drug trials, data at follow up measurements represented more than 80% of the baseline sample. All but three drug trials performed analysis based on intention-to-treat principles (Freemark 2001; Ozkan 2004; Srinivasan 2006).

Other potential sources of bias

The sample sizes of studies ranged from 16 to 218 participants in the lifestyle interventions, and from 24 to 539 participants in the drug trials. Power calculations were only discussed in 15 lifestyle studies included in this review. Two of which did not report statistical power ((De Mello 2004 (n=38); Nova 2001 (n=186)) and three did not reach the statistical power calculated ((Kalavainen 2007 (n=70); Munsch 2008 (n=56); Weintraub 2008 (n=21)). Sample sizes for studies with power calculations ranged from 27 to 209 participants. Thirty-eight of 54 lifestyle interventions randomised less than 30 children to at least one study arm. Four of the drug intervention studies did not discuss power. In the other six drug trials power was not reported in one ((Godoy-Matos 2005 (n=60)) and ranged from 80 to 93% in the others. Most drug trials included in this review had small sample sizes; six out of ten drug trials randomised less than 30 children to at least one study arm.

Baseline differences between intervention and control groups were discussed in most studies, four lifestyle studies found a significant difference in body composition between the experimental and control group (Ebbeling 2003, fat mass; Graf 2005a, BMI; Nova 2001, percentage overweight and BMI; Rodearmel 2007, waist circumference). In four studies, baseline differences between study arms were found in terms of socio-economic status (McCallum 2007), lifestyle behaviours (De Mello 2004 - higher spontaneous leisure activity in control group; Nova 2001 - higher propensity for snacks in the control group), and child perceptions of parenting styles (Epstein 2008a). Two drug studies found a significant difference in body composition between the experimental and control group at baseline ( Freemark 2001, BMI; Ozkan 2004, BMI and weight for height). One study found a baseline difference in mean baseline heart rate between the two study arms (Garcia-Morales 2006). None of these baseline differences between groups were taken into account in analyses reported in the original papers, neither in the lifestyle, nor in the drug trials.

Seven studies (Braet 2004; Grey 2004; Gutin 2002; Johnston 2007a; Johnston 2007b; Williamson 2005) reported measures undertaken to minimise contamination between study arms. One study reported that protection against contamination was not done, but it was assessed and found to be minimal (McCallum 2007). Forty-six studies did not discuss the potential of contamination between study groups. In drug interventions in which allocation to intervention or placebo is concealed, contamination might not be a problem. Furthermore, most of these studies compared drug treatment with placebo treatment, with participants in both arms also receiving the same lifestyle intervention. The two studies in which allocation concealment was unclear or not done (Godoy-Matos 2005; Ozkan 2004), did not report measures against contamination between study groups. 

Only five of 16 lifestyle studies published after 2005, and two of the drug trials reported a clinical trials registration number. Forty-four lifestyle studies reported funding or financial disclosure. This is an important issue since there could be a conflict of interest when the operators of a specialist clinic also carry out research which might well be seen as evaluating the work of the clinic. In addition, some of the included studies may have been poorly funded, which may explain the small sample sizes found in many studies. However, no conflicts of interest of any note were reported. Most studies were funded by national health institution research grants. All drug trials reported funding sources. Most of these studies were industry-sponsored but four studies reported non-industry sources of funding (Freemark 2001; Maahs 2006; Ozkan 2004; Srinivasan 2006).

Effects of interventions

The studies included in this review varied greatly in intervention design, outcome measurements and methodological quality. Most studies demonstrated beneficial effects of interventions on child adiposity from baseline to the end of intervention or follow up. The challenge is to determine which intervention is most effective.

In this section effects of interventions on child adiposity are described. Measures of harm are also discussed. Secondary outcome data for studies will be included in future revisions of this review. Primary results are reported in the table Characteristics of included studies.

Lifestyle intervention studies

Two-thirds of lifestyle studies were conducted in children (defined as having a mean age less than 12 years, n=37), with one-third of studies including adolescents (defined as having a mean age at or above 12 years, n=17). 

Three types of lifestyle interventions were identified: dietary, physical activity and behavioural interventions. Behavioural therapy was defined as therapy aimed at changing thinking patterns and actions, especially in relation to dietary intake and eating, physical activity and sedentary behaviours, and the family's food and physical environment. If interventions did not specifically include a behavioural program they were classified as a dietary or physical activity intervention as appropriate. If diet and physical activity were combined in an intervention, classification for meta-analysis was based on the intensity of the diet or physical activity and the comparison made between the study arms, for example Rolland-Cachera 2004 consisted of both a diet and a physical activity program, but comparison between study arms was made based on the diet in the experimental and the control group and therefor this study is classified under dietary interventions.

Follow-up measurements were most often reported at 6, 9, 12 and 24 months. As a primary outcome, 41lifestyle intervention studies reported either BMI-SDS (n=22) or percentage overweight (n=17), 11 studies reported absolute BMI, one reported fat mass, and one BMI percentile. Eleven lifestyle studies included fat distribution (waist circumference, waist circumference-SDS, waist-to-hip ratio and subcutaneous or abdominal subcutaneous fat distribution) as a secondary outcome. One study reported intima media thickness as a secondary outcome (Woo 2004). Including these kinds of secondary measures may help to establish a full risk profile for the child. Furthermore, from a research perspective, it will help to further delineate the mechanisms by which interventions may be working. 

Interventions in children under 12 years old

Dietary interventions

Four studies concerning a dietary intervention were identified (Epstein 2008a; Gillis 2007; Nova 2001; Satoh 2007). Epstein 2008a and Nova 2001 fulfilled all the criteria for pooling in a meta-analysis, but they involved different comparisons i.e. Epstein 2008a compared two interventions whereas Nova 2001 compared dietary intervention to self-help. Epstein 2008a demonstrated beneficial effects in both the ‘making healthy food choices’ group and the ‘decrease high energy dense foods’ group at 6, 12 and 24 months on child weight status. However, after 12 months follow up, the effects were superior for the children in the ‘healthy food choices’ group. Nova 2001 demonstrated beneficial effects on child adiposity of a dietary intervention compared to an intervention with general health and obesity information leaflets at 6 and 12 months of follow up.

Activity-based interventions

Nine studies focused mainly on the activity content of the intervention (Epstein 1985a; Epstein 1985b; Epstein 1995; Epstein 2000b; Rodearmel 2007; Rooney 2005; Schwingshandl 1999; Weintraub 2008; Woo 2004). Epstein 2000b; Rodearmel 2007; Schwingshandl 1999 and Weintraub 2008 fulfilled the earlier mentioned quality criteria, but dealt with incomparable study designs and interventions. Schwingshandl 1999 did not report useful outcome data at six months of follow up or later. Both Epstein 2000b and Rodearmel 2007 found beneficial effects on adiposity from baseline to six months in all the intervention groups. However, no significant differences between groups were found. Rodearmel 2007 compared an intervention where families were guided to achieve two small lifestyle changes (mainly focused on pedometer walking) with a self monitoring group. Both interventions seemed effective after six months, but to the same degree. At 6 and 24 months follow up, Epstein 2000b reported similar findings: no differences in adiposity change from baseline were found between interventions (high and low dose) that focused on decreasing sedentary activity or interventions targeting increasing physical activity. Weintraub 2008 compared an after school soccer program to an ‘active placebo’ i.e. a health and nutrition education program. Six months after commencing the intervention, children in both groups had increased their absolute BMI, with a significant smaller increase in favour of the soccer group.

Behavioural interventions

Twenty-four studies incorporated interventions with a large behavioural component, but only eight reported analyses based on intention-to-treat principles (Epstein 2005; Flodmark 1993; Golan 2006; Golley 2007; Hughes 2008; Kalavainen 2007; McCallum 2007; Munsch 2008). Of these eight, five studies fulfilled all criteria to be pooled in meta-analysis to establish the effect on change in BMI-SDS of a behavioural family program compared to standard or minimal care (Epstein 2005; Golan 2006; Golley 2007; Hughes 2008; Kalavainen 2007) at 6 months follow up. However, data for change in BMI-SDS for study 1 by Epstein 2005 were presented in figures only and could not be included. Epstein 2005 found significant decreases in BMI-SDS over time in both intervention groups, but the rate at which they changed was the same in both groups, suggesting no additional effects of positively reinforcing youth for increasing alternative behaviours (any freely chosen activity that did not involve simultaneous eating) to eating in a standard family-based treatment of paediatric obesity. Meta-analysis of the remaining four studies including 301 participants, showed a small favourable effect of -0.06 (95% CI: -0.12 to -0.01) in BMI-SDS in the parent-focused behavioural group intervention over standard care (Z=2.14, P=0.03; Analysis 1.1) [Note: the experimental (behavioural intervention for parents only) and control (behavioural intervention for the parent and child) groups of Golan 2006 were exchanged to assure that all experimental interventions grouped for meta-analysis involved similar parental and child participation].

McCallum 2007 found no beneficial effect on adiposity either when compared to baseline or between groups at nine months of follow-up, when a three-month solution-focused brief counselling intervention delivered by general practitioners was compared to a control condition (no intervention). Munsch 2008 compared a behavioural program addressed to mother and child, or to mothers only. At nine months of follow up, the authors reported amelioration of weight status in both groups, but the temporal course of changes did not differ between groups.

Outcomes at 12 months of follow up were reported by Flodmark 1993; Golley 2007; Hughes 2008; Kalavainen 2007; McCallum 2007 and at 24 months of follow up by Epstein 2005 and Golan 2006.  In all studies, results found at the end of intervention persisted until 12 or 24 months of follow-up. Three studies reporting change in BMI-SDS in 264 participants at 12 months were pooled in meta-analyses (Golley 2007; Hughes 2008; Kalavainen 2007). No additional beneficial effect of a parent focused behavioural group intervention over standard care was found on BMI-SDS at 12 months follow up (Analysis 1.2). 

Flodmark 1993 compared a school-based family treatment to conventional therapy or a control group without intervention. At the end of intervention (14 to 18 months) the family therapy group demonstrated a significantly smaller increase in BMI, than the conventional therapy group (controls were not measured at this time point). At follow-up one year after the end of intervention the increase in BMI was significantly smaller in the family therapy group when compared to the untreated control group, but no significant differences were found between the family therapy and conventional therapy group, or between the conventional therapy compared to the untreated control group. 

Interventions in children 12 years and older

Dietary interventions

Two studies which focused on dietary interventions in adolescents were included (Ebbeling 2003; Rolland-Cachera 2004). Only Ebbeling 2003 performed analysis based on intention-to-treat. At 12 months follow up, the authors found a favourable effect on absolute BMI and fat mass of a dietary intervention with reduced glycaemic index when compared to a standard dietary intervention with reduced fat load (both in combination with behavioural therapy). Changes were significant from baseline to twelve months for the reduced glycaemic index group only and between groups as well, in favour of the reduced glycaemic index intervention. 

Activity-based interventions

Three studies compared an experimental activity program to an ‘active placebo’ or control intervention (Carrel 2005; Daley 2006; Gutin 2002). Daley 2006 fulfilled all quality criteria. The authors compared an after school activity program to an ‘active placebo’ (relaxation therapy) and a control group without intervention. At six months follow up, no significant changes in BMI-SDS, neither from baseline to end of follow up, nor between groups, were found. 

Behavioural interventions

Twelve lifestyle interventions in adolescents with a behavioural component as the main focus of intervention were identified. Seven fulfilled the above mentioned criteria to be pooled in meta-analysis (Grey 2004; Jelalian 2006; Johnston 2007a; Johnston 2007b; Saelens 2002; Savoye 2007; Williamson 2005). However, only four studies reported similar outcome measures at six months (Johnston 2007a; Johnston 2007b; Savoye 2007; Williamson 2005).  At six months follow up, Johnston 2007a and Johnston 2007b reported a favourable effect of the nutrition education and physical activity program with behavioural strategies over the self-help control condition on BMI-SDS. Savoye 2007 showed decreases in absolute BMI in a family-based, intensive lifestyle program with a behavioural modification component compared to increases in BMI in the control condition at six months after the beginning of the intervention. Williamson 2005 found more moderate changes between groups for BMI-SDS, when an internet-based behavioural program for teenage girls was compared to an internet-based control program. Data at six months follow up from Johnston 2007b; Savoye 2007 and Williamson 2005 were pooled in a meta-analysis. The overall effect on BMI-SDS found in 291 participants was -0.14 (95% CI: -0.17. to -0.12, Z=11.51, P<0.00001; Analysis 2.1). The same studies also presented changes in absolute BMI at 6 months follow up. Pooled data for meta-analysis in 362 participants demonstrated an overall effect of a behavioural intervention over standard care or control condition of -3.04 (95% CI: -3.14 to -2.94) kg/m2on absolute BMI (Z= 61.57, P<0.00001) as presented in Analysis 2.2) 

Saelens 2002 reported non-significant decreases in BMI-SDS in the adolescents engaging in a four-month behavioural weight control intervention (phone and email contact), compared with significant increases in BMI-SDS in adolescents in the standard single physician care. This led to a significant between groups difference at the end of intervention (four months). At seven-months follow up, however, there were no significant interactions of condition by time or main effects of time for any secondary outcomes from baseline to post-treatment to follow-up. 

Jelalian 2006 hypothesized that peer-enhanced adventure therapy would have an additional effect on adolescent adiposity, when compared to standard care. Although significant changes in BMI from baseline were found at ten-months follow up, no difference was shown in rate of BMI change between groups. 

Three studies provided outcome data for BMI at 12 months follow-up (Grey 2004; Savoye 2007; Williamson 2005). At 12-months follow up, Grey 2004 did not demonstrate effectiveness of adding coping skills training to a four-month behavioural program for children aged 7-17 years. Neither change in absolute BMI from baseline to 12 months, nor between groups, was significantly different. Savoye 2007 and Williamson 2005 were comparable based on intervention type and length, and 12-month data from these studies were pooled for meta-analysis. Savoye 2007 and Williamson 2005 demonstrated that significant changes in BMI-SDS and absolute BMI in favour of the behavioural weight management program at six months after commencement of the intervention remained significant at the 12 month follow up). Pooled data for meta-analysis in 321 participants demonstrated an overall effect of a behavioural intervention over standard care or control condition of -0.14 on BMI-SDS (95% CI: -0.18. to -0.10, Z=7.11, P<0.00001, Analysis 2.3) and -3.27 kg/m2on absolute BMI (95% CI: -3.38 to -3.17, Z= 60.10, P<0.00001, Analysis 2.4).

However, in their comparison of an internet-based behavioural program for teenage girls to an internet-based control program, Williamson 2005 demonstrated that earlier significant differences between groups in favour of the internet-based behavioural program had disappeared at 18 months to 24 months follow up, since girls in the intervention group regained weight.

Drug intervention studies

All drug studies were performed in adolescents (defined as having a mean age at or above 12 years). Three types of medication were identified in included drug trials: metformin, a hypoglycaemic agent (Freemark 2001; Srinivasan 2006); orlistat, a gastrointestinal lipase inhibitor (Chanoine 2005; Maahs 2006; Ozkan 2004); and sibutramine, a serotonin and noradrenalin reuptake inhibitor (Berkowitz 2003; Berkowitz 2006; Garcia-Morales 2006; Godoy-Matos 2005; Van Mil 2007). 

The following measures of fatness were reported in the drug trials: BMI-SDS, change in absolute BMI, percentage change in initial BMI and the proportion of participants achieving more than 5% or more than 10% decrease in initial BMI, and fat-mass (absolute and percentage). Six drug studies also included fat distribution (waist circumference [with or without SDS] and subcutaneous or abdominal subcutaneous fat distribution) as a secondary outcome.

Metformin

Both included metformin trials (Freemark 2001; Srinivasan 2006) did not perform analysis based on intention-to-treat. Therefore these data were not pooled in meta-analysis. 

Orlistat

Both Chanoine 2005 and Maahs 2006 fulfilled the quality criteria. Pooled meta-analysis in 579 participants, found an additional effect of orlistat over placebo on absolute BMI at 6 months follow up, when given in combination with a lifestyle intervention (-0.76 kg/m2, 95% CI: -1.07 to -0.44, Z= 4.70, P<0.00001; Analysis 3.1).

Sibutramine

Four of five sibutramine trials were comparable based on our quality criteria (Berkowitz 2003; Berkowitz 2006; Garcia-Morales 2006; Godoy-Matos 2005). Berkowitz 2003 and Berkowitz 2006 also reported BMI-SDS outcomes (figures only). All four studies reported changes in absolute BMI at 6 months but Berkowitz 2003 and Berkowitz 2006 only reported change in absolute BMI and BMI-SDS outcomes in figures and therefore were not included in a meta-analysis. Both of these studies found a significant between groups effect of sibutramine in combination with a lifestyle intervention over placebo in combination with a lifestyle intervention. Outcome data at six months of Garcia-Morales 2006 and Godoy-Matos 2005 in 111 participants were pooled in a meta-analysis. A favourable effect on absolute BMI of sibutramine over placebo was found of -1.66 kg/m2 (95% CI: -1.89 to -1.43, Z=14.23, P<0.00001; Analysis 4.1).

Berkowitz 2006 was the only study reporting long-term outcome data. At 12 months follow up, the authors found an estimated mean change in BMI for sibutramine plus behavior therapy of -2.9 kg/m2 versus -0.3 kg/m2 for placebo plus behavior therapy. When data were expressed as BMI-SDS a statistically significant treatment difference of 0.22 favoured sibutramine.

Van Mil 2007, as opposed to the other trials in which duration of drug intervention was six months, only gave sibutramine for three months; the authors report the decrease in BMI-SDS was comparable in both groups at three months. From three to six months follow up there was an increase in BMI-SDS in the sibutramine group in contrast to a further decrease in the placebo group, but this was notsignificant in the intention-to-treat analysis. The cumulative change in BMI-SDS from baseline to end of follow up at six months was not reported.  

Adverse effects

Reporting of harm was noticeably absent in lifestyle studies. Only 18 out of 54 lifestyle studies reported measures of harm such as occurrence or deterioration of disordered eating, depression or anxiety. However, changes in linear height growth over time and reasons for dropouts were commonly reported in lifestyle studies. In contrast, the majority of drug studies reported total adverse events and possible medication-related adverse events.

Lifestyle interventions

None of the lifestyle studies reported an adverse effect on linear height growth.

Ten lifestyle studies (Braet 2004; Epstein 1985a; Epstein 1985c; Golan 1998; Israel 1985; Israel 1994; Jelalian 2006; Munsch 2008; Saelens 2002; Williamson 2005) reported measures of disordered eating and/or behaviours. The duration of the intervention in these studies ranged from 4 to 24 months. Braet 2004 found significant improvements for drive for thinness, bulimia, body dissatisfaction, external eating, eating concern, weight concern and shape concern. Furthermore, the total number of binges per month decreased significantly from pre- to post intervention. Considerable improvements were maintained in the majority of adverse effects until follow up at 14 months. Similarly, Epstein 1985a and Epstein 1985c found significantly improved eating behaviours at 6, 12 and 24 months of follow up. Golan 1998, Israel 1985 and Israel 1994 collectively reported positive changes in eating styles and habits post treatment, yet no differences were apparent across groups. Adolescents in the internet-based behavioural program demonstrated lower scores of emotional eating and overeating, whereas changes in the levels of concern relating to dieting remained unchanged, compared to lower levels of concern relating to dieting and weight loss in the adolescents in the internet-based control program (Williamson 2005). No adverse changes were reported in any of the studies.

Measures of psychological well-being, like global self-worth, self-esteem, quality of life and absence of depressive symptoms or internalising behaviour problems were provided in 11 studies (Braet 2004; Daley 2006; Epstein 2000a; Hughes 2008; Jelalian 2006; McCallum 2007; Mellin 1987; Munsch 2008; Wadden 1990; Warschburger 2001; Weintraub 2008). Intervention duration for the aforementioned studies ranged from 3 to 24 months. Braet 2004 recorded positive changes in global, athletic and physical well-being and Epstein 2000a recorded improvement in child problem solving, internalising behaviours and total competence in both study arms at the end of treatment and persisting at follow up. Jelalian 2006 found that adolescents randomised to both treatment conditions demonstrated significant improvements on dimensions of global self-concept, physical appearance, and physical self-worth over time. Depression scores were recorded in five studies (Daley 2006; Mellin 1987; Munsch 2008; Wadden 1990; Weintraub 2008). A reduction in depression scores was evident in all studies. However, the decrease over time reported by Daley 2006 was not significant. Munsch 2008 recorded a decrease in both groups, with a significant decrease identified in the children from the behavioural therapy for mother only study arm. This decrease was also noted to be particularly prominent in the early intervention stages. Depressive symptoms were shown to be slightly higher in the control group than that of the soccer group at six months by Weintraub 2008. However this change was not reported as being significant. Hughes 2008, McCallum 2007 and Warschburger 2001 found significant improvements in quality of life by child- and/-or parent-report over time, without differences across groups. None of the studies reported adverse changes in the children's psychological well-being.

Jelalian 2006 reported that no adverse events or untoward side effects occurred in either the peer-enhanced cognitive behaviour therapy or the standard cognitive behaviour therapy study arm during the intervention. Furthermore, drop-out rates in both groups were similar. The standard care arm of the study was discontinued due to patient and parent concerns with treatment acceptability and associated significant difficulties with retention. In Munsch 2008, study arms consisted of behavioural therapy delivered to mother and child compared to behavioural therapy delivered to the mother only, with drop outs recorded as 31% and 70% respectively at six months (p=0.004), even though suitability ratings at this time-point did not differ between groups. In contrast, Golan 2006 reported a higher full attendance rate for the parents-only group vs the parents and children group and no difference in dropout rate per group. In Golan 1998, the attendance rate for both groups (behavioural therapy for parents only vs behavioural therapy for children only) was similar, but there were nine (30%) drop-outs in the behavioural therapy for children only group, compared to one (3%) in the behavioural therapy for parents only group. The majority of studies specified reasons for drop out e.g. lost to follow up due to moves, family problems, no longer interested, car accidents or lack of motivation.

Weintraub 2008 was the only lifestyle study to report withdrawals due to adverse events. In total three participants withdrew from the intervention group and six from the control. Headaches, rash and pain were among the complaints made. However it was specified that all recorded adverse events, both for the intervention and control groups, were unrelated to the intervention.

Metformin

Participants received metformin for 6 months at a daily dose of 1g (0.5g twice daily) (Freemark 2001) or 2g (1g twice daily) (Srinivasan 2006). Median adherence to metformin was 78% (range 15-99%) in one study which was not different from the placebo group (Srinivasan 2006). There were no withdrawals due to adverse events in either study; however, medication dose was lowered due to nausea in three participants (Freemark 2001 n=1; Srinivasan 2006 n=2).  In both studies there was no adverse effect on serum lactate, or measures of liver or renal function. Freemark 2001 reported that there were no episodes of vomiting or lactic acidosis. Srinivasan 2006 reported that there was no biochemical evidence of metformin toxicity. In one study, three metformin treated patients, and one placebo patient, complained of transient abdominal discomfort or diarrhoea that resolved within the first one to two weeks of therapy and another participant may have had an exacerbation of migraine (Freemark 2001).

Orlistat

Participants in each study received 120mg orlistat three times a day as well as a daily multivitamin supplement (Chanoine 2005; Maahs 2006; Ozkan 2004). Adherence to orlistat was assessed in two studies and shown to be 73% (Chanoine 2005) and >80% (Maahs 2006). The duration of the intervention in the three studies was 6 months, 12 months and between 5-15 months. In all studies, withdrawals due to adverse events were higher in the orlistat intervention compared with the placebo/control intervention (Chanoine 2005: 3.4% vs 1.7%; Maahs 2006: 15% vs 0%; Ozkan 2004: 31.8% vs 0%). Chanoine 2005 reported serious adverse events in 3.1% of those receiving orlistat and 2.7% of those receiving placebo, with only the symptomatic cholelithiasis that led to cholecystectomy in a 15 year old girl being considered possibly related to orlistat by the investigators. The same author reported that at least one adverse event was reported by 97% and 94% of participants in the orlistat and placebo interventions respectively (Chanoine 2005); equivalent data were not reported in the other studies.

The most common types of adverse events in all three studies were associated with the gastrointestinal tract (GIT) and were more prevalent in the orlistat intervention compared with the placebo intervention. The most common GIT adverse events were fatty/oily stool or evacuation, oily spotting, increased defecation, cramps and abdominal pain. Changes in blood vitamin A, D, and E levels were reported in two studies and all levels increased or stayed the same, except in one study where vitamin D levels decreased in both the orlistat and placebo interventions (Maahs 2006).

Chanoine 2005 also measured estradiol levels, cardiovascular effects, gallbladder structure, renal structure, bone mineral content/density, and other non-GIT adverse events.  Girls in the orlistat group had a statistically significant decrease in estradiol compared with a slight increase shown in the placebo intervention. Ten participants in the orlistat intervention and one participant in the placebo intervention developed abnormalities during the study that were detected on electrocardiograms; none of these was believed to be related to the medication based on review by an independent cardiologist. No other adverse cardiovascular effects were found. At the end of the study, six participants in the orlistat intervention (compared with one participant in the placebo intervention) were found to have asymptomatic gallstones not seen at baseline; five of these patients had lost large amounts of weight (8.2-29.4 kg) and two were siblings. Another patient had multiple gallstones on ultrasound at day 167 after a 15.8 kg weight loss and had a subsequent cholecystectomy. Ultrasound also identified two additional new renal abnormalities in the orlistat intervention group (mild left hydronephrosis and 6-mm echogenic focus without evidence of renal calculus). There were no differences in bone mineral content/density between the two interventions. Most other non-GIT adverse events were also more prevalent in the orlistat group compared with the placebo group but the difference between groups was less pronounced than for GIT adverse events; the most common adverse events in this category were headache, upper respiratory tract infection, and nasopharyngitis. 

Sibutramine

Across studies, participants received sibutramine at a dose of 10g or 15g for the majority of the intervention period which ranged from 3 to 12 months (Berkowitz 2003; Berkowitz 2006; Garcia-Morales 2006; Godoy-Matos 2005; Van Mil 2007). Medication adherence was measured in all studies but only reported in four: mean 79.1% (Berkowitz 2003); mean 89.1% (Berkowitz 2006); and 90-100% (Garcia-Morales 2006); all participants >60%(Godoy-Matos 2005). 

Three studies reported a safety protocol relating to blood pressure and pulse rate cut-offs that would be used to initiate withdrawal of participants from the study or a sibutramine dose reduction (Berkowitz 2003; Berkowitz 2006; Garcia-Morales 2006). In three studies there were withdrawals due to adverse effects/events. One study had two (4.7%) withdrawals in the sibutramine group due to adverse effects, one in the first 6 months (ventricular premature complexes) and another in the second 6 months (increases in blood pressure [BP] and pulse rate); there were no withdrawals in the placebo control group (Berkowitz 2003).  In the same study 19 participants had a sibutramine dose reduction in the first 6 months in response to elevations in BP, pulse rate or both. During the full 12 month study, sibutramine was reduced to 10 mg in 16 participants, to 5 mg in seven additional adolescents and discontinued in 10 participants (six because of increased BP and/or pulse rate, two for ecchymoses, one for ventricular premature complexes and one because of rash) (Berkowitz 2003). In the study by Berkowitz 2006 there were 22 (5.7%) withdrawals due to adverse events in the sibutramine group (2.4% were due to tachycardia and 1.4% due to hypertension) and seven (5.4%) withdrawals in the placebo group (1.5% were due to tachycardia; and none was due to hypertension). In the same study an adverse event was reported by 89% of participants in the sibutramine group and 85% of participants in the placebo group; the proportion of serious adverse events in each group was 2.7% and 0.8% respectively and the incidence of excessive nausea and vomiting in one patient was considered to be the only serious adverse event possibly related to study medication and resulted in premature discontinuation. In the same study, there was one incidence of suicide in both the sibutramine and placebo groups which were considered unlikely to be related to the study drug and 1.4% and 0.8% of participants in both groups respectively were found to have depression (Berkowitz 2006). In the study by Van Mil 2007, symptoms of clinical depression led to the withdrawal of one subject (out of 12) - as was confirmed by both the mother and the participant, these symptoms disappeared thereafter; there were no withdrawals in the placebo group or reports of sibutramine dose reduction for safety concerns. In the same study 41 participants in the sibutramine group, compared with 22 in the placebo group reported adverse events but the difference was not statistically significant (Van Mil 2007). Two studies had no withdrawals due to adverse events (Garcia-Morales 2006; Godoy-Matos 2005) although four participants in both the sibutramine and placebo groups in one study had an elevated diastolic blood pressure or pulse that disappeared within one week (Garcia-Morales 2006). 

All studies reported data on cardiovascular variables including absolute values or change in systolic blood pressure, diastolic blood pressure, and pulse rate. Greater reductions in these variables were generally seen in the placebo group compared with the sibutramine group and these were statistically significant at various time points in some studies: systolic blood pressure (Berkowitz 2003), diastolic blood pressure (Berkowitz 2006; Van Mil 2007), and pulse rate (Berkowitz 2003; Berkowitz 2006). Echocardiography data were reported in three studies but changes were not statistically or clinically significant (Berkowitz 2006; Godoy-Matos 2005; Van Mil 2007). In one study the increase in ST segment of the electrocardiogram in both the sibutramine and placebo group was statistically significant (Garcia-Morales 2006).  

Most of the studies also reported the prevalence of non-cardiovascular adverse events. Symptoms that were more prevalent in the sibutramine group compared with the placebo group in two or more studies were dry mouth (Berkowitz 2006: 11% versus 6%; Garcia-Morales 2006: 14.3% versus 5.3%; Godoy-Matos 2005: 23.3% versus 10%), dizziness (Berkowitz 2006: 8% versus 4%; Godoy-Matos 2005: 10% versus 6.7%; Van Mil 2007: 25% versus 8.3%), and some form of rash (Berkowitz 2003: 2.3% versus 0%; Berkowitz 2006: 7% versus 5%; Van Mil 2007: 16.7% versus 0%), For other adverse events a higher incidence (P<0.05) was found in the sibutramine group compared with the placebo group for abdominal complaints (Van Mil 2007: 58.3% versus 0%) and constipation (Godoy-Matos 2005: 40.0% versus 13.3%). 

Discussion

  1. Top of page
  2. Abstract
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Implications for research
  10. Acknowledgements
  11. Characteristics of studies
  12. Data and analyses
  13. Appendices
  14. What's new
  15. History
  16. Contributions of authors
  17. Declarations of interest
  18. Sources of support
  19. REFERENCES

Sixty-four randomised controlled studies were included in this review (and a further two trials met our criteria but are ongoing and have yet to report outcomes), sharing similar overall goals and objectives. However, there were multiple differences in terms of study design (particularly intervention comparisons), quality (particularly sample size and thus power) and outcome measures. Most studies reported beneficial effects of the intervention on adiposity from baseline to end of intervention or follow up. The challenge is to ascertain which intervention is more effective than another. Although we have not been able to fully answer this, we have identified further evidence as to the effectiveness of various strategies for treating childhood obesity. The importance of a combined dietary, physical activity and behavioural component has been highlighted by several studies included in this review (Epstein 2005; Flodmark 1993; Golan 2006; Golley 2007; Hughes 2008; Jelalian 2006; Johnston 2007a; Johnston 2007b; Kalavainen 2007; McCallum 2007; Munsch 2008; Saelens 2002; Savoye 2007; Williamson 2005). Parental involvement has been recognised as an important feature of behavioural programs, particularly in pre-adolescent children (Golan 1998; Golan 2006; Munsch 2008).

Positive outcomes for treating obesity in children were achieved in several studies, including high quality studies. Meta-analysis in children under twelve years of age showed that family-targeted behavioural lifestyle interventions decreased BMI-SDS more than did standard care at six months follow up. The effect size was small but statistically significant and clinically relevant. In these studies (Golan 2006; Golley 2007; Hughes 2008; Kalavainen 2007) new behavioural interventions were compared to established standard care, thus providing an additional effect. The effect size found in meta-analysis at 12 months was no longer significant, although decreases in BMI-SDS persisted in the three pooled studies (Golley 2007; Hughes 2008; Kalavainen 2007). In adolescents, a similar pattern was seen, albeit with an even greater effect size, given that behavioural interventions were compared to a self-help condition (Johnston 2007a; Johnston 2007b; Savoye 2007; Williamson 2005). In adolescents the effect size remained significant at 12 months after beginning of the intervention, demonstrating that beneficial effects of the behavioural program persisted in the longer-term. In addition, in the meta-analyses of included drug trials, both orlistat and sibutramine, as an adjunct to a lifestyle intervention, led to significant improvements in adiposity in adolescents, although a range of adverse events was also noted. 

It is important to note that interventions to reduce obesity may vary in effect depending on the age of the child, due to differences in metabolism, nutritional needs, physical maturation and psycho-social development throughout childhood. Some studies reported delivering interventions separately to different age groups (Berry 2007; Weyhreter 2003). Three studies developed interventions in line with their target group behaviour, such as a phone or internet-based facility or peer-enhanced activity training (Jelalian 2006; Saelens 2002; Williamson 2005). It is very likely that the level of parental involvement will change with age and developmental stage. Therefore it is a priority to develop interventions that account for these differences throughout child and adolescent development. An important finding in this review was the lack of interventions for preschool-aged children and the relatively low number of lifestyle interventions targeted at adolescents.

Most studies were underpowered (44 out of 64 randomised less than 30 children to at least one group) and only 15 out of 54 lifestyle studies reported power calculations. In these circumstances it is possible that small study biases will arise, in particular a tendency to publish positive studies more than negative studies. As so few common interventions could be pooled it was not feasible to examine this formally using Funnel plots and Begg and Eggar tests. Most studies did not account for missing data in analyses and less than half (n=28) of all included studies performed analysis based on intention-to-treat principles. This might be an important issue, since many of the studies dealt with high dropout rates; only 31 studies reported follow up of more than 80% of the baseline participants. It is possible that participants with a successful intervention experience or outcome may be more likely to return for follow up assessments, whereas participants who fail to change their adiposity status may not return for follow-up, leading to an overestimation of the treatment effect. However, in most studies dropout rates were not significantly different between comparison groups. Many of the included trials were run from a specialist obesity clinic within a hospital setting. Some studies reported transportation to the clinic as a barrier to participate in the intervention or follow up assessment (e.g. Berry 2007). It is possible, that community interventions, which may be provided closer to home and thus may be more accessible, might lead to a greater proportion of specific target groups being reached. 

One important research challenge in this area has been the variations in the definitions of fatness in children. Although a positive trend towards a consistent approach to the measurement of childhood obesity has been noted in studies included in this review, many different methods are still used to estimate body fatness or relative weight and changes over time. A further limitation is the large proportion of included studies that did not adjust calculated changes in adiposity for age and sex.  The International Obesity Taskforce BMI for age cut-points (Cole 2000) are increasingly used for epidemiological studies and the WHO has recently introduced the Child Growth Standards for children aged 0 to 5 years, and the WHO growth reference for 5 to 18 year olds (De Onis 2007a; De Onis 2007b). However, the use of a consistent approach to the measurement of childhood obesity remains a priority issue in this field (Barlow 1998).

A new feature in this update was the inclusion of drug interventions and the consideration of surgical interventions for the treatment of adolescent obesity. While no surgical study met the inclusion criteria, several drug interventions were ultimately included in the review. In comparison with the lifestyle interventions, the drug trials generally met more of the CONSORT criteria (Moher 2001) and several had relatively large sample sizes. We were also able to undertake meta-analyses for two of the drug interventions (orlistat and sibutramine). The adverse event profile of the drug trials was well documented.

The proposed relationship between treating obesity and eating disorders, particularly in young populations, is a vital area of consideration. Although eating disorders are clearly of public significance and while dieting may be a risk factor for eating disorders in some people, the literature about this relationship remains equivocal, with some studies finding no association (Schleimer 1983) and others suggesting that an association does exist in some women (Patton 1990; Killen 1994). In this review ten lifestyle studies (Braet 2004; Epstein 1985a; Epstein 1985c; Golan 1998; Israel 1985; Israel 1994; Jelalian 2006; Munsch 2008; Saelens 2002; Williamson 2005) that reported on measures of disordered eating, did not find any adverse changes. It is important to acknowledge that the proportion of the population who are obese far exceeds the proportion of the population who have eating disorders and most obesity treatments are not about “dieting”. However, obesity treatments should make assessments of potential unintended effects since there is a lack of data on this aspect of treating obesity in children and adolescents. Nevertheless, one-third of the lifestyle intervention studies included in this review reported measures of harm, but no adverse effects on linear growth, eating behaviours or psychological well-being were noted.

Furthermore, measurement of predicted antecedent behaviours in the area of obesity treatment, such as dietary intake and physical activity, remains relatively weak. The development and use of appropriate measures in future studies is likely to be affected by limited sources. Given that the quality of these measurements ultimately predicts the quality of study findings, the importance of funding the design, validation and use of appropriate tools for this age group cannot be overstated. 

While we agree that research in the area of obesity treatment is difficult to conduct, this must be considered against a background which acknowledges that obesity is now considered to be a global epidemic (WHO 2000). Halting this epidemic may ultimately be determined by the quality and co-ordination of a range of obesity treatment initiatives, alongside an effective obesity prevention strategy. It is desirable, from both ethical and fiscal perspectives, to understand how interventions can most effectively and appropriately halt the population trend to fatness. However, the heterogeneity of data at hand make it difficult to conclude that one particular strategy, or combinations of strategies, is or are more important than others in the treatment of child and adolescent obesity, although several strategies appear promising. The mismatch between the high prevalence and significance of the condition and the limited knowledge base from which to inform treatment strategies remains a feature of this review. The potential outcome of effective obesity treatment interventions for children and adolescents include both short and long-term health benefits. Studies are needed that are designed to disentangle the relative importance and effects of targeted antecedent behaviours in paediatric obesity treatment. In addition, study designs must adopt current knowledge regarding the most appropriate theoretical underpinnings of behavioral change. When interpreting the results of such studies the role of general health promotion programmes as potential confounding factors needs to be assessed. In assessing drug interventions in adolescents, the adjunctive role of lifestyle change interventions needs to be further investigated, and the effectiveness of intervention needs to be weighed up against the impact of potential adverse events. The role of surgical interventions in severely obese older adolescents also requires detailed study. All such issues are important in terms of identifying the most cost-effective and sustainable range of interventions.

Authors' conclusions

  1. Top of page
  2. Abstract
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Implications for research
  10. Acknowledgements
  11. Characteristics of studies
  12. Data and analyses
  13. Appendices
  14. What's new
  15. History
  16. Contributions of authors
  17. Declarations of interest
  18. Sources of support
  19. REFERENCES

Implications for practice

While there are relatively limited quality data to ascertain which intervention is more effective than another in child and adolescent obesity treatment programs, several strategies are recognised as being potentially useful. A combined dietary, physical activity and behavioural component appears effective. Evidence from this review shows that family-based, lifestyle interventions with a behavioural program aimed at changing diet and physical activity thinking patterns provide significant and clinically meaningful decrease in overweight in both children and adolescents compared to standard care or self-help in the short- and the long-term. In obese adolescents, consideration should be given to the use of either orlistat or sibutramine, in the context of a lifestyle change program, although such therapy needs to be carefully weighed up against the potential for adverse events.

With many of the studies included in this review, it is unlikely that the implications for practice can be directly extrapolated from one group to another. The practicalities of delivering effective advice on lifestyle changes to obese children and adolescents will vary with the wide span of social, ethnic and economic circumstances, as well as with the many variations in available resources for local health service delivery. In terms of validity, a number of the studies had small sample sizes, a likelihood of small study biases, relatively high drop-out rates, and unadjusted outcome measurements. The findings from many of the included studies may be non-generalisable owing to sampling problems - the majority of research in the field has been conducted in motivated, middle class, Caucasian populations. A positive tendency to address these lifestyle and/or drug interventions at specific target populations was noted (Munsch 2008; Weintraub 2008; Williamson 2005). The failure to address and measure vital and important psychological and social factors in these intervention studies hinders the potential for intervention effectiveness. Other than in the drug trials, adverse effects of the interventions were infrequently considered, and reporting of long-term outcomes beyond one year is also limited.

Implications for research

  1. Top of page
  2. Abstract
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Implications for research
  10. Acknowledgements
  11. Characteristics of studies
  12. Data and analyses
  13. Appendices
  14. What's new
  15. History
  16. Contributions of authors
  17. Declarations of interest
  18. Sources of support
  19. REFERENCES

The validity and generalisability of several of the studies included in this review remain questionable. The questions that remain largely unanswered by this review are:

  • What interventions are most effective at different levels of obesity severity and at different ages and developmental stages?

  • What strategies are most effective for long-term maintenance of healthy weight or reduced weight following initial treatment of obesity?

  • What are the family characteristics that promote success in the treatment of child and adolescent obesity?

  • What interventions are most effective for specific ethnicities, religious groups or culturally diverse populations?

  • What is the role of psychological and social factors such as self-esteem and the family's capacity to change behaviour in the treatment and management of child and adolescent obesity?

  • What are the most cost- and resource-effective methods of treating child and adolescent obesity in different health care settings?

  • What is the role of bariatric surgery in the treatment of severely obese adolescents?

  • What are the potential harms as well as benefits of different interventions?

Governments, non-government organisations, industry and research bodies must recognise that:

  • Child and adolescent obesity has reached epidemic proportions and, as such, requires commensurate resources in prevention and treatment in order to achieve change for individuals, families and the population.

  • Treatment of obesity in children and adolescents remains a relatively new science necessitating careful review of the evidence-base in terms of what appears to be effective as well as carefully designed and evaluated innovative programs of research.

  • Trials that are conducted following the criteria of the CONSORT statement and are designed with enough power are required to provide the necessary evidence base.

  • Innovative non-RCT interventions with a rigorous external evaluation may also provide useful evidence.

  • Qualitative research employed within interventions will provide a powerful evidence-base on the views of participants: patients and families as well as providers, highlighting why interventions may be more or less successful.

  • The cost-effectiveness of treatment programs for children and their families needs to be incorporated into programs of research or non research action. Cost measures need to include child, family and community opportunity costs over the short and long term.

  • Appropriate short- and long-term outcomes need to be defined for children and youth at various weight levels, rather than using conventional or adult-oriented outcomes. Weight loss (or failure to gain) may not be an appropriate measure of therapeutic interventions for all growing children, and behaviours such as habitual physical activity, healthy eating, and improved psychosocial outcomes are likely to be more meaningful, until their growth and development stabilise.

  • Interventions are likely to be more relevant, successful and less harmful if interventions are pre-tested with groups similar to those intended to receive the intervention.

  • Studies should include process indicators which provide information on whether the study was adhered to and conducted as it was intended. If variation is observed, researchers should consider the implication of this on the effectiveness of the intervention. The importance of statistical analyses that account for dropouts and missing data can not be overstressed in this matter.

Acknowledgements

  1. Top of page
  2. Abstract
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Implications for research
  10. Acknowledgements
  11. Characteristics of studies
  12. Data and analyses
  13. Appendices
  14. What's new
  15. History
  16. Contributions of authors
  17. Declarations of interest
  18. Sources of support
  19. REFERENCES

Liz Bickerdike, Margaret Burke and Joey Kwong, Cochrane Heart Group, London School of Hygiene & Tropical Medicine, London, UK.

Hedde Strooisma, Department of Epidemiology, University Medical Center Groningen, the Netherlands. We would like to thank the authors for providing additional data which made meta-analyses in this review possible.

Characteristics of studies

  1. Top of page
  2. Abstract
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Implications for research
  10. Acknowledgements
  11. Characteristics of studies
  12. Data and analyses
  13. Appendices
  14. What's new
  15. History
  16. Contributions of authors
  17. Declarations of interest
  18. Sources of support
  19. REFERENCES

Characteristics of included studies [author-defined order]

Berry 2007
MethodsRandom allocation: yes, telephone numbered, opaque sealed envelopes Blinding: Children: No Providers: No Outcome assessors: Yes Length of intervention and follow up: 12 weeks, follow up at 3 months (after intervention) and at 6 months Unit of allocation: Individual child + parent Unit of analysis: Individual child + parent Protection against contamination: Not clear Drop outs: end of intervention 25% [20/80], follow up at 6 months: 25% [20/80]
Participantsn= 80 randomised, 60 completedAge range (mean): child: 7-17 years (experimental group 11.9±2.5, control group 11.9±2.3) % Male: child: 58.8% Weight entry criteria: BMI >85th percentile for children Weight on entry (mean): not reported Setting: Outpatient clinic Geographic Region: Yale, USA
InterventionsIntervention: Bright Bodies weight management program with and without addition of Coping Skills Training for obese multiethnic parents Intervention: Bright Bodies weight management program Target of intervention: Child & parent Behavioural or psychological component: - Children in both groups attended additional (after the first six weekly NEEP classes) six weekly 45-minute NEEP classes with behaviour modification without parents. The Bright Bodies' registered dietitians taught this behaviour modification classes with NEEP. Behaviour modification focused on improving self-image and learning new skills such as self-awareness, stress control and stress management. - The CST classes were taught to the parents in the experimental group by an advanced practice nurse in sic weekly 60-minute classes. The CST classes included an introduction, cognitive behaviour modification and exercise, social problem solving and barriers to weight loss, assertiveness training and how to motivate oneself, conflict resolution and rebounding from relapse, and social problem solving and weight maintenance. Physical activity: - The Bright bodies' registered dietitians taught the NEEP (Nutrition and Exercise Education Program) classes once a week. Exercise education focused on increasing physical activity and decreasing sedentary behaviours. Parents and children in both groups attended six weekly 45 minute classes together. - Children in both groups attended 12 twice-a-week 45-minute exercise classes. The Bright Bodies' exercise physiologists taught the exercise classes twice a week. The exercise classes for the children were held in an exercise room at the hospital or at a local middle-school gymnasium. Activities included basketball, dancing, tag, walking, and stair climbing. - Parents in both groups were encouraged by the research assistant to walk between 30 and 60 minutes a day and keep track of their progress in their pedometer logbooks. Nutrional advice: The Bright bodies' registered dietitians taught the NEEP (Nutrition and Exercise Education Program) classes once a week. Nutrition education focused on making better food choices, ethnic menu plans, lowering fat and calories, and portion control. Parents and children in both groups attended six weekly 45 minute classes together. Other: No Usual care/ alternative intervention: Control group Target of intervention: Child & parent Behavioural or psychological component: As above, but parents did not attend the CST. Physical activity: As above Nutrional advice: As above Other: No
OutcomesHeight (cm), weight (kg), BFP (Body Fat Percentage) (%), BMI (kg/m2), Family Assessment Device (FAD), Eating  Self-Efficacy Scale (ESES), Health-Promoting Lifestyle Profile II (HPLPII), pedometer steps (count of steps).
NotesSmall changes in BMI and BFP in children. Intervention seems to work better for the parents than the children.
Risk of bias
ItemAuthors' judgementDescription
Allocation concealment?YesTelephone numbered, opaque sealed envelopes
Braet 2004
MethodsRandom allocation: No description of randomisation process Blinding: Children: No Providers: No Outcome assessors: Not clear, not specified Length of intervention and follow up: 10 months, follow up 24 months (from commencement of intervention) Unit of allocation: Individual child Unit of analysis: Individual child Protection against contamination: Done Drop outs: end of intervention 19% [28/150], follow up at 9 months: 19% [28/150]
Participantsn= 150 randomised, 122 completedAge range (mean): 7-17 years (12.7±2.3) % Male: Unclear Weight entry criteria: BMI > 95th percentile according to age and gender Weight on entry (mean): 84.7kg (19.7), mean BMI 32.5 (5.3), degree of obesity 77% (SD 29) Setting: Inpatient clinic Geographic Region: Ghent, Belgium
InterventionsInterventions: Inpatient treatment program plus cue exposure therapy vs inpatient treatment program plus cognitive therapy vs inpatient treatment program without coping strategies. Intervention: Cue exposure treatment (within the normal treatment program) Target of intervention: Children + parents Behavioural or psychological component: During the first 4 months of treatment, all children received a 12 week cognitive-behavioral treatment (CBT) program, in small groups. As part of the CBT program, the children were taught about the energy balance as a model to understand the mechanism of obesity. To achieve lifestyle changes, the children were taught self-regulation skills, such as self-observation, self-instructions, self-evaluation and self-reward. The children were invited to design a personal plan for managing their eating habits on the weekends. Parents were seen on a 2-week basis, when they visited the centre. They were requested to assist their child in adopting a new lifestyle. For this purpose, they were provided with leaflets that gave information on how to prepare healthy food, how to organize shopping habits, and ho to organize aerobic exercises. The protocol developed by Jansen et al, 1993 describes in vivo exposure sessions with relevant food cues. It included the following steps: The participant is invited to bring in the typical food that he or she finds difficult to resist; next the participant is allowed to open up the different packages, take the food in the hands and smell it. It is hypothesized that if the exposure lasts long enough, the craving for food slowly diminishes after 30-50 minutes. Physical activity: Before and after school hours, the children were encouraged to exercise. The centre offers organized sport events for 2 h a day or 10 h a week. Apart from that, each child received 4 h of individual guided exercises, such as swimming (1 h/week), cycling on a home trainer, jogging at their own speed, and performing abdominal exercises, with the aim being for each child to reach a heart rate that was 20% lower than his or her maximum heart rate. Although individual variations were possible, all children had facilities to take part in exercise programs for at least 14 h per week. Nutrional advice: The children ate three meals a day and two snacks. The children were encouraged to drink water, preferably up to 1.5 L a day. Total intake was about 1400 to 1600 cal per day. During each meal, fruit or vegetables were offered, and the children were allowed to decide for themselves wether they wanted a small or large portion. At home, the children were allowed some consumption of soft drinks and high-calorie foods, albeit in limited portions, which meant they were left to make their own choices. Other: No Usual care/ alternative intervention: Cognitive protocol (within the normal treatment program) Target of intervention: Children + parents Behavioural or psychological component: During the first 4 months of treatment, all children received a 12 week cognitive-behavioral treatment (CBT) program, in small groups. As part of the CBT program, the children were taught about the energy balance as a model to understand the mechanism of obesity. To achieve lifestyle changes, the children were taught self-regulation skills, such as self-observation, self-instructions, self-evaluation and self-reward. The children were invited to design a personal plan for managing their eating habits on the weekends. Parents were seen on a 2-week basis, when they visited the centre. They were requested to assist their child in adopting a new lifestyle. For this purpose, they were provided with leaflets that gave information on how to prepare healthy food, how to organize shopping habits, and ho to organize aerobic exercises. The cognitive protocol teaches the children to analyse emotional situations with cognitive techniques, and it helps them to cope with antecedents of their problem behaviour. In contrast to the standard treatment program, where only high risk eating situations were analysed, problem situations were no extended to a variety of problems(loneliness, bullying by peers). Included were relaxation exercises that the children could use to assist them in coping with emotional antecedents. Physical activity: See above Nutrional advice: See above Other: No Usual care/ alternative intervention: Standard treatment protocol Target of intervention: Children Behavioural or psychological component: 12 week cognitive-behavioral treatment (CBT) program, as above. Physical activity: See above Nutritional advice: See above Other: As above
OutcomesHeight (cm), weight (kg), estimates of % fat content e.g. BMI, ponderal index, skin-fold thickness, behaviour changes (Child Behaviour Checklists (CBCL), Dutch Eating Behaviour Questionnaire (DEBQ), Eating Disorder Inventory (EDI), Eating Disorder Examination (EDE)), measures of self esteem, health status, QOL - describe if stated validated measure, name, effect size etc (Self-perception profile (SPPS)).
NotesThis inpatient treatment program seems to work, but data are only presented for groups overall. No conclusions can be made regarding the value of the different cognitive behaviour treatment programs (the extended coping programs) because of small treatment effects and lack of power.
Risk of bias
ItemAuthors' judgementDescription
Allocation concealment?UnclearNo description of randomisation process.
Carrel 2005
MethodsRandom allocation: No description of randomisation process    Blinding: Children: No Providers: No Outcome assessors: Not clear, not specified Length of intervention and follow up: 9 months Unit of allocation: Individual child Unit of analysis: Individual child Protection against contamination: Not clear Drop outs: end of intervention 6% [3/53], follow up at 6 months: 6% [3/53] (intervention group: 0, control group: 3)
Participantsn= 53 randomised, 50 completedAge range (mean): 11- 14 years (intervention group 12.5±0.5), control group 12.5±0.7) % Male: 52% Weight entry criteria: BMI > 95th percentile Weight on entry (mean): Not reported Setting: Rural middle school and an academic children's hospital Geographic Region: probably Wisconsin, USA
InterventionsIntervention: Lifestyle focused, fitness-oriented gym classes Target of intervention: Child Behavioural or psychological component: No Physical activity: Participants in the intervention group were in class sizes limited to 14 students to ensure adequate supervision and more direct time spent with each instructor. Classes were designed to make fitness and good nutrition fun and achievable and to maximize the amount of movement during the class period. Class size was limited to allow for increased instructor attention, increased opportunity for motivation, and less time standing in line. The curriculum was personalized to match the student's skill levels and encourage student participation. Competitive games were de-emphasized, and lifestyle-focused activities (walking, cycling, and snowshoeing) were encouraged. A consistent warm-up plan brought students into movement participation as quickly as possible soon after they entered the gym. Typical movement time was 42 minutes of a 45-minute class period, as children did no change clothes for this class to increase activity time. Skills were taught with the class broken down into groups of 2 for promoting more movement and less time watching. The ethos of the class encouraged physical fitness, less self-conscious focus on appearance, and full group participation. The frequency of the classes was 5 times every 2 weeks for a 45-minute class period. Nutritional advice: Students randomised to fitness classes also received a small nutrition education component. This consisted of educational handouts to participants to develop healthier eating habits. The nutrition portion focuses on the Food Guide Pyramid, recommended servings of food, appropriate portion sizes, healthier food choices, and the benefits of those choices. Other: No Usual care/ alternative intervention: Standard gym classes Target of intervention: Child Behavioural or psychological component: No Physical activity: Control subjects participated in the traditional physical education classes of 35-40 students. After accounting for the time changing clothes, taking attendance, and giving instructions, movement time averaged 25 minutes of the 45-minute period. The same class topics (e.g. football, mile run/walk, kickball) were taught as in the intervention group, but in a different format, as typical issues in the traditional class were a greater range of skill levels, longer lines during skill development drills, and larger numbers of students on teams when games were played. These issues tended to result in less movement and a tendency for students to hold back and not enter into play. Nutritional advice: No Other: No
OutcomesHeight (cm), weight (kg), BMI (%), cardiovascular fitness assessment (ml/kg per minute), insulin (µlU/ml), glucose (mg/dl).
NotesBMI increased in the experimental group and remained stable in the control group, whereas body fat percentage significantly lowered in the experimental group compared to the control group.
Risk of bias
ItemAuthors' judgementDescription
Allocation concealment?UnclearNo description of randomisation process.
Daley 2006
MethodsRandom allocation: An independent researcher performed the randomisation procedures by allocating participants to groups according to a computer generated random list Blinding: Children: No Providers: No Outcome assessors: Not clear, not specified Length of intervention and follow up: 8 weeks, follow-up at 14 weeks and 28 weeks after baseline assessmentsUnit of allocation: Individual child Unit of analysis: Individual child Protection against contamination: Not clear Drop outs: end of intervention 7% [6/81], follow up at 6 months: 11% [9/81]
Participantsn= 81 randomised, 71 completedAge range (mean): 11-16 years, mean age 13.1 years. % Male: 44.4% Weight entry criteria: BMI > 98th percentile for age and gender Weight on entry (mean): Not given Setting: Outpatient clinic, trial centre Geographic Region: UK
InterventionsIntervention: Exercise therapy Target of intervention: Child Behavioural or psychological component: Exercise counselling for behavior change, was also an integral part of the exercise sessions. In line with the transtheoretical model, weeks 1 to 4 focused on cognitively based intervention strategies such as cognitive reappraisal and consciousness raising. During weeks 5 to 8, more behaviorally based interventions were introduced, for example, goals setting, self-monitoring, and finding social support. Participants followed a broad structured curriculum of topics over the course of the intervention. The researcher also encouraged participants to discuss their thoughts and feelings about exercise, to assist with problem-solving. Physical activity: The exercise therapy group participated in a range of aerobic exercise activities  (e.g. stepping, cycling, rowing, dance mat, and walking) and were asked to exercise intermittently at a moderate intensity (40-59% of heart rate (HR) reserve) for 30 minutes 3 times per week for 8 weeks (24 sessions). Minigames were also included in the sessions; these were designed primarily with fun in mind, but they also gave participants the opportunity to see personal development throughout the program and to introduce a small self-referenced competitive element into the sessions. After participants completed their 8-week interventions, they were given an individualized home exercise program to follow on their own for an additional 6 weeks (14 weeks follow-up period). No researcher contact was provided during the home program phase. Nutritional advice: Sensible eating habits were encouraged as part of the exercise therapy intervention. All participants were given a brief dietary advice information sheet, prepared by a dietician, at entry into the trial. Other: Financial incentives: To facilitate recruitment and retention, a £25 sports store voucher was given to participants at the end of the intervention phase, and a contribution of £2.50 toward travel expenses to attend intervention sessions and assessments was made for each visit to the trial centre. An additional £10 sports store voucher was given to participants when they completed their final follow-up assessment. Usual care/ alternative intervention: Exercise placebo group Target of intervention: Child Behavioural or psychological component: No Physical activity: Participants performed light body-conditioning/stretching exercises, during which HR was maintained at <40% of HR reserve, and no exercise counselling or behavioural change advice was given. This group also participated in other sedentary activities, such as balance and catching tasks, pool, darts, and table football. After participants completed their 8-week interventions, they were given an individualized body conditioning program to follow on their own for an additional 6 weeks (14 weeks follow-up period). No researcher contact was provided during the home program phase. Nutritional advice: All participants were given a brief dietary advice information sheet, prepared by a dietician, at entry into the trial. Other: As above Usual care/ alternative intervention: Usual care Target of intervention: Child Behavioural or psychological component: No Physical activity: No Nutritional advice: No Other: The usual care group were asked to continue with their lives as normal.
OutcomesHeight (cm), weight (kg), estimates of % fat content e.g. BMI, ponderal index, skin-fold thickness, BMI SD score, Physical Self-Perceptions (physical self worth (PSW)), global self worth, sport/ athletic competence, conditioning /stamina competence, attractive body adequacy, strength competence), depression and affect score's (depression, positive affect, negative affect), self-perceptions (scholastic competence, social competence), physiologic outcomes (resting HR, aerobic function, physical activity).
Notes 
Risk of bias
ItemAuthors' judgementDescription
Allocation concealment?YesAn independent researcher performed the randomization procedures by allocating participants to groups according to a computer generated random list.
De Mello 2004
MethodsRandom allocation: No description of randomisation process. After explanation of the study, without specifying the two types of treatment, subjects were then allocated to one of two groups by lottery. Blinding: Children: Yes Providers: Not clear, not specified Outcome assessors: Not clear, not specified Length of intervention and follow up: Participants in both groups attended monthly meetings for six months, follow up 6 months Unit of allocation: Individual child (+ family) Unit of analysis: Individual child (+ family) Protection against contamination: Not clear Drop outs: end of intervention 42% [28/66], follow up at 6 months: 42% [28/66]
Participantsn= 66 randomised, 38 completedAge range (mean): 7-13 years (9.9±1.5) % Male: 57,9% Weight entry criteria: BMI> IOTF cut off for obesity in children Weight on entry (mean): BMI: intervention group 29.0 ± 3.5, control group 28.9 ± 3.7 Setting: outpatient clinic based in a University School of Medicine Geographic Region: Residents in the state Rio Grande del Sul who sought out the Pediatrics service at the Hospital of Poto Alegre
InterventionsInterventions: Group education program versus Individual outpatient care Intervention: Education Program (PG) Target of intervention: Parent and child Behavioural or psychological component: Parents and guardians were put into groups in order to discuss their problems and techniques for changing feeding habits. The program compromised six meetings (45 min). The subjects covered were: what obesity is and what its complications are, foodstuffs and the food guide pyramid, food substitutes and modes of preparation, how to be more active, and behavioral, postural and self-esteem related aspects and how to maintain healthy habits that had been suggested. Physical activity: After the lesson the children were divided by sex and aged into four fixed groups and performed tailored activities under the supervision of the research assistant. Nutritional advice: See behavioural component; only little nutrition advice Other: No Usual care/ alternative intervention: Outpatient care (OG) Target of intervention: Child only? Behavioural or psychological component: No Physical activity: the individual outpatient treatment consisted of monthly meetings of the children in which they received guidance on increasing physical activity. Nutritional advice: the individual outpatient treatment consisted of monthly meetings of the children in which they received guidance on nutritional intake management. Other: Children were weighed and measured monthly. Each subject was given a manual with the main features of treatment and in which directions were noted.
OutcomesHeight, weight, estimates of % fat content e.g. BMI, ponderal index, skin-fold thickness, behaviour changes, metabolic health outcomes (total cholesterol, HDL, triglycerides).
Notes 
Risk of bias
ItemAuthors' judgementDescription
Allocation concealment?UnclearNo description of randomisation process. After explanation of the study, without specifying the two types of treatment, subjects were then allocated to one of two groups by lottery.
Duffy 1993
MethodsRandom allocation: no description of randomisation process. Blinding: Children: No Providers: No Outcome assessors: Unclear Length of intervention and follow up: 8 Weeks and 6 Months Unit of allocation: Child Unit of analysis: Child Protection against contamination: Unclear Drop outs: end of intervention 22% [6/27], follow up at 6 months: 37% [10/27] (unclear how many children were randomised to each treatment group. 8 children in BT group and 9 children in CBT group remained at 6 months)
Participantsn= 27 randomised, 17 completedAge range (mean): 7-13 years (118.71 months±20.16) % Male: 21% Weight entry criteria: 15% overweight for age, height and sex Weight on entry (mean): 48.6% overweight for age, height and sex (SD 22.12) Setting: Not clear, probably clinic Geographic Region: Australia
InterventionsInterventions: behaviour therapy plus cognitive self-management vs behaviour therapy plus attention placebo control Intervention: behaviour therapy plus cognitive self-management - Target of intervention: child and parent - Behavioural or psychological component: Both groups had behavioural therapy (8 week 90 minute sessions) - the intervention group had additional cognitive self-management.  Parents were also taught to use goal setting and positive reinforcement strategies to facilitate behaviour change with a financial arrangement.  Parents children and therapists signed written agreements. The Cognitive component of the non-placebo intervention included monitoring of negative thoughts, restructuring of maladaptive or negative thoughts, problem solving skills and self instructional training, and self reinforcement. Overall, there was a financial incentive paid to both parents and children for their participation in elements of the program (children) and the follow ups at 3 and six months. A behavioural contract approach was used in which parents paid a redeemable $30. - Physical activity: Information and target setting relating to increased lifestyle, callisthenic and aerobic exercise. Children also monitored their exercise to record energy expenditure. - Nutrional advice: The Epstein Traffic Light system was used - Other: No Usual care/ alternative intervention: behaviour therapy plus attention placebo control - Target of intervention: child and parents - Behavioural or psychological component: As above, but instead of additional cognitive self-managment the control group received relaxation training. - Physical activity: The placebo group received progressive muscular relaxation training, commencing in week 4. - Nutrional advice: As above - Other: No
OutcomesWeight status: Weight (kg) and % overweight presented at pre treatment, post treatment, 3 and 6 months follow up.
Notes 
Risk of bias
ItemAuthors' judgementDescription
Allocation concealment?Unclearno description of randomisation process.
Ebbeling 2003
MethodsRandom allocation: no description of randomisation process. Blinding: Children: Not clear, not specified Providers: Not clear, not specified                                         Outcome assessors: Not clear, not specified                                         Length of intervention and follow up: 6 months intervention, follow up 12 months from commencement of intervention Unit of allocation: Individual patients Unit of analysis: Individual patients Protection against contamination: Not clear Drop outs: end of intervention 13% [2/16], follow up at 6 months: 13% [2/16] (intervention group 1, control group 1)
Participantsn= 16 randomised, 14 completedAge range (mean): 13 to 21 years (intervention group 16.9 ± 1.3, control group 15.3 ± 0.9) % Male: 31.25%Weight entry criteria: BMI that exceeds sex-and age-specific 95th percentiles Weight on entry (mean): intervention group 103.5 ± 6.0, control group 104.7 ± 4.8 Setting: In general clinical research centre of the children's hospital Geographic Region: Boston, USA
InterventionsIntervention: Ad libitum reduced-glycaemic load (GL) diet Target of intervention: Child Behavioural or psychological component: Social cognitive therapy provided a framework for the educational and behavioural components of the treatment and was consistent between both groups. Counseling focused on enhancing self-efficacy for dietary change using the concepts of behavioral capability and self-control. Patient expectations, expectancies and perceptions of environmental influences were discussed during treatment sessions. During dietary counselling sessions, written materials were provided on various food-related topics and menu choices/lists which were tailored toward the each group. For experimental group, lists corresponded to food groups delineated by a reduced GL food pyramid. In contrast, for the conventional group, the lists corresponded to the diabetes food pyramid and were presented as an exchange system. The select-a-meal menu contained recipes and ideas for meal planning to complement the food choice lists. Physical activity: One module was devoted to physical activity, with subjects in both groups receiving information based on current recommendations. Nutritional advice: The reduced-GL prescription emphasized selection of carbohydrate-containing foods (e.g. non-starchy vegetables, fruits, legumes, nuts, and dairy) that are characterized by a low to moderate GI. Patientes were instructed to balance consumption of carbohydrates with protein and fat at every meal and snack. The prescription was no energy restricted. Rather, subjects were advised to eat to satiety and to snack when hungry. The targeted proportion of energy from carbohydrate and fat were 45% to 50% and 30 to 35%, respectively, with the remainder from protein. Delivered in the form of modules by the study dietitian (12 dietary counselling sessions in first 6 months, then 2 dietary counselling sessions in the 6 month follow-up phase). Other: No Usual care/ alternative intervention: Energy restricted reduced fat diet Target of intervention: Child Behavioural or psychological component: Same as for intervention. Physical activity: Same as for intervention Nutritional advice: The reduced-fat prescription was based on current recommendations for weight loss and diabetes prevention, with emphasis on limiting dietary fat intake and increasing the intake of grains, vegetables , and fruits. Meal plans were designed to elicit a negative energy balance of 250 to 500 kcal/day. Energy requirements were estimated using the Harris-Benedict equation with an activity factor of 1.5 and consideration of baseline dietary intake. Subjects were counselled to obtain 55% to 60% of energy from carbohydrates, 25% to 30% from fat and the remainder from protein. Other: No
OutcomesHeight (cm), weight (body mass, kg), BMI, total body mass and fat mass by DEXA, HOMA estimation of insulin resistance (Mm/L).
Notes 
Epstein 1985a
MethodsRandom allocation: no description of randomisation process. Blinding: Children: Unclear Providers: Unclear Outcome assessors: Unclear Length of intervention and follow up: 8 week treatment followed by 10 month maintenance and 12 and 24 month follow up Unit of allocation: Child Unit of analysis: Child Protection against contamination: Unclear Drop outs: end of intervention 15% [6/41], follow up at 24 months: 15% [6/41]
Participantsn= 41 randomised, 35 completersAge range (mean): 8 to 12 years % Male: 40% Weight entry criteria: > 20% bodyweight for height Weight on entry (mean):123.9 kg, 48% overweight for height Setting: No details Geographic Region: USA
InterventionsInterventions: Different exercise regimes (3 groups: lifestyle, aerobic and callisthenics) + diet and behaviour modification Intervention: Aerobic exercise programme - Target of intervention: child and parent - Behavioural or psychological component: Self-monitoring: food diaries, chart weight daily, parent asked to review diaries for accuracy and completeness. Praise and modelling: parents and children asked to behave as appropriate models for each other. Therapist contact; seen before treatment meetings (first 8 weeks) to review habit books and give feedback on past weeks progress, + phone calls once a week during treatment period and once a month during maintenance period. Parent management: instructing parents to use modelling and reinforcement for child behaviour change and maintenance. - Physical activity: Aerobic exercise: walk, run, bicycle or swim, based on family preference. 3 times per week advancing to 3 miles of running/walking 6 miles cycling, 75 miles of swimming in regular intervals. - Nutrional advice: Traffic Light diet, 1200 Kcal daily. Each treatment session had a lecture and discussion on nutrition, diet and behaviour management techniques. Traffic Light Diet (calorie-based food exchange system) colour coded: green = foods <20 Kcal per serving, yellow = staple foods, red = high fat/high sugar foods. - Other: Financial incentives: Contracting $85 was deposited before treatment and returned piecemeal at treatment/assessment sessions, parents also asked to use non-monetary reinforcers as incentives for weight loss. Usual care/ alternative intervention: Lifestyle exercise program - Target of intervention: child and parent - Behavioural or psychological component: As above - Physical activity: Lifestyle  (isocaloric to aerobic programme) participants chose from the exercise menu and chose own intensity and could include school activity. - Nutrional advice: As above - Other: As above Usual care/ alternative intervention: Calisthenics program - Target of intervention: child and parent - Behavioural or psychological component: As above - Physical activity: Callisthenics: 6 of 12 callisthenics 3 times per week. Repetitions increased in intervals similar to aerobic exercise programme. - Nutrional advice: As above - Other: As above
OutcomesHeight, weight, BMI, % overweight (based on ideal weight for height, age and sex [Metropolitan life Insurance company 1959 and Robinson 1968]), Eating Behaviour Inventory and Physical work capacity.
Notes 
Risk of bias
ItemAuthors' judgementDescription
Allocation concealment?Unclearno description of randomisation process.
Epstein 1985b
MethodsRandom allocation: Stratified by age, % overweight and physical work capacity Blinding: Children: Unclear Providers: Unclear Outcome assessors: Unclear Length of intervention and follow up: 8 weeks treatment and 10 months maintenance and 12 months follow up Unit of allocation: Child Unit of analysis: Child Protection against contamination: Unclear Drop outs: end of intervention 13% [3/23], follow up at 12 months: 17% [4/23]
Participantsn= 23 randomised, 19 completedAge range (mean): 8 to 12 years % Male: 0% Weight entry criteria: > 20% overweight for height and age Weight on entry (mean): 53.86kg, 48.05% overweight for age and height Setting: No details Geographic Region: US
InterventionsInterventions: Diet + controlled exercise vs diet without exercise Intervention: Diet + controlled exercise - Target of intervention: child and parent - Behavioural or psychological component: Self-monitoring: food diaries, chart weight daily, parent asked to review diaries for accuracy and completeness. Praise and modelling: parents and children asked to behave as appropriate models for each other. Therapist contact; seen before treatment meetings (first 8 weeks) to review habit books and give feedback on past weeks progress, + phone calls once a week during treatment period and once a month during maintenance period. Parent management - Physical activity: Aerobic programme 3 times per week for 6 weeks. 10 min of stationary aerobic exercise, warm up games, + 3 mile walk/run (parents instructed to walked once a week with therapists + two other times). Children and parents also got exercise session at the maintenance meetings (10 months). - Nutrional advice: Traffic Light diet, 900-1200 kcal daily. Each treatment session had a lecture and discussion on nutrition, diet and behaviour management techniques. Traffic Light Diet (calorie-based food exchange system) colour coded: green = foods <20 kcal per serving, yellow = staple foods, red = high fat/high sugar foods. Daily intake: 900-1200 kcal. Two rules: 1. stay within the prescribed calorie range; 2. No more than 4 red foods per week. - Other: Contracting $80 was deposited before treatment and returned piecemeal at treatment/assessment sessions, parents also asked to use non-monetary reinforcers as incentives for weight loss. Usual care/ alternative intervention: Diet - Target of intervention: child and parent - Behavioural or psychological component: As above - Physical activity: No - Nutrional advice: As above - Other: As above
OutcomesWeight status: Weight (kg) and % overweight (% overweight based on ideal weight standards) presented at 0, 2, 6 and 12 months. Others: Leisure time activity survey questionnaire and Physical work capacity.
Notes 
Risk of bias
ItemAuthors' judgementDescription
Allocation concealment?UnclearStratified by age, % overweight and physical work capacity
Epstein 1985c
MethodsRandom allocation: no description of randomisation process, but assumed to be the same stratified method as other papers Blinding: Children: Unclear Providers: Unclear Outcome assessors: Unclear Length of intervention and follow up: 12 month treatment program, no follow up. Unit of allocation: Child Unit of analysis: Child Protection against contamination: Unclear Drop outs: end of intervention 25% [6/24], follow up at 12 months: 25% [6/24]
Participantsn= 24 randomised, 5 dropped out before treatment and mothers measurements for one child include in analysis Age range (mean): 5 to 8 years % Male: 0% Weight entry criteria: No details given Weight on entry (mean): 40.55% overweight, 22.75kg/m2Setting: No Details Geographic Region: US
InterventionsInterventions: family based behavioural treatment vs family-based non-behavioural programme Intervention: family based behavioural treatment - Target of intervention: family - Behavioural or psychological component: Both groups received the same amount of therapist time. Therapist contact; seen before treatment meetings (first 6 weeks) to review habit books and give feedback on past weeks progress, + phone calls once a week during treatment period and once a month during maintenance period. Contracting $90 was deposited before treatment and returned piecemeal at treatment/assessment sessions. Intervention group also received following methods of parent management techniques and Social Learning principles: Self-monitoring: food diaries, chart weight daily, parent asked to review diaries for accuracy and completeness. Parents asked to keep diet diaries for themselves. Praise and modelling: parents and children asked to behave as appropriate models for each other. Positive social reinforcement. Contracting: parents assigned points for children meeting desired criteria e.g. staying within daily cal. Intake. Points exchanged for non-monetary reinforcements. - Physical activity: Education programme: lifestyle activities designed to increase typical daily expenditure (based on Cooper Aerobics Point System, 1977). Both groups: exercise six times per week with activity point goals to meet. These points were increased twice over a 12 week period. - Nutrional advice: Traffic Light diet, children < 7 years had an upper limit of 1000 kcal daily and >7, 1200 kcal daily. Both groups treated identically. Each treatment session had a lecture and discussion on nutrition, diet and behaviour management techniques. Traffic Light Diet (calorie-based food exchange system) colour coded: green = foods <20 kcal per serving, yellow = staple foods, red = high fat/high sugar foods. Daily intake: 1000-1200 kcal. Two rules: 1. stay within the prescribed calorie range, 2. No more than 4 red foods per week. - Other: Financial incentive. At the first meeting, each parent deposited 90 dollars, with one 15-dollar cheque to be returned for each of the following: a) attending 5 of 6 (one introductory meeting and 5 treatment meetings) weekly treatment meetings, b) attending 8mo assessment, c) attending 12mo assessment. A 5-dollar check was returned each time the parent and child attended 1 of the 9 monthly maintenance meetings. Usual care/ alternative intervention: family-based non-behavioural programme - Target of intervention: family - Behavioural or psychological component: As above. In addition to the therapist contact time, parents were additional health information - reading labels, shopping, sugar, salt, health risks of obesity. Any behaviour management questions were reflected back to parents for discussion. - Physical activity: As above. - Nutrional advice: As above. - Other: As above.
OutcomesWeight status: % Overweight (based on reference to child [Robinson 1968] and adult [Metropolitan life insurance company 1959] standards) and BMI presented at 0, 4, 8 and 12 months. Others: eating behaviour, self control, parents % overweight, parents BMI and parents self control.
Notes 
Risk of bias
ItemAuthors' judgementDescription
Allocation concealment?Unclearno description of randomisation process
Epstein 1994a
MethodsRandom allocation: no description of randomisation process. Blinding:Children: Unclear Providers: Unclear Outcome assessors: Unclear Length of intervention and follow up: 26 weeks treatment and 6 monthly follow ups to 2 years Unit of allocation: Child Unit of analysis: Child Protection against contamination: Unclear Drop outs: end of intervention 11% [5/44], follow up at 6, 12, 24 months: 11% [5/44]
Participantsn= 44 randomised, 39 completedAge range (mean): 8 to 12 years (10.2 ± 1.1) % Male: 26% Weight entry criteria: Between 20% and 100% overweight for height Weight on entry (mean): 59.6% ± 22.0% over the 50th percentile for BMI Setting: Unclear, probably outpatient clinic and university medical school Geographic Region: US
InterventionsInterventions: Comparison of behavioural treatments: mastery criteria vs contingent reinforcement. Intervention: Targeted for mastery of behaviours - Target of intervention: child and parents - Behavioural or psychological component: Manual (self-monitoring, diet, exercise, parenting and maintenance in 22 modules). Behavioural principles used at weekly meetings to reinforce appropriate behaviour changes. Behaviour changes divided into 5 Levels. Parents and children in experimental group had to demonstrate mastery of behavioural skills before progressing to next level. (Subjects who reported eating less and doing more, but who did not lose weight were not reinforced or advance to next level. Similarly, neither were subjects who lost weight but who did not demonstrate mastery of behavioural skills at that level.) Treatment given over 26 weekly meetings and 6 monthly meetings. - Physical activity: Lifestyle activities. Subjects choose aerobic activities (walking, swimming, tennis) that can be incorporated into their daily routine. Programme goal progression: 50 kcal per day for 7 days to 300 kcal per day for 5 days, recorded in habit books. - Nutrional advice: Traffic Light diet. 900-1800 kcal daily on Level 1 down to 900-1200 kcal by Level 4, Level 5 individually adjusted for maintenance. Daily food records. - Other: Quizzes based on information in intervention manuals, parent skills lottery (tickets for local cultural activities with more chance of winning with greater mastery). No mention of money. Usual care/ alternative intervention: Contingent reinforcement. Yoke to intervention - moved on when 50% of intervention group showed mastery of behaviours. - Target of intervention: child and parents - Behavioural or psychological component: Intervention for control group was the same except for the timing of moving to the next level of behavioural skills. The presentation of new information and introduction of new skills was carried out when 50% of the intervention group had mastered the skills at each level (i.e. the controls were yoked to the experimental group). The control group progressed through the intervention at the same rate as the experimental group. - Physical activity: As above. - Nutrional advice: As above. - Other: As above.
OutcomesWeight status: Weight (kg) and % over the 50th percentile for BMI (as the reference child and adult weight for height based on population standards [Must et al 1991]), presented at 0, 6, 12, 18 and 24 months. Others: parental knowledge.
Notes 
Risk of bias
ItemAuthors' judgementDescription
Allocation concealment?Unclearno description of randomisation process
Epstein 1995
MethodsRandom allocation: no description of randomisation process Blinding: Children: Unclear Providers: Unclear Outcome assessors: Unclear Length of intervention and follow up: 4 month treatment and 1 year follow up Unit of allocation: Child Unit of analysis: Child Protection against contamination: Unclear Drop outs: end of intervention 7% [44/61], follow up at 12 months: 10% [6/61]
Participantsn= 61 families randomised, 2 dropped out during treatment, 2 refused to take part in follow up, 1 child had a leg injury and in 1 family a parent died Age range (mean): 8 to 12 years (10.1y) % Male: 27% Weight entry criteria: Between 20% and 100% overweight Weight on entry (mean): 51.8% overweight for height Setting: Unclear, probably outpatient clinic at University medical school Geographic Region: US
InterventionsInterventions: Comparisons of diet and physical activity reinforcement regimes. 3 groups: decreasing sedentary behaviours vs increasing active behaviours vs targeting both Intervention: decreasing sedentary behaviours - Target of intervention: child and parent - Behavioural or psychological component: Mastery approach to teaching. Manuals divided into modules. Self-monitoring: weight daily and graph weight. Habit book for food and caloric intake, number of red foods and time spent in active or sedentary activity. Sedentary group recorded minutes, Exercise group recorded points, both group recorded minutes and points. Stimulus control: Parents and children model appropriate eating and activity behaviours. Change environment (cues: decrease red foods or make cycles more accessible, turn TV to wall). Reinforcement: review habit book nightly, reciprocal contracting between parents and children (mutually agreed reinforcers for when behavioural criteria are met). - Physical activity: All 3 groups received same PA information. Sedentary group: reinforced for decreasing time in sedentary behaviours. Activities targeted were those that compete with active behaviours (e.g. watching TV, playing computer games or board games, talking on the phone, not listening to music, homework or reading). - Nutrional advice: Traffic Light diet, 1000-1200 kcal daily, red foods limited to 7 or fewer per week and eat balanced meals (using food pyramid). - Other: Quizzes based on manual information. Usual care/ alternative intervention: increasing active behaviours - Target of intervention: child and parent - Behavioural or psychological component: As above. - Physical activity: Exercise group: reinforced for increasing PA beyond those at school. - Nutrional advice: As above. - Other: As above. Usual care/ alternative intervention: targeting both - Target of intervention: child and parent - Behavioural or psychological component: As above. - Physical activity: Both groups: reinforced for decreasing sedentary and increasing active behaviours. - Nutrional advice: As above. - Other: As above.
OutcomesWeight status: % overweight (based on height and weight data [Hamil et al 1977]) presented at 0, 4, 8 and 12 months. Others: % body fat, waist-to-hip circumference and physical work capacity.
Notes 
Risk of bias
ItemAuthors' judgementDescription
Allocation concealment?Unclearno description of randomisation process
Epstein 2000a
MethodsRandom allocation: Families stratified by gender and degree of child and parent obesity Blinding: Children: Unclear Providers: Unclear Outcome assessors: unclear Length of intervention and follow up: 6 months treatment and follow up at 12 and 24 months Unit of allocation: Child Unit of analysis: Child Protection against contamination: Unclear Drop outs: end of intervention 7% [5/67], follow up at 24 months: 14% [15/67] (5 children had self-reported heights and weights at 24 months)
Participantsn= 67 randomised, 52 completedAge range (mean): (10.3 years, SD 1.1) % Male: 48% Weight entry criteria: 20% overweight Weight on entry (mean): 59.8 kg (SD 53.1) Setting: No details Geographic Region: US
InterventionsInterventions: family-based behavioral weight-control program + parent and child problem solving vs family-based behavioral weight-control program + child problem solving vs family-based behavioral weight-control program without additional problem solving Intervention: family-based behavioral weight-control program + parent and child problem solving - Target of intervention: family - Behavioural or psychological component: The 6-month treatment program included 16 weekly meetings followed by two monthly meetings. At treatment meetings, family members were weighed, met with an individual therapist for 15 to 30 minutes, and attended separate 30-min group meetings (one for parents and one for children). All of the parents and children were provided workbooks with information on the traffic light diet, a 1,200-kcal diet based on the food pyramid, with foods color-coded to the traffic light on the basis of nutrient density, lifestyle physical activity, and behavior changes techniques, including self-monitoring, positive reinforcement, stimulus control, and preplanning. Problem-solving was integrated into the group and individual content of the groups in several ways. Didactic training in problem solving was provided in group formats for parents and/or children. In the problem-solving group and individual family sessions, group leaders and therapists used problem-solving methods when a question was asked. In group and individual family sessions in which problem solving was not assigned, group leaders or therapists used didactic methods to address problems to make contrast with problem solving as distinct as possible. Parents and children in problem-solving groups were provided problem-solving worksheets and problem-solving homework. Families in the non-problem-solving groups were provided similar homework assignments not based on problem solving. - Physical activity: See behavioral component. - Nutrional advice: See behavioral component. - Other: Parents deposited $75, which was returned contingent on completion of 75% of the treatment sessions and attendance at the 6- and 12-month follow-up. The families were paid $50 for their attendance at the 24-month follow-up. Usual care/ alternative intervention: family-based behavioral weight-control program + child problem solving - Target of intervention: family - Behavioural or psychological component: Described above. - Physical activity: See behavioral component. - Nutrional advice: See behavioral component. - Other: Parents deposited $75, which was returned contingent on completion of 75% of the treatment sessions and attendance at the 6- and 12-month follow-up. The families were paid $50 for their attendance at the 24-month follow-up. Usual care/ alternative intervention: family-based behavioral weight-control program without additional problem solving - Target of intervention: family - Behavioural or psychological component: Described above, but no problem-solving training. - Physical activity: See behavioral component. - Nutrional advice: See behavioral component. - Other: Parents deposited $75, which was returned contingent on completion of 75% of the treatment sessions and attendance at the 6- and 12-month follow-ups. The families were paid $50 for their attendance at the 24-month follow-up.
OutcomesWeight status: Weight (kg) and BMI z scores presented at 0, 6, 12 and 24 months. Others: child problem solving, parent problem solving, child psychological problems (CBCL), parent psychological problems (SCL-90) and use of behaviours related to weight control (Adherence Questionnaire).
Notes 
Risk of bias
ItemAuthors' judgementDescription
Allocation concealment?Unclearno description of randomisation process, families stratified by gender and degree of child and parent obesity
Epstein 2000b
MethodsRandom allocation: Families stratified by gender and degree of child and parent obesity Blinding: Children: Unclear Providers: Unclear Outcome assessors: Unclear Length of intervention and follow up: 6 month treatment and 2 year follow up Unit of allocation: Family Unit of analysis: Child Protection against contamination: Unclear Drop outs: end of intervention 11% [10/90], follow up at 12 months: 12% [11/90] and at 24 months follow up 19% [17/90] (Activity group = 4/22 in low dose, 4/23 in high dose and 4/23 in low dose and 2/22 in high dose, 3/76 measures were parent-reported at the 2 year follow up.)
Participantsn= 90 families randomised, 76 completedAge range (mean): 8 to 12 years (10.5 years, SD 1.2) % Male: 32% Weight entry criteria: Between 20 % and 100% overweight Weight on entry (mean): 60.6, SD 10.9 kg Setting: Childhood obesity research clinic Geographic Region: US
InterventionsInterventions: Comprehensive family-based behavioral weight control program with varied targeted behaviours and treatment dose: (1) increase physical activity - low vs (2) increase physical activity - high vs (3) decrease sedentary behavior - low vs (4) decrease sedentary behavior - high Intervention: (1) increase physical activity - low - Target of intervention: family - Behavioural or psychological component: The 6-month treatment included 16 weekly meetings, followed by 2 biweekly and 2 monthly meetings. Families received parent and child workbooks, which included introduction to weight control and self-monitoring, the Traffic Light Diet, the specific activity program, behavior change techniques and maintenance of behavior change. At treatment meetings participating family members were weighed, their weight was graphed, they met with an individual therapist for 15-30 minutes, and they attended separate 30-minute parent and child group meetings. During the individual meetings, therapists reviewed weekly weight change and diet, targeted physical or sedentary activities, and the behavioral contract. Parents and children were taught positive reinforcement techniques including praise for targeted behaviours and reciprocal contracts in which parents and children set goals and reinforcers to be provided by the parent (or child) based on meeting the goal. - Physical activity: Participants assigned to the increase physical activity group were reinforced for increasing physical activities in addition to those engaged in at the onset of the program. Physical activities done as a required part of the work or school day were not counted in meeting activity goals. Low dose for the increase physical activity group was the equivalent expenditure of 16.1 km per week. - Nutrional advice: The Traffic Light Diet was used to decrease energy intake and promote a balanced diet. Foods are categorized on the basis of their caloric and nutrient content. While they were attempting to lose weight, children and overweight parents were instructed to consume between 4184 and 5021 kJ/day, to limit red foods to 10 or fewer per week, and to maintain nutrient balance by eating the recommended servings based on the food pyramid. Families were provided additional nutritional information, including reading food labels and shopping, and were taught stimulus control to reduce access to high-calorie foods and increase access to healthy lower-calorie foods. Preplanning was taught to facilitate decision making and problem solving for difficult eating and activity situations, such as parties, holidays, and school or work functions. - Other: Parents deposited $75 to be returned contingent on completing 75% of the treatment sessions and attending the 6- and 12-month follow-up. Families were paid $50 for their attendance at the 24-month follow-up. Usual care/ alternative intervention: (2) increase physical activity - high - Target of intervention: family - Behavioural or psychological component: As above. - Physical activity: As above. High dose for the increase physical activity group was the equivalent expenditure of 32.2 km per week. - Nutrional advice: As above. - Other: As above. Usual care/ alternative intervention: (3) decrease sedentary behavior - low - Target of intervention: family - Behavioural or psychological component: As above. - Physical activity: Participants assigned to the decrease sedentary behavior group were reinforced for reducing sedentary behaviours that compete with being active or set the occasion for eating (watching television/videotapes, playing computer games, talking on the telephone, or playing hard board games). Not all sedentary activities were targeted, so that participants could substitute non-targeted sedentary activities for targeted sedentary behaviors. Low dose for the decrease sedentary behavior group was 10 h/week of targeted sedentary behaviors. - Nutrional advice: As above. - Other: As above. Usual care/ alternative intervention: (4) decrease sedentary behavior - high - Target of intervention: family - Behavioural or psychological component: As above. - Physical activity: As above. High dose for the decrease sedentary behavior group was 20 h/week of targeted sedentary behaviors. - Nutrional advice: As above. - Other: As above.
OutcomesWeight status: Weight (kg) and % overweight (based on comparison of subjects BMI to the 50th BMI percentile based on subject sex and height) presented at baseline, 6, 12 and 24 months. Others: % body fat and physical work capacity.
NotesUnclear whether a sub sample of the participants in this study also took part in the previous Epstein 1995 paper.
Risk of bias
ItemAuthors' judgementDescription
Allocation concealment?Unclearno description of randomisation process, families stratified by gender and degree of child and parent obesity
Epstein 2004
MethodsRandom allocation: no description of randomisation process.      Blinding: Children/family: No Providers: No Outcome assessors: Not clear, not specified                                           Length of intervention and follow up: 6 months intensive treatment. Follow up at 12 months. Unit of allocation: Child/family Unit of analysis: Child/family Protection against contamination: Not clear Drop outs: end of intervention 15% [11/72], follow up at 12 months: 17% [12/72]
Participantsn= 72 randomised, 60 completedAge range (mean): 8 to 12 years (mean(SD): 9.8(1.3)) % Male: 37.1%Weight entry criteria: over 85th BMI percentile Weight on entry (mean): 57.6 (7.8) kg stimulus control, 57.1 (11) kg reinforced reduce sedentary Setting: Unclear, but assume outpatient clinic Geographic Region: Not clear
InterventionsInterventions: behavioural therapy with stimulus control vs behaviour therapy with reinforced reduce sedentary behaviours. Intervention: Stimulus control Target of intervention: Child/family - Behavioural or psychological component: The treatment program included 16 weekly meetings, followed by two biweekly meetings and two monthly meetings during the 6-month intensive treatment. Families received parent and child family-based weight control workbooks, which included four main sections, (a) introduction to weight control and self-monitoring, (b) the Traffic Light Diet (described below), (c) behavior change techniques, and (d) maintenance of behavior change. Families in both groups were taught to praise children for meeting goals specific to their group. In addition, children in both groups were provided a contract reinforcement system to motivate children for behavior change. Preplanning was taught to facilitate eating and exercise control when difficult eating and activity situations could be anticipated, such as parties, holiday gatherings, and school or work functions. The stimulus control group received additional instructions to aid sedentary behavior change, which involved posting signs indicating the sedentary limit and unplugging targeted sedentary activities such as televisions or computers. - physical activity: There was no specific activity program provided for the participants. They were provided general information on lifestyle and aerobic activities, but there were no specific goals for any participant. Participants did not self-monitor their activity, and they were not positively reinforced for increasing their activity. - nutritional advice: Families were instructed to record daily food intake (food description; amount; calories; and number of high-calorie high-fat, “Red,” foods, described below) and targeted sedentary behavior times (TV/VCR/DVD, video games, and non-school use of a computer) in habit books. Parents were taught to review habit books during a daily meeting the parent had with the child. Families were also told to record and graph home weights at least once per week. The Traffic Light Diet (Epstein et al. 1998) was used to decrease energy intake, increase nutrient density, and balance nutrients in the participants' diet. This diet categorizes foods on the basis of their macro- and micronutrient content into the colors of a traffic light with similar meaning. The diet starts at 800–1,200 calories per day, with children encouraged not to go below 800 calories per day. The weight loss goal in this study was for children to lose 0.5 lbs. (0.2 kg) per week. If children are losing more than 2 lbs. (0.9 kg) per week for 3 or more weeks, the calorie range is adjusted upward. The goal is for children to gradually reduce the number of Red foods per week to 15 or fewer. Families who achieved non-overweight status were taught how to identify energy values that would facilitate maintenance of normal growth. Information regarding food labels and shopping were included in the diet instruction. - Other: No Usual care/ alternative intervention: reinforced reduce sedentary behaviours - Target of intervention: child/family - Behavioural or psychological component: As above, but In the reinforced reduction group positive reinforcement was contingent on reducing targeted sedentary behaviours, whereas in the stimulus control group positive reinforcement was contingent on recording targeted sedentary behaviours. - Physical activity: As above. - Nutrional advice: As above. - Other: No.
OutcomesHeight, mean BMI z score and % overweight (SDs), mean waist circum (SDs), change BMI z score (SDs), change waist circum (SDs), behaviour changes (pa including sedentary behaviour, F&V, and red foods).
Notes 
Epstein 2005
MethodsRandom allocation: Yes. No description of randomisation process. Blinding: Children: No Providers: No Outcome assessors: Not clear, not specified                                           Length of intervention and follow up: Intervention: 2 years, but more intense early on. Follow up: 2 years from commencement of intervention. Unit of allocation: Families Unit of analysis: Families Protection against contamination: Not clear Drop outs: end of intervention 20% [9/44], follow up at 24 months: 20% [9/44]
Participantsn= 44 randomised, 35 completedAge range (mean): 8-12 at baseline (mean(SD) age (yr.) experimental group: 10.2 (1.1); mean(SD) age (yr.) standard treatment group: 10.1 (1.3)) % Male: 43.9% Weight entry criteria: > or = to 85th percentile BMI Weight on entry (mean): mean(SD) weight on entry (lb) experimental group: 137.5 (24.8); mean (SD) weight on entry (lb) standard treatment group: 142.9 (23.7). Setting: Unclear, assume outpatient clinic Geographic Region: Unclear
InterventionsIntervention: experimental group using behavioral economic treatment Target of intervention: Family - Behavioural or psychological component: Children in both groups were provided a reinforcement system to motivate children for behavior change. Children could earn points only if they met behavioral goals and lost weight. The dual contingency of behavioral and weight goals was designed to minimize youth being reinforced for self-report of behavior change in the absence of true behavior change. All behaviours reinforced in the standard group were also reinforced in the experimental group. However, in addition, the experimental group also earned 1 point for each “Alternative Behavior to Eating,” defined as any freely chosen activity lasting at least 30 minutes that did not or could not involve simultaneous eating. Participants who used physical activity as the incompatible behavior could earn an extra point in addition to the points for being active. Targeted sedentary behaviours (television watching, recreational computer use, and video or computer games) were not reinforced even if eating was not engaged in. - Physical activity: Families were provided general information on lifestyle and aerobic activities and taught to increase physical activity and decrease targeted sedentary behavior (television watching, recreational computer use, and video or computer games). The activity program used was a lifestyle program. Participants were provided a list of activities and their associated caloric expenditures (metabolic equivalents, or METS) and were instructed to accumulate at least 30 minutes of moderate intensity (3 METS or greater) accumulated in increments of at least 10 min per bout at least 6 days/week. Participants could engage in traditional, high-intensity aerobic exercise on some days but would be expected to engage in lifestyle physical activity on other days. - Nutritional advice: All families were provided basic information about the Traffic Light Diet, Food Guide Pyramid, and healthy eating. The focus was on calorie reduction and reduction in intake of RED foods, and families were taught the importance of eating a balanced diet. The caloric target range was 1,000 to 1,500 kcal/day. Children and their parents started on a 1,200 to 1,500 kcal/day diet, and their individual calorie level was adjusted based on their weight change. If the children consistently lost more than 1 pound per week, or the adults lost more than 2 pounds per week over 3 weeks, the calorie level was increased; if the children did not lose at least 0.5 pounds/week and the overweight adults did not lose 1 pound/week, the calorie level was decreased to no less than 1,000 kcal/day. - Other: No Usual care/ alternative intervention: standard family-based behavioral intervention - Target of intervention: Family - Behavioural or psychological component: As above, but without reinforcement for alternative eating behaviours. - Physical activity: As above. - Nutritional advice: As above. - Other: No.
OutcomesHeight, weight, BMI, BMI-z-score, percent overweight, behaviour changes, physical activity.
Notes 
Epstein 2008a
MethodsRandom allocation: Randomization was implemented using a random number algorithm stratifying by gender Blinding: Children: Not clear, not specified                                          Providers: Not clear, not specified                                          Outcome assessors: Not clear, not specified Length of intervention and follow up: Intervention: 6 months. Follow-up from commencement of intervention: 24 months. Unit of allocation: Child Unit of analysis: Child + Parent Protection against contamination: Unclear Drop outs: end of intervention 34% [14/41], follow up at 12 and 24 months: 34% [14/41]
Participantsn= 41 randomised, 27 completedAge range (mean) 8-12 years % Male: 56% Weight entry criteria: Over the 85th BMI percentile Weight on entry (mean): Increase healthy food group: mean (SD) zBMI 2.3 (0.3). Reduce High-Energy-Dense food group: mean (SD) zBMI 2.3 (0.2). Setting: Not clear Geographic Region: U.S.A.
InterventionsIntervention: Increase healthy food - Target of intervention: family - Behavioural or psychological component: Stimulus control for food recommendations for the healthy food group were to arrange a food environment to make it easier to increase their fruit, vegetables, and low-fat dairy food consumption. Parents were encouraged to model healthy behaviours for their children, and in addition to the point system, family members were encouraged to praise each other for practicing healthy behaviours. Preplanning and problem solving were taught to facilitate decision-making and handling of difficult eating and activity situations. - Physical activity: Both groups received information about physical activity and positive effects of exercising. The goal was at least 60 minutes per day of moderate to vigorous intensity physical activity for 6 days a week, shaped in 15-minute increments beginning at 15-minutes of moderate to vigorous intensity physical activity per day. - Nutrional advice: The Traffic Light Diet was used to decrease energy intake and promote a healthy diet for overweight children and their parents. Traffic Light Diet foods are categorized as Green, Yellow, and Red, based upon their amount of fat and sugar per serving. Serving sizes used in the Traffic Light Diet are derived from the serving sizes used in the food pyramid. Green foods are high in nutrient density and low in energy density. Most Green foods come from the fruit and vegetable groups. Yellow foods are higher in energy density than Green food, and Red foods are higher in energy density than Yellow and Green foods. Many Red foods come from the fats, oils, and sweets groups and are to be used sparingly. Overweight participants were instructed to consume between 1,000 and 1,500 calories per day. All participants were educated to maintain nutrient balance by eating the recommended number of servings based on the food guide pyramid. Families were provided education on reading food labels and healthy shopping. Each group received reinforcement for meeting their dietary goals  through a point system. The increase healthy food group focused on replacing high-energy dense food with fruits, vegetables and low-fat dairy. They had a weight loss target, but no calorie goal. - Other: No Usual care/ alternative intervention: Reduce High-Energy-Dense food - Target of intervention: family - Behavioural or psychological component: Stimulus control control recommendations were designed to reduce consumption of Red foods by limiting them in their home environment, reducing purchasing of Red foods, and alter food preparation and eating out. Family members were also encouraged to praise each other for practicing healthy behaviours, to model healthy behaviours and to use preplanning and problem solving to handle difficult eating and activity situations. - Physical activity: As above. - Nutrional advice: As above. - Other: No
OutcomesWeight status: Height, weight, BMI, zBMI, fruit/vegetable intake, RED food servings, low-fat dairy intake, minutes of general physical activity, minutes of MVPA, Parental feeding practices, Child-rearing behaviours
Notes 
Risk of bias
ItemAuthors' judgementDescription
Allocation concealment?YesRandomization was implemented using a random number algorithm stratifying by gender
Flodmark 1993
MethodsRandom allocation: Method not described Blinding: Children: Unclear Providers: Unclear Outcome assessors: Unclear Length of intervention and follow up: 14-18 months treatment and one year follow up Unit of allocation: Children Unit of analysis: Children Protection against contamination: No details Drop outs: end of intervention 10% [9/94], follow up at 12 months: 10% [9/94] (Baseline and outcome measures for 39/44 treatment children and 48/50 control children [Table 1]) For all but 1 child height and weight data were available.
Participantsn= 94 randomised (44 for treatment [family and conventional] and 50 for control), 87 completed follow up, (39 treatment and 48 control) Age range (mean): 10 to 11 years % Male: 48% Weight entry criteria: BMI > 23.0 Treatment groups weight on entry (mean): BMI 22.0 Control group weight on entry (mean): BMI 25.1 Setting: Screened in schools and attended sessions with paediatrician Geographic Region: Sweden
InterventionsInterventions: Standard care of comparable dietary counselling and medical checkups for a period of 14-18 months + family therapy vs standard care of comparable dietary counselling and medical checkups for a period of 14-18 months alone Intervention: Standard care of comparable dietary counselling and medical checkups for a period of 14-18 months + family therapy - Target of intervention: family - Behavioural or psychological component: Family therapy component included the treatment component below, plus an program across 14-18 months where families were seen every 2-3 months.  During therapy the therapists tried to reinforce the resources of the family and to create an optimal emotional climate for helping the obese child.  The overall aim was to promote mutual respect and a confident atmosphere.  Within the session, first the seriousness of the obese condition was defined for the family.  Then the hierarchy of the family was adjusted with interventions focused on family structure.  The de Shazer model, a brief solution-based therapy focusing, through language, on how to construct solutions.  Failures, past or present are not discussed, allowing families to feel less like failures.  - Physical activity: The importance of exercise was emphasized and exercise by the obese children was encouraged. - Nutrional advice: Dietary counselling by a dietician (only half took up this option), and (assume) some dietary related advice from the paediatrician as they go on to say that the dietary component prescribed contained 15-1700 calories and families were advised to reduce the energy content of food to 30%.  - Other: No Usual care/ alternative intervention: Standard care of comparable dietary counselling and medical checkups for a period of 14-18 months alone - Target of intervention: family - Behavioural or psychological component: No. - Physical activity: The importance of exercise was emphasized and exercise by the obese children was encouraged. - Nutrional advice: Dietary counselling by a dietician (only half took up this option), and (assume) some dietary related advice from the paediatrician as they go on to say that the dietary component prescribed contained 15-1700 calories and families were advised to reduce the energy content of food to 30%. - Other: No
OutcomesWeight status: BMI presented at start, end and 1 year follow up. Others: skin-fold thickness and physical fitness. Length of treatment was 14-18 months and follow up was one year after completion of treatment, hence > 1 year data that are presented.
Notes 
Risk of bias
ItemAuthors' judgementDescription
Allocation concealment?UnclearB - Unclear
Gillis 2007
MethodsRandom allocation: No description of randomisation process. Blinding: Children: Not clear, not specified Providers: Not clear, not specified                                          Outcome assessors: Not clear, not specified Length of intervention and follow up: Six months duration, with healthy lifestyle talks at baseline and three months. Assessment and examinations were conducted at baseline and follow-up, six months. Unit of allocation: Individual children Unit of analysis: Individual children Protection against contamination: Not clear Drop outs: end of intervention 33% [9/27], follow up at 6 months: 33% [9/27]
Participantsn= 27 randomised, 18 completedAge range (mean): 7-16 years (intervention group 11.2 ± 2.5, control group 9.9 ± 2.0) % Male: Gender not stated Weight entry criteria: BMI>90th percentile Weight on entry (mean): Not stated. (BMI SDS: intervention group 1.98 ± 0.21, control group 2.16 ± 0.34) Setting: Two urban, primary care clinics in Jerusalem. Geographic Region: Jerusalem/Israel
InterventionsIntervention: Guidance-based intervention reinforcing nutrition and exercise modification Target of intervention: Child Behavioural or psychological component: Self-monitoring: diaries recording the contents of food ingested and the amount of exercise performed on one day of each week. Practitioner contact: talks/discussions based on healthy diet/exercise were held with the intervention group at baseline and at three months, together with weekly telephone calls to encourage adherence to the prescribed plan. Physical activity: Intervention was in the form of talks, at both baseline and 3 months, discussing the benefits of exercise/physical activity. Physical fitness was assessed by a modified Harvard step test (discussed later). Nutritional advice: Advice given to participants via talks at baseline and 3 months, together with reinforcement of 'ideal diets' via telephone calls on a weekly basis. As part of these calls, food diaries were reviewed with further advice if necessary. Other: No Usual care/ alternative intervention: Control group Target of intervention: Child Behavioural or psychological component: Control group received identical talks to the intervention at baseline and three months. Other elements of the study were specifically for the intervention group only. Physical activity: Advice provided in the form of talks at baseline and three months, based around the benefits and impact of exercise/physical activity. Nutritional advice: Advice provided in the form of talks at baseline and three months, regarding the benefits of healthy eating. Other: No
OutcomesHeight, weight, BMI, BMI SDS, lifestyle changes (food intake, physical fitness) LDL (mg/dl), HDL (mg/dl), triglycerides (mg/dl), CRP (mg/dl), ALT, AST, HbA1c, fasting glucose and insulin.
NotesNone
Golan 1998
MethodsRandom allocation: No description of randomisation process. Blinding: Children: Not clear Providers: Not clear Outcome assessors: Not clear Length of intervention and follow up: One year Unit of allocation: Child Unit of analysis: Child Protection against contamination: Not clear Drop outs: end of intervention 17% [10/60], follow up at 6 months: 17% [10/60] (9/30 in control group, 1/30 in intervention group)
Participantsn= 60 children randomised, 50 completedAge range (mean): 6 to 11 years (9.2 years, SD 1.0) % Male: 38% Weight entry criteria: > 20% over expected weight for age, height and gender Weight on entry (mean): 39% overweight Setting: Not stated Geographic Region: Israel
InterventionsInterventions: Behavioural modification targeted at parents as agents of change (intervention) vs children as agents of change (control). Intervention: Behavioural modification targeted at parents as agents of change. - Target of intervention: parent - Behavioural or psychological component: Parents taught to apply behaviour modifications, practice relevant parenting skills, + limits of responsibilities, parental modelling, cognitive restructuring and coping with resistance. 2 subgroups of 15 parents. Each subgroup attended 14 one hour sessions; first 4 were weekly, next 4 biweekly, last 6 were once every 6 weeks. + family also attended 15 min individual sessions at certain points among the last 6 group sessions. (all siblings weighed and measured to emphasise growth and children told their Parents were on a health promotion course). ‘5 only’s: eat only in the dining room, while sitting, proper plate, when not doing anything else and when hungry. - Physical activity: Parents taught to alter sedentary lifestyle (no details). - Nutrional advice: Parents taught to decrease fats and reduce family's exposure to food stimuli. Parents controlled the quality and pattern of the food environment but not restrict the amount of food eaten. - Other: No Usual care/ alternative intervention: Children as agents of change. - Target of intervention: child - Behavioural or psychological component: Children divided into 2 equal subgroups. Each subgroup attended 30, one hour sessions with a clinical dietician. First 8 weeks were held weekly and remaining 22, bi-weekly. Taught how to control food stimuli, self-monitoring techniques, practice problem solving, cognitive restructuring and make use of social support. Individual counselling was offered if child missed session of needed extra support. - Physical activity: Taught how to increase exercise. - Nutrional advice: 6.3 MJ/d, taught how to follow a prudent diet, restrict energy intake. - Other: No
OutcomesWeight status: Weight (kg) and % overweight at baseline presented in earlier paper (ref 26, table 1) and outcome change in % overweight presented at 12 month follow up. Others: Family Eating and Activity Questionnaire (designed for study) and parental weight.
Notes 
Risk of bias
ItemAuthors' judgementDescription
Allocation concealment?UnclearNo description of randomisation process.
Golan 2006
MethodsRandom allocation: Telephone numbered, opaque sealed envelopes. Blinding: Children: No  Providers: No  Outcome assessors: Yes      Length of intervention and follow up: 6 months, follow-up 18 months. Unit of allocation: Child. When 2 siblings from 1 family participated, they were both assigned to the same group. Unit of analysis: Child. When 2 siblings from 1 family participated, they were both assigned to the same group. Protection against contamination: Not clear Drop outs: end of intervention 16% [5/32], follow up at 6 months: 16% [5/32]
Participantsn= 32 randomised, 27 completedAge range (mean): 6 to 11 years (8.8 in intervention group, 8.7 in control group) % Male: Not clear Weight entry criteria: >20% overweight (BMI for age and sex over 85th centile) Weight on entry (mean): Parent-only group: 47.1 (12.4); Parent-and-child group: 45.5 (15.9) Setting: Unclear but assume in a hospital outpatient setting Geographic Region: Israel
InterventionsIntervention: A family-based, health-centred orientation targeted at parents only vs targeted at parents and children Intervention: behavioural program targeted at parents only Target of intervention: Parent only Behavioural or psychological component: Parents in both groups were trained in coping techniques in order to encourage and foster an authoritative feeding style. Parents were also encouraged to de-emphasise thinness and focus on addressing their and the child's internal needs by expressing feelings and nurturing the child emotionally. Physical activity/ Nutritional advice: The programme emphasised healthy eating patterns (decrease exposure to obesogenic foods, establish designated times for family meals, set at least one family meal per day, allocate individual portions, etc), encouraged an increase in daily physical activity (a goal of 4 h/week), and a decrease in sedentary behaviours (3 h/d). Other: No Usual care/ alternative intervention: behavioural program targeted at parents and children Target of intervention: Parent and child Behavioural or psychological component: Both programmes were similar in content; however, the programme for the parents and children group was adapted to fit the children included (the same issues were discussed in a different manner). Physical activity/ Nutritional advice: As above. Other: No
OutcomesHeight, weight, mean BMI, BMI z-score, %overweight (SDs), mean change BMI z score and % overweight (SDs), behaviour changes.
NotesThe authors state that parents only-group is the experimental group. However, for comparison in meta-analysis, we included the parents & children-group as experimental group tfor similar comparison to other studies that were pooled in meta-analysis.
Goldfield 2001
MethodsRandom allocation: No description of randomisation process. Blinding: Children: Not clear, not specified Providers: Not clear, not specified                                         Outcome assessors: Not clear, not specified Length of intervention and follow up: 20 weeks, follow up 6 and 12 months after treatment began Unit of allocation: Families Unit of analysis: Families Protection against contamination: Not clear Drop outs: end of intervention 23% [7/31], follow up at 6 months: 23% [7/31]
Participantsn= 31 randomised, 24 completedAge range (mean): 8 to 12 years (intervention group 9.8 ± 1.3, control group 10.3 ± 1.3) % Male: 29.2% Weight entry criteria: >20% over ideal weight for height and age Weight on entry (mean): intervention group 56.5 ± 15.1, control group 57.8 ± 9.7 Setting: Not stated Geographic Region: Not stated
InterventionsIntervention: Mixed (group and individual treatment) Target of intervention: Family - Behavioural or psychological component: Several types of reinforcement were used. Parents and children were instructed to meet nightly to review the habit book and were trained to use praise to increase desired behaviours. A point system was used to help meet behavior goals. Each child and parent received points every time they lost weight and met a behavioral goal, and points were exchanged for reinforcers, which both children and parents had mutually agreed upon at the beginning of the program. Children and parents could earn two points (small reinforcer) by losing a half-pound of weight plus meeting both behavioral goals (e.g. red food goal and physical activity goal). Four points (medium reinforcers) were earned when participants lost one pound of weight and met behavioral goals, and six points (large reinforcers) were earned for a two pound loss combined with meeting behavioural goals. Participants who met weight loss goals but only met one behavior goal were given one, two, or three points depending on the degree of weight loss. No points were earned if the behavioral goals were achieved without a weight loss, so objective weight change was needed to corroborate changes in self-reported behaviours. Including weight loss as a criterion of reinforcement was based on the rationale that weight loss often occurs as a result of behavior change, but since change in behavior were measured by self-report and may be inaccurate, we did not want to provide reinforcement for changes that were not achieved. The sessions for participants in the mixed treatment consisted of 15 - 20 min individual sessions with a therapist and 40 min of group therapy. - Physical activity: Participants in both groups received similar information through written manuals on the positive effects of increased physical activity and the negative effects of sedentary behaviours. All participants were reinforced for increasing physical activity; either programmed activity or lifestyle activity, done at moderate intensity or higher. Physical activities done as a required part of the work or school day were not included. Physical activity goals began at 30 min per week and increased by 30 min increments each time the goals were met, with 180 min per week preformed at moderate intensity or higher representing the highest activity goal.  - Nutritional advice: The Traffic Light Diet was used to decrease energy intake and promote a balanced diet. Foods are categorized as red, yellow or green on the basis of their calorie and nutrient content. Green foods (e.g. fruit and vegetables) are very low in calories. Yellow foods (e.g. yogurt, 2% milk) are higher in calories and include the dietary staples needed for a balanced diet. Red foods (e.g. potato chips, candy) are foods higher in calories with low nutrient density. Participants were instructed to consume between 1000 and 1200 calories per day, shaping a reduction in red foods to no more than 15 per week, and to maintain nutrient balance by eating the recommended servings based on the food pyramid. When participants, weight decreased to the non-obese range, they were instructed to eat additional 100 calories per day for a week until weight gain occurred, and they should attempt to maintain the caloric values associated with weight maintenance. Non-overweight parents had no caloric restriction, but were asked to limit red foods. Families were provided with additional nutritional information, including reading food labels and shopping. - Other: Participants were instructed to weigh themselves daily at home and graph their weight. They were also taught to keep a habit book in which they recorded food and caloric intake, number of red foods and time spent on physical activity. Parents and children were instructed to model appropriate eating and activity behaviours. Families were encouraged to rearrange their environment e.g. encouraged to keep red foods out of the house in order to decrease consumption of these foods. Similarly, families were also instructed to keep exercise and athletic equipment easily accessible to serve as cues to increase physical activity. Suggestions, such as putting the television in a room with uncomfortable chairs. Individual therapy was designed to identify the behaviours that influenced their weight changes, to determine the accuracy of habit book recording, to evaluate whether program goals were met and reinforcers earned were delivered, to provide performance feedback, and to problem solve situations that hinder behavior change. Children were brought to the parent group for 15 - 20 min at the beginning of each group sessions so that parents and children could collaboratively determine the number of points earned for weight loss and behavior change. Usual care/ alternative intervention: Group treatment only - Target of intervention: Family - Behavioural or psychological component: As above, but participants did not receive individual attention. An additional 20 min of group treatment in order to equate time in treatment across groups. - Physical activity: As above - Nutritional advice: As above - Other: As above
OutcomesHeight (cm), weight (kg), estimates of % fat content i.e. BMI, Z-BMI and percentage overweight, cost effectiveness.
Notes 
Golley 2007
MethodsRandom allocation: Telephone numbered, opaque sealed envelopes  Blinding: Children: No Providers: No Outcome assessors: Yes Length of intervention and follow up: Intervention 6 months, follow-up from commencement of intervention 12 months Unit of allocation: Child Unit of analysis: Child Protection against contamination: Unclear Drop outs: end of intervention 19% [22/115], follow up at 24 months: 21% [24/115]
Participantsn= 115 randomised, 91 completedAge range (mean) 6-9 years (8.2 ± 1.1) % Male: 37% Weight entry criteria: overweight according to IOTF criteria Weight on entry (mean): Parenting-skills training + life-style education group: mean (SD) BMI z-score 2.74 (0.58). Parenting-skills training alone group: mean (SD) BMI z-score 2.76 (0.58). Wait-list control group: mean (SD) BMI z-score 2.75 (0.39). Setting: Outpatient clinic Geographic Region: Adelaide, Australia
InterventionsIntervention: Parenting-skills training with intensive life-style education - Target of intervention: family - Behavioural or psychological component: Parenting-skills training was used to facilitate and support parents to undertake family lifestyle changes. Parents participated in the Positive, Parenting Program, a standardized and evaluated general parenting program. Triple P is based on child development theory and social learning principles and aims to promote parental competence to manage their child's behavior. The program consisted of  4 weekly 2-hour group sessions followed by 4 weekly, then 3 monthly 15- to 20-minut individual telephone sessions. Standard Triple P resource materials were used with program examples adapted to reflect dietary and activity behaviors. Application of Triple P to eating and activity behaviors was supported by provision of a general healthy lifestyle pamphlet. - Physical activity: While parents attended the lifestyle sessions, children in the P+DA group attended structured, supervised activity sessions developed by physical activity experts. The sessions consisted of fun, non-competitive games designed around aerobic activity and development of fundamental motor skills. Sessions were designed as play rather than exercise and were diversional rather than interventional. The activities required minimal equipment and were deliverable by nonexpert staff and easily replicated at home. - Nutrional advice: Parents in the P + DA group participated in an additional 7 intensive llifestyle support group sessions. These sessions commenced after completion of the 4 weekly parenting sessions, every 2 weeks at first, then monthly. These sessions focused on lifestyle knowledge and skills including the following: family-focused healthy eating with specific core food serve recommendations, monitoring, label reading, snacks, modifying recipes, being active in a variety of ways, roles and responsibilities around eating, managing appetite, self-esteem and teasing. - Other: No Usual care/ alternative intervention: Parenting-skills training alone - Target of intervention: family - Behavioural or psychological component: As above. - Physical activity: No - Nutrional advice: No - Other: No Usual care/ alternative intervention: Wait-list control group - Target of intervention: family - Behavioural or psychological component: No. The WLC group received the same general healthy lifestyle pamphlet as het parenting (P) alone group. During the 12-month wait-listed period, the WLC group was contact by telephone 3 to 4 times for 5 minutes as a retention strategy. - Physical activity: No - Nutrional advice: No - Other: No
OutcomesHeight, weight, BMI, BMI z-score, waist, waist z-score, total cholesterol, LDL, HDL triacylglycerol, SBP, DBP, glucose and insulin
Notes 
Risk of bias
ItemAuthors' judgementDescription
Allocation concealment?YesTelephone numbered, opaque sealed envelopes 
Graf 2005a
MethodsRandom allocation: cluster randomisation (7 schools out of about 150 out of the region of Cologne) further randomised by lot by lot - three intervention and four control schools. Blinding: Children: No Providers: No Outcome assessors: Not clear, not specified                                           Length of intervention and follow up: Entire academic year Sep-July, follow up at 10 months from commencement of intervention Unit of allocation: School Unit of analysis: child Protection against contamination: Not clear Drop outs: 11% [21/195] at the end of intervention (=9 months follow up; 11/40 in intervention group, 10/155 in control group)
Participantsn= 195 randomised, 174 completedAge range (mean): 6 to 11 years (mean in intervention group 8.70, mean in control group 8.47) % Male: Not clear Weight entry criteria: Overweight was defined as BMI > 90th centile, but less than 97th centile. Obesity > 97th centile (based on German centile charts). Weight on entry (mean): mean (sd) BMI-SDS intervention group: 1.99 (0.52), control group: 1.87 (0.41) Setting: School Geographic Region: Cologne, Germany
InterventionsInterventions: School and family based behavioural program vs regular school program. Intervention: School and family based behavioural program - Target of intervention: Child & family - Behavioural or psychological component: Step one consists of health education and physical activity taught by regular teachers during the normal school day.The so-called StEP TWO programme is the intervention designed for overweight and obese children. The educational contents included information about selecting healthy foods, and the importance of getting regular physical exercise. Parents were involved in events relating to overweight and obesity in childhood, for 1 evening, the importance of physical activity for 1 evening, healthy nutrition for 2 evenings, and psychosocial aspects of a healthy lifestyle, also for 2 evenings. - Physical activity: After the meal (twice a week), the children undertook a programme of physical activity lasting for between 60 and 90 minutes. Examples for the activity used are aerobic dance, endless relay, and games like soccer, and so on. Two family events were organised where they learned and practised inline skating together. - Nutritional advice: The specialists cooked and ate with the children twice a week, using a diet based on the OPTIMIX pyramidal programme for nutrition for children. Examples for lunch are raw fruits, vegetables, wholemeal products, and vegetarian food like the vegetarian hamburger and so on. - Other: No Usual care/ alternative intervention: Control group - Target of intervention: Child - Behavioural or psychological component: No - Physical activity: No - Nutritional advice: No - Other: just regular school program
OutcomesHeight, mean BMI and BMI z score (SDs), mean waist circum (SDs), change BMI and BMI z score (SDs), change waist circum (SDs), bioelectrical impedance, BP, waist, waist to hip, body weight.
NotesProportion of those invited to take part in the intervention was very low, unlike the control group. Study design should have included similar sessions and effort for the control group, but unrelated to body weight.
Risk of bias
ItemAuthors' judgementDescription
Allocation concealment?Nocluster randomisation (7 schools out of about 150 out of the region of Cologne) further randomised by lot by lot - three intervention and four control schools.
Graves 1988
MethodsRandom allocation: Children were ranked according to % overweight for age sex and height and then assigned randomly from stratified blocks to treatment groups Blinding: Children: Unclear Providers: Unclear Outcome assessors: Unclear Length of intervention and follow up: 8 weeks intervention and 6 months follow up Unit of allocation: Children Unit of analysis: Children Protection against contamination: Unclear Drop outs: end of intervention 3% [1/40], follow up at 6 months: 23% [9/40]
Participantsn= 40 children randomised, 39 (97.5%) completed treatment and 31 (77.5%) took part in the follow up Age range (mean): 6 to 12 years (9.3 years) % Male: No details given Weight entry criteria: At least 20% overweight for age, sex and height Weight on entry (mean): 124.5 (lb), 53.7% overweight for age, sex and height Setting: University Geographic Region: USA
InterventionsInterventions: Parents targeted for 1. problem solving (I) vs 2. Behavioural (I2) vs 3. Instruction only group (C). Intervention: Problem-solving group - Target of intervention: child and parent - Behavioural or psychological component: Means-end problem-solving: at sessions 1, 8 and 3 and 6-month follow ups, parents scored on ability to solve 5 weight loss problems (Shure and Spivack, 1972). Treatment 60 min sessions: 40 mins same as behavioural group (control - see below) 20 mins devoted to problem solving exercises directed at child weight control. Parents and children asked to identify problems related to session, list possible alternatives and develop plans. Parents instructed to choose measure of effectiveness and restructure plans each week if necessary. - Physical activity: Record of activity using colour coded charts during 1st and 8th week of treatment. Point score derived from record. - Nutrional advice: Record of dietary intake with parents help using colour coded charts (based on Traffic Light Diet) during 1st and 8th week of treatment. Point score derived from record. - Other: Financial incentive $35 deposited. Amount returned at last follow-up was dependent on no. of sessions attended. Usual care/ alternative intervention: Behavioral group - Target of intervention: child and parent - Behavioural or psychological component: Used puppets, stories and games etc. to present weight reduction methods such as self-monitoring, diet information, exercise information, stimulus control strategies, family support, cognitive restructuring, peer relations and maintenance strategies. 60 min sessions: 10 mins on reviewing previous week's diet and activity sheets, 20 mins of behavioural weight related methods, 10 mins children weighed, 20 mins parents swapped strategies. - Physical activity: Record of activity using colour coded charts during 1st and 8th week of treatment. Point score derived from record - Nutrional advice: Record of dietary intake with parents help using colour coded charts (based on Traffic Light Diet) during 1st and 8th week of treatment. Point score derived from record. - Other: Financial incentive $35 deposited. Amount returned at last follow-up was dependent on no. of sessions attended. Usual care/ alternative intervention: Instruction only group - Target of intervention: child and parent - Behavioural or psychological component: Participants were presented with the same diet and exercise information as the problem-solving and behavior groups. Parents exchanged recipe and exercise ideas during the closing 20 min of each session. - Physical activity: Subjects self-monitored exercise during the 1 st and 8th treatment weeks; however, this was not introduced as a behavior-change strategy. Exercise for 15 mins at the beginning of each session. - Nutrional advice: Subjects self-monitored food consumption the 1 st and 8th treatment weeks; however, this was not introduced as a behavior-change strategy. - Other: Financial incentive $35 deposited. Amount returned at last follow-up was dependent on no. of sessions attended.
OutcomesAssume baseline and outcome weight data presented for 31/40 (Table 1.) % overweight calculated as % above average weight for age, sex and height. Others: BMI, diet charts, physical activity charts, parental problem-solving ability
Notes 
Risk of bias
ItemAuthors' judgementDescription
Allocation concealment?UnclearB - Unclear
Grey 2004
MethodsRandom allocation: A coin toss randomized schools to the experimental or control condition Blinding: Children: No Providers: No Outcome assessors: Partly. Trained research assistants, blinded to the study group, collected psychosocial data. Nurse practitioners in the school-based clinic, not blinded to the study group, collected BMI and central adiposity measurements Length of intervention and follow up: Intervention: 16 weeks. Follow-up from commencement of intervention: 12 months Unit of allocation: School Unit of analysis: Child and parent Protection against contamination: Unclear Drop outs: end of intervention 0% [0/41], follow up at 6 months: 0% [0/41], follow up at 12 months 22% [9/41].
Participantsn= 41 randomised, 41 completed the intervention, but 9 failed to attend follow up session Age range (mean) 10-14 years % Male: 37% Weight entry criteria: BMI > 95th percentile Weight on entry (mean): Coping skills training group: mean (SD) BMI 35.8 (5.8). Control group: mean (SD) BMI 37.0 (7.1). Setting: School Geographic Region: New Haven/US
InterventionsIntervention: Experimental group: CST (Coping Skills Training) - Target of intervention: child and parent- Behavioural or psychological component: CST was taught in nutrition classes by a registered dietitian who was trained in CST techniques. Training included culturally sensitive weight management materials. Within each session participants were allowed ample time to "try out" new skills and set goals for applying these skills to their nutrition and exercise goals the coming week - Physical activity: The after school physical activity program was scheduled two days a week for 45 minutes over the 16 week period with a licensed personal trainer and research assistant. Adolescents were encouraged to partner with their parent an additional three days per week at home to increase their physical activity, and decrease sedentary behaviours. Coping skills training (CST) was reinforced by the personal trainer and research assistant opportunistically in the experimental group. - Nutrional advice: A family-centred culturally sensitive interactive nutrition curriculum designed to slow weight gain and improve glucose metabolism was provided for 45 minutes weekly. A brief nutrition assessment was completed with each student and evaluated by the registered dietitian to elicit information regarding previous diets, food consumption habits, dining styles, and daily activities. A non-diet approach taught participants to incorporate a pattern of regular meals with a dietary goal of nutritious and satisfying meals that decreased portion size. Creation of weekly goals with assistance from the registered dietitian supported participants in taking small steps toward success. Particpants and their parents were encouraged to attend the weekly classes which used culturally appropriate materials for Hispanic and African American families. - Other: During the summer, an advance practice nurse and registered dietitian telephoned participants in the experimental group once each week. Phone calls reinforced weekly nutrition and exercise goals and CST. Usual care/ alternative intervention: Control group - Target of intervention: child and parent- Behavioural or psychological component: No - Physical activity: The after-school physical activity program was scheduled two days a week for 45 minutes over the 16 week period with a licensed personal trainer and research assistant. Adolescents were encouraged to partner with their parent an additional three days per week at home to increase their physical activity, and decrease sedentary behaviours. Coping skills training (CST) was reinforced by the personal trainer and research assistant opportunistically in the experimental group. - Nutrional advice: A family-centred culturally sensitive interactive nutrition curriculum designed to slow weight gain and improve glucose metabolism was provided for 45 minutes weekly. A brief nutrition assessment was completed with each student and evaluated by the registered dietitian to elicit information regarding previous diets, food consumption habits, dining styles, and daily activities. A non-diet approach taught participants to incorporate a pattern of regular meals with a dietary goal of nutritious and satisfying meals that decreased portion size. Creation of weekly goals with assistance from the registered dietitian supported participants in taking small steps toward success. Particpants and their parents were encouraged to attend the weekly classes which used culturally appropriate materials for Hispanic and African American families. - Other: During the summer, an advance practice nurse and registered dietitian telephoned participants in the control group once each month. Phone calls assessed nutrition and exercise goals.
OutcomesGlucose (120 min.; baseline three-hour oral glucose tolerance test), Insulin (120 min.; baseline three-hour oral glucose tolerance test), HOMA, HbA1c, total cholesterol, HDL, LDL, triglycerides, BMI, waist circumference, Revised Godin-Shepard Activity Survey, Dietary intake, Health promoting lifestyle profile, Health Behavior Questionnaire, Children's Depression Inventory (CDI)
Notes 
Risk of bias
ItemAuthors' judgementDescription
Allocation concealment?NoA coin toss randomised schools to the experimental or control condition
Gutin 2002
MethodsRandom allocation: Method not described Blinding: Children: No Providers: No Outcome assessors: Unclear Length of intervention and follow up: Intervention: 8 months. Follow-up from commencement of intervention: 8 months Unit of allocation: Individual adolescent Unit of analysis: Individual adolescent Protection against contamination: Done: Subjects from the 2 physical training groups were combined and the subjects in the LSE alone group were seen in separate sessions in alternating weeks to minimize contamination across the physical training and no physical training groups. Drop outs: end of intervention 29% [21/80], follow up at 8 months: 29% [21/80]. assumptions made from results table (n=59).
Participantsn= 80 randomised, 59 completedAge range (mean) 13-16 years % Male: 31% Weight entry criteria: triceps skinfold greater than the 85th percentile for sex, ethnicity and age Weight on entry (mean): Only given stratified by ethnicity and sex. White boys: mean (SD) weight (kg) 95.2 (8.7). White girls: mean (SD) weight (kg) 88.5 (4.6). Black boys: mean (SD) weight (kg) 100.2 (4.4). Black girls: mean (SD) weight (kg) 94.8 (2.9). Setting: Not clear, probably outpatient clinic Geographic Region: Not clear
InterventionsIntervention: LSE (Life-Style Education) + high-intensity physical training) - Target of intervention: child - Behavioural or psychological component: The 1 hour Life-Style Education-sessions were offered once every 2 weeks for the 8 months intervention; youths were paid $5 for each LSE class attended. The LSE included principles of learning and behavior modification, information about nutrition and physical activity, discussions of various aspects of the food consumption process, psychosocial factors related to obesity and problem solving and coping skills. The LSE sessions were taught by a licensed clinical psychologist who specializes in the treatment of eating disorders and obesity and has experience in providing LSE to children, adolescents, and adults. - Physical activity: The physical training was offered 5 d/week, except during the weeks when the group was scheduled for LSE on 1d. The estimated EE was held constant at 1045 kJ (250kcal) per session, regardless of physical training group assignment. An exercise prescription was then developed for each subject on the basis of the data collected from the baseline treadmill test. First, the peak VO2 achieved by each youth on the treadmill test was identified, and the EE associated with 55-60% of peak VO2 (moderate-intensity) physical training or 75-80% (high-intensity) physical training was determined. Because the high-intensity physical activity group used more energy per minute, they were scheduled to exercise for fewer minutes per session than the moderate-intensity group. Each exercise session provided some flexibility for the youths to select activities of their preference. Activities included exercise on machines, aerobics, basketball, badminton, kickball and aerobic slide. The instructors helped the youths to modify the intensities to stay within their prescribed target heart zones. As an incentive ,each youth was awarded points for maintenance of target heart rates that were redeemed for prizes. To encourage attendance, each subject was paid $1 for each physical activity training class attended. - Nutrional advice: No - Other: No Usual care/ alternative intervention: LSE + moderate-intensity physical training - Target of intervention: child - Behavioural or psychological component: As above. - Physical activity: As above, but moderate-intensity physical activity. - Nutrional advice: No - Other: No Usual care/ alternative intervention: Life-style education (LSE) only - Target of intervention: child - Behavioural or psychological component: As above. - Physical activity: No - Nutrional advice: No - Other: No
OutcomesHeight, weight, %fat mass, %bone mineral content, %fat-free soft tissue, %fat-free mass, VAT (visceral adipose tissue), SAAT(subcutaneous abdominal adipose tissue), cardiovascular fitness, free-living physical activity, dietary data (total energy, fat, carbohydrate, protein), plasma triacylglycerol, total cholesterol, VLDLC, HDLC, TC/HDLC, LDLC, ApoA1, ApoB, Lp(a), fasting insulin, glucose, LDL particle size, SBP, DBP, leptin
NotesDropouts were excluded from analysis and only participants who attended at least 40% of lifestyle education and physical activity sessions, were analysed (N=37-41).
Hughes 2008
MethodsRandom allocation: Yes, computer-generated randomization list  Blinding: Children: No Providers: No Outcome assessors: Yes Length of intervention and follow up: 8 appointments (7 at outpatient clinic, 1 at home) over 26 weeks. Total patients contact time approx 5 hours, follow up 12 months from commencement of intervention. Unit of allocation: Individual child Unit of analysis: Individual child Protection against contamination: Not clear Drop outs: end of intervention 28% [37/134], follow up at 12 months: 36% [48/134] (intervention group 24, control group 24)
Participantsn= 134 randomised, 86 completedAge range (mean): 5 to 11 years (intervention group 9.1± 1.7, control group 8.5± 1.9) % Male: 44% Weight entry criteria: BMI ≅ 98th centile relative to UK 1990 reference data Weight on entry (mean): BMI-z-score (median plus range) intervention 3.2 (2.7 to 3.6), control group: 3.3 (2.8 to 3.6) Setting: Outpatient clinic Geographic Region: Edinburgh and Glasgow, United Kingdom
InterventionsInterventions: Individualised behavioural intervention vs standard dietetic care Intervention: Individualised behavioural intervention Target of intervention: Family Behavioural or psychological component: Family-centered counselling and behavioural strategies to modify diet, physical activity and sedentary behaviours. Physical activity: Children were encouraged to increase their physical activity, and restrict their sedentary behavior (television viewing and playing computer/video games) to no more than 2 hours per day or the equivalent of 14 hours per week. Nutritional advice: Children were encouraged to alter their diet by using a modified traffic-light approach [reduce intake of foods high in fat and sugar (red), increase intake of fruit and vegetables (green). Other: No Usual care/ alternative intervention: Standard dietetic care Target of intervention: Family, but directed toward the parents rather than the child Behavioural or psychological component: No Physical activity: No Nutritional advice: Concentrated on dietary change with minimal focus on physical activity or sedentary behavior, and involved a didactic “medical model” rather than a behavioral, client-centred approach. 3-4 outpatient appointments. Main focus on healthy eating. Total contact time approx. 1.5 hours Other: No
OutcomesHeight, weight, median (IQR) BMI z score, median (IQR) weight, change BMI z score (95% CIs), change weight (95% CIs), behaviour changes (total activity + time in sedentary behaviour, light activity and MVPA), measures of self esteem, health status, QOL.
NotesBMI-z-score median (se) are presented. Mean values provided by author for meta-analysis.
Israel 1985
MethodsRandom allocation: Randomly assigned to conditions from stratified blocks based on child % overweight and age Blinding: Children: No Providers: No Outcome assessors: Unclear Length of intervention and follow up: 9 Week, plus brief problem solving discussions and monthly telephone calls at 1, 2, 4, 6, 9 and 12 months post intervention. So follow up at 3, 4, 6, 8, 11 and 14 months from commencement of intervention. Unit of allocation: Child Unit of analysis: Child Protection against contamination: Not Clear Drop outs: 39% at end of intervention [13/33] children (Attrition rates for children are unclear as 33 children were split between 30 families and drop outs mention families not children).
Participantsn= 33 children (30 families = 24/30 were treatment families and 6/30 were initially control, 3/30 dropped out before session 9, another 7/30 (7/27) dropped out during follow up. 20/30 families completed, also equal to 20 children, WRO n= 9, PT n= 11. Age range (mean): 8 to 12 years (10.8 in WRO, 10.4 in ST) % Male: 30% Weight entry criteria: 20% Overweight for height Weight on entry (mean): Not stated Setting: No details Geographic Region: US
InterventionsInterventions: 3 cycles: experimental conditions included: behavioural weight reduction only (WRO), behavioural weight reduction plus parent training (PT), and waiting list control.  Intervention: Behavioural Weight Reduction Only. - Target of intervention: child and parent - Behavioural or psychological component: Stimulus control cues - Physical activity: Exercise - Nutrional advice: Calories and nutrition - Other: Rewards. - Overall: Overall program described as: 9 weekly 90 minute sessions. Separate parent and child groups.  A four-prong format (CAIR) was employed using stimulus control cues, activity (exercise), food intake (calories, nutrition), and rewards were addressed at each session and individualised for each family.  Subjects were requested to monitor food and caloric intake, energy expenditure, and adherence to recommended changes in weight-related habits.  Depending on ability the responsibility for monitoring was divided between parent and child to encourage active participation while giving parent ultimate responsibility for record keeping. Homework was collected and reviewed at each treatment session. Parent and child's groups were conducted in lecture discussion format to provide individualised programming while facilitating exchange of information and experiences. After 9th weekly session, parents and children came in for weighing and brief problem solving discussions at 1,2,4,6,9 and 12 months. After the 4 month session phone calls were made monthly. Usual care/ alternative intervention: Behavioural weight reduction plus parent training. - Target of intervention: child and parent - Behavioural or psychological component: Treatment included above plus parents in the PT attended two hour-long sessions in behavioural child management skills.  Lectures were based on the presentation: Living with Children (Patterson 1976).  Three brief quizzes were administered at the two initial sessions and at the first treatment session. Concepts were systematically referred to during the ensuing treatment program for PT groups only.  - Physical activity: As above. - Nutrional advice: As above. - Other: As above. Usual care/ alternative intervention: Waiting list control. - Target of intervention: child - Overall: Waiting list control subjects were seen for measurement purposes at the beginning and end of the weight reduction program.  After serving as controls they were offered treatment in the next cycle of the study.
OutcomesWeight status : Weight (kg) and % overweight presented at week 1, 9 and 1 year follow up. % overweight based on the assumption that ideal weight was the weight at the same percentile as the child's height. Percentiles based on comparison norms (Hamil et al 1977) for child's sex and age (Foreyt and Goodrick 1981). Others: triceps skinfold (data not presented),parental weight, Eating Habit Checklist (EHC) and Knowledge of Behavioral Principles as Applied to Children Scale(KBPAC).
NotesControl subjects only followed up for 9 weeks and then 6 families became treatment families but baseline data includes those families.
Risk of bias
ItemAuthors' judgementDescription
Allocation concealment?UnclearNo description of randomisation process
Israel 1994
MethodsRandom allocation: No description of randomisation process Blinding: Children: Unclear Providers: Unclear Outcome assessors: Unclear Length of intervention and follow up: 26 weeks treatment and 1 and 3 years follow up Unit of allocation: Children Unit of analysis: Children Protection against contamination: Unclear Drop outs: 24% [8/34 families] at end of intervention, 41% at 1 & 3 years follow up [14/34 families, 7/18 in ST and 7/16 in ECI]
Participantsn= 36 families randomised, 34 families took part; 18 in ST and 16 in ECI Age range (mean): 8 years 11 months to 13 years 0 months (10 years 11 months) % Male: No details given Weight entry criteria: > 20% overweight for weight, height and sex Weight on entry (mean): 47% overweight for age, height and sex Setting: Assume outpatient clinic Geographic Region: US
InterventionsInterventions: Behavioral oriented treatment program in which parents were given primary responsibility for following program prescriptions (Sandard Treatment) vs enhanced child involvement condition (ECI). Intervention: Enhanced child involvement - Target of intervention: child and parent - Behavioural or psychological component: Parents and children met in separate groups comprising 5 to 7 families for 8 weekly 90-minutes sessions followed by 9 biweekly sessions for a total of 26 weeks of treatment. Treatment for both conditions was based on four-prong approach identified by the acronym CAIR consisting of discussions and homework assignments regarding Cue control, physical Activity, food Intake, and rewards. Families were asked to monitor children's food intake, activity and adherence to cue control rules, and parents were asked to reward appropriate behaviours such as staying under a prescribed calorie limit, and reaching an activity minimum. Parents also received training in general child-management principles (e.g.. identifying problem behaviours, planning a program to change behaviours, and implementing such a program) and were required to read the book Living with children which paralleled the content of parent training. The enhanced child involvement condition placed less emphasis on parental control and focused more attention on the children's management of their own weight loss efforts.  Chilren received comprehensive training in self-management skills introduced sequentially throughout treatment with a particular emphasis after week 8. - Physical activity: See behavioral component, not further described. - Nutrional advice: See behavioral component, not further described. - Other: No. Usual care/ alternative intervention: Standard treatment - Target of intervention: child and parent - Behavioural or psychological component: As above, Standard treatment included all the above mentioned components with emphasis on parent-responsibility for the completion of homework assignments and for the motivation of their children to follow program rules or prescriptions. - Physical activity: See behavioral component, not further described. - Nutrional advice: See behavioral component, not further described. - Other: No.
OutcomesWeight status: % overweight (based on weight for age, height and sex) presented at week 1, 26 and year 1 and 3. Others: BMI (not described), triceps skinfold thickness, measures of self-regulation and self-control.
Notes 
Risk of bias
ItemAuthors' judgementDescription
Allocation concealment?UnclearNo description of randomisation process
Jelalian 2006
MethodsRandom allocation: A randomization procedure, with percent overweight and gender as covariates, was used to assign adolescents to treatment condition. Randomization was conducted by the study coordinator. Blinding: Children: No Providers: No Outcome assessors: Unclear Length of intervention and follow up: Intervention: 16 weeks. Follow-up from commencement of intervention: 10 months Unit of allocation: child Unit of analysis: child Protection against contamination: Unclear Drop outs: end of intervention 21% [19/89], follow up at 10 months: 29% [26/89] (one treatment arm (standard care, n = 13) was discontinued due to patient and parents concern with treatment acceptability and associated significant difficulties with retention)
Participantsn= 89 randomised, 56 completed (n=13 discontinued) Age range (mean) 13-16 (14.51) years % Male: 29% Weight entry criteria: Between 20 and 80% overweight Weight on entry (mean): mean (SD) 86.41 (12.40) kg, BMI mean (SD) 32.48 (3.07) Setting: Outpatient clinic Geographic Region: Not clear
InterventionsIntervention: CBT (Cognitive Behavior Therapy) + PEAT (Peer-Enhanced Adventure Therapy) - Target of intervention: adolescent and parent - Behavioural or psychological component: Cognitive-behavioral weight loss intervention was standard across both group conditions and was modeled on child and adult weight control programs. Treatment groups were conducted by doctoral level psychologists with experience in adolescent weight management. Behavioral topics included self-monitoring, motivation for weight loss, goal setting, the importance of physical activity, implementation of stimulus control strategies, use of parent-teen contracts to support nutrition and physical activity goals, social influences on diet and exercise, the relationship between stress and eating, and relapse prevention. Nutrition topics included presentation of the exchange system, portion control, dining out, dietary fat, and healthy snack choices, and were presented by a dietitian. The parent meeting for both treatment conditions included didactic content that paralleled that presented to adolescents. In addition, parents were provided guidance regarding implementing change at a family level and supporting positive eating and physical activity habits in their adolescents. In the CBT+PEAT group, adolescents participated weekly in an additional session of the peer-based intervention, held separately from the above described 60-min. meeting. Peer-enhanced adventure therapy. The peer-based activity session consisted of an initial ‘warm-up’ activity that included physical activity followed by the primary challenge for the group, processing of the activity, and establishing weekly personal goals. Group activities consisted of both physical and mental challenges that were aimed at development of socials skills, problem solving abilities, and self-confidence. The goal of each activity was to increase individual self-confidence while developing trust among group members. Sessions were structured sequentially to target increasingly challenging activities. - Physical activity: Participants were asked to gradually increase physical activity to a minimum of 30 min daily for 5 days a week. All adolescents participated in 30 minutes of on-site physical activity supervised by either an exercise physiologist or physical therapist. The goal of the brief exercise session was for adolescents to achieve a target heart rate of 40-60% above resting for a minimum of 20 min.                                      - Nutrional advice: Adolescents were prescribed a balanced deficit diet (1400-1600kcal) based on the dietary exchange system. - Other: No Usual care/ alternative intervention: CBT (Cognitive Behavior Therapy) + EXER (Aerobi exercise) - Target of intervention: Adolescent and parent- Behavioural or psychological component: As above, but not peer-enhanced. - Physical activity: In the CBT+EXER group, adolescents participated weekly in an additional session of supervised physical activity, held separately from the above described 60-min. meeting. Activities for the supervised exercise intervention included use of treadmills, stationary bicycles, and brisk walking within the hospital setting. Each session included a 10-min warm-up period, 30 min of physical activity, and a 20min wrap-up period that consisted of ‘cool down’ and review of weekly physical activity goals. - Nutrional advice: As above. - Other: No
OutcomesHeight, weight, BMI, % overweight, self-concept, self-concept related to physical appearance, social support, peer-rejection
Notes 
Risk of bias
ItemAuthors' judgementDescription
Allocation concealment?YesAn urn randomization procedure, with percent overweight and gender as covariates, was used to assign adolescents to treatment condition. Randomization was conducted by the study coordinator.
Jiang 2005
MethodsRandom allocation: No description of randomisation process. Blinding: Children: No Providers: No Outcome assessors: Not clear, not specified. Height and weight measurements were performed by a trained researcher. Length of intervention and follow up: Monthly home visits during 24 months. Length of home visits not reported. Follow up 24 months. Unit of allocation: Individual child (+ family) Unit of analysis: Individual child (+ family) Protection against contamination: Not done; not specified, but very unlikely. Drop outs: end of intervention 9% [7/75], follow up at 24 months: 9% [7/75]
Participantsn= 75 randomised, 68 completedAge range (mean): 12-14 (intervention group 13.3 ± 0.6, control group 13.2 ± 0.7) % Male: 60,29% Weight entry criteria: Weight for height >= 120% of the Chinese reference Weight on entry (mean): intervention group 70.1 ±  5.7 kg, control group 71.2 ±  6.4 kg Setting: Middle school Geographic Region: Beijing, China
InterventionsInterventions: Family based lifestyle intervention (I) vs controls (C) with no intervention Intervention: Family based lifestyle intervention. Target of intervention: Child Behavioural or psychological component: One or two main behaviours which were related to obesity were chosen for each child based on an assessment of relevant dietary and exercise patterns at baseline. Then a new goal behaviour and interval behaviours were defined. Each goal and interval behaviour was discussed with the child and the parents and was agreed to by the child. A diary was kept by the children and their behaviour in order to monitor adherence to the recommended lifestyle changes. The parents monitored the diary and their child's progress in achieving the new behaviour(s). Physical activity: The intervention aimed to increase physical activity as well. Exercise for 20-30 minutes per day for four days per week was advised. Physical education teachers monitored intervention children's exercise after class. Children were also urged to decrease sedentary time, for example television viewing. Nutritional advice: No. Throughout the study the researchers visited the families once per month. They observed the family environment and looked for where foods were stored, cooking styles and what kinds of foods were used commonly in the family. A ‘traffic light’ food item list was given to the children to help decrease the energy intake and promote a balanced diet. ‘Red light’ foods were those high in fat or calories. ‘Green light’ products were low in fat and calories, ‘yellow light’ foods were intermediate. Children were urged to eat less ‘red light’ foods and more ‘green light’ foods. Parents were encouraged to buy more ‘green light’ foods and less ‘red light’ foods. Children and their parents were informed about daily calorie requirements, based on the Chinese recommended daily allowance. Also Chinese food composition tables were given to each family, so they could calculate the calorie intake of their child every day and compare with the calorie requirements. To avoid the feeling of hunger dietary behaviours like eating slowly, having soup, eating ‘green light’ foods first, were suggested to the families.  What the child ate each day was recorded in the diary. The researchers checked the diaries at home visits and evaluated the dietary intake. Dietary suggestions were given after each evaluation. Other: No Usual care/ alternative intervention: Controls without any intervention Target of intervention: Child Behavioural or psychological component: No Physical activity: No Nutritional advice: No Other: Controls without any intervention
OutcomesHeight (mm), weight (kg), estimates of % fat content e.g.. BMI, ponderal index, skin-fold thickness, blood pressure, metabolic health outcomes (total cholesterol, triglycerides, after overnight fast).
NotesRather big effect size compared to other studies, completers only.
Risk of bias
ItemAuthors' judgementDescription
Allocation concealment?UnclearNo description of randomisation process.
Johnston 2007a
MethodsRandom allocation: No description of randomisation process. An unbalanced randomisation (i.e. a greater number of participants were assigned to the behavioural intervention) was used. Blinding: Children: No Providers: No Outcome assessors: Not clear, not specified                                           Length of intervention and follow up: 6 months, follow-up 6 months. Unit of allocation: Child. Unit of analysis: Child. Protection against contamination: interventions were held in separate classrooms (important since all children came from the same school) Drop outs: end of intervention 7% [5/71], follow up at 6 months: 7% [5/71]
Participantsn= 71 randomised, 66 completed (I = 44; C = 22) Age range (mean): 10 to 14 years (mean not given) % Male: Not clear Weight entry criteria: > or = to 85th percentile BMI according to CDC guidelines. Weight on entry (mean): BMI-SDS: 1.86 (0.48) intervention group, 1.64 (0.44) in control group Setting: School Geographic Region: Houston, Texas.
InterventionsInterventions: Behavioural family treatment vs self help Intervention:Target of intervention: Family Behavioural or psychological component: An instructor/trainer-led intervention for 12 weeks of daily sessions (Monday until Friday) and l2 weeks of bi-weekly sessions. All instructors were trained to use contingency management, reinforcement, and modelling to encourage participant adherence. A graduate level student trained in behavior modification monitored and assisted interventionists on a daily basis, providing feedback to improve their use of these strategies. Parents were invited to attend monthly meetings to facilitate family adoption of healthy habits. For parents who did not attend meetings, information was sent home that was intended to be discussed between the parent and the child. Behavioral strategies were used to encourage adoption of program principles. A token economy system was implemented for reinforcing healthy changes. Participants received points for trying new fruits/vegetables, keeping their bodies moving during physical activity, and for meeting specific program goals. These points were exchanged weekly for prizes. Each point provided was worth approximately one cent with children typically accumulating 150 points on a weekly basis. Participants also learned to self-monitor, set goals, and control environmental stimuli to increase healthy actions. Behavioral techniques were additionally used with parents as they were expected to assist their families to improve health by providing healthier options for eating and activity. They were taught to use stimulus control strategies and how to reward dietary changes that promoted improved health. Behavior theory has been effective in modifying eating, exercise, and other factors that contribute to or maintain obesity. Physical activity: consisted of four physical activity lessons weekly. Children went outside for physical activity and were instructed by undergraduate students trained in physical activity/ nutrition. During weeks 1-6, the physical activity intervention was administered using a modified circuit training approach to maintain heart rate within a target zone (60-85% of heart rate reserve) and develop a basic level of physical fitness. Participants were at each station for no more than 2 minutes with participants rotating through all stations I to 2 times during the period. Activities included sports and fitness drills for building endurance, strength and flexibility during which time participants monitored heart rates to learn how to regulate intensity. During weeks 7-12, the stations were modified to focus on sport skill development for either school/ community sponsored teams (e.g. dance, soccer, softball) or leisure (e.g. jumping rope, basketball, kickboxing). Nutritional advice: consisted of one nutrition lesson and weekly. Nutrition instruction was held indoors and led by a bachelor level instructor trained in nutrition. In addition, children received snack bars for a daily afternoon school snack and a cereal for breakfast. Children and parents were encouraged to provide information regarding the foods they liked, and they were taught methods for modifying and/or substituting them with others available to promote improved health. Traditional Mexican American foods were modified to make them less calorically dense. Nutrition instruction focused on reading food labels, selecting appropriate portion sizes, establishing regular eating times throughout the day, and categorizing foods into groups with varying degrees of health benefit. The food groups were labelled "safety", "caution", and "danger" zone foods with rules for determining how to categorize them. Safety (i.e., foods that are more healthy for overall nutrition and maintaining a healthy weight) consisted of most fruits and non-starchy vegetables. Caution foods (i.e., use caution not to overeat) included low-fat meats, low-fat dairy, and complex carbohydrates. Danger (i.e., foods that were less healthy for overall nutrition and may lead to weight gain if overeaten) consisted of foods with 5 or more grams of fat or 15 or more grams of sugar per serving. Other: Biweekly quizzes were given to evaluate acquisition of the material. Children with absences, low quiz grades, and/or continued weight gain for more than 2 weeks received individual education and treatment planning. Usual care/ alternative intervention: Self help Target of intervention: family Behavioural or psychological component: Participants in the self-help (SH) condition were given instructions to follow a 12-week parent-guided manual that included instructions for weight loss and maintenance. SH participants and their parents were instructed to use a book, Trim Kids, aimed at improving diet quality and increasing time spent doing physical activity. The program provided 12 weekly sessions followed by maintenance activities. Physical activity: No Nutritional advice: No Other: No
OutcomesHeight, weight, BMI, BMI Z score, change in BMI %ile, body fat % lipids, glucose, insulin, blood pressure.
Notes 
Johnston 2007b
MethodsRandom allocation: No description of randomisation process. An unbalanced randomization (i.e. a greater number of participants were assigned to the behavioural intervention) was used. Blinding:                                                                       Children: No  Providers: No  Outcome assessors: Not clear, not specifiedLength of intervention and follow up: 6 months, with follow up at 3 months and 6 months Unit of allocation: Child Unit of analysis: Child Protection against contamination: interventions were held in separate classrooms (important since all children came from the same school) Drop outs: end of intervention 5% [3/60], follow up at 6 months: 5% [3/60]
Participantsn= 60 randomised, 57 completedAge range (mean): 10 to 14 years (mean not given) % Male: Unclear Weight entry criteria: > or = to 85th percentile BMI according to CDC guidelines. Weight on entry (mean): zBMI (mean [SD]) intervention group: 1.6 (0.6) control group: 1.7 (0.6) Setting: School Geographic Region: Houston, Texas
InterventionsInterventions: Behavioural family treatment vs self help Intervention:Target of intervention: Family Behavioural or psychological component: An instructor/trainer-led intervention for 12 weeks of daily sessions (Monday until Friday) and l2 weeks of bi-weekly sessions. All instructors were trained to use contingency management, reinforcement, and modelling to encourage participant adherence'. A graduate level student trained in behavior modification monitored and assisted interventionists on a daily basis, providing feedback to improve their use of these strategies. Parents were invited to attend monthly meetings to facilitate family adoption of healthy habits. For parents who did not attend meetings, information was sent home that was intended to be discussed between the parent and the child. Behavioral strategies were used to encourage adoption of program principles. A token economy system was implemented for reinforcing healthy changes. Participants received points for trying new fruits/vegetables, keeping their bodies moving during physical activity, and for meeting specific program goals. These points were exchanged weekly for prizes. Each point provided was worth approximately one cent with children typically accumulating 150 points on a weekly basis. Participants also learned to self-monitor, set goals, and control environmental stimuli to increase healthy actions. Behavioral techniques were additionally used with parents as they were expected to assist their families to improve health by providing healthier options for eating and activity. They were taught to use stimulus control strategies and how to reward dietary changes that promoted improved health. Behavior theory has been effective in modifying eating, exercise, and other factors that contribute to or maintain obesity. Physical activity: consisted of four physical activity lessons weekly. Children went outside for physical activity and were instructed by undergraduate students trained in physical activity/ nutrition. During weeks 1-6, the physical activity intervention was administered using a modified circuit training approach to maintain heart rate within a target zone (60-85% of heart rate reserve) and develop a basic level of physical fitness. Participants were at each station for no more than 2 minutes with participants rotating through all stations I to 2 times during the period. Activities included sports and fitness drills for building endurance, strength and flexibility during which time participants monitored heart rates to learn how to regulate intensity. During weeks 7-12, the stations were modified to focus on sport skill development for either school/ community sponsored teams (e.g. dance, soccer, softball) or leisure (e.g. jumping rope, basketball, kickboxing). Nutritional advice: consisted of one nutrition lesson and weekly. Nutrition instruction was held indoors and led by a bachelor level instructor trained in nutrition. In addition, children received peanuts/peanut butter with a fruit or vegetable, to enhance satiety and to provide an opportunity for fruit/vegetable consumption, a daily afternoon school snack. Children and parents were encouraged to provide information regarding the foods they liked, and they were taught methods for modifying and/or substituting them with others available to promote improved health' Traditional Mexican American foods were modified to make them less calorically dense. Nutrition instruction focused on reading food labels, selecting appropriate portion sizes, establishing regular eating times throughout the day, and categorizing foods into groups with varying degrees of health benefit. The food groups were labelled "safety", "caution', and "danger" zone foods with rules for determining how to categorize them. Safety (i.e., foods that are more healthy for overall nutrition and maintaining a healthy weight) consisted of most fruits and non-starchy vegetables. Caution foods (i.e., use caution not to overeat) included low-fat meats, low-fat dairy, and complex carbohydrates. Danger (i.e., foods that were less healthy for overall nutrition and may lead to weight gain if overeaten) consisted of foods with 5 or more grams of fat or 15 or more grams of sugar per serving. Other: Biweekly quizzes were given to evaluate acquisition of the material. Children with absences, low quiz grades, and/or continued weight gain for more than 2weeks received individual education and treatment planning. Usual care/ alternative intervention: Self help Target of intervention: family Behavioural or psychological component: Participants in the self-help (SH) condition were given instructions to follow a 12-week parent-guided manual that included instructions for weight loss and maintenance. SH participants and their parents were instructed to use a book, Trim Kids, aimed at improving diet quality and increasing time spent doing physical activity. The program provided 12 weekly sessions followed by maintenance activities. Physical activity: No Nutritional advice: No Other: No
OutcomesBMI, zBMI, change in BMI %, body fat %, lipids, blood pressure, glucose, insulin.
Notes 
Kalavainen 2007
MethodsRandom allocation: Telephone numbered, opaque sealed envelopes. Stratified on basis of weight for height in 4 blocks. Siblings (3 pairs in the study) were randomized together, based on the higher weight for height percentile. Blinding: Children: No Providers: No Outcome assessors: No. Performed by researcher, who was not blinded for treatment allocation. Length of intervention and follow up: The group program consisted of 15 sessions of 90 minutes in duration, held separately for parents and children. The first 10 sessions were held weekly, the next 5 sessions were held every two weeks for three months. In the routine care group two appointments in 6 months were held; at the end of fall and spring terms. Follow up 12 months. Unit of allocation: Individual child (+ family) Unit of analysis: Individual child (+ family) Protection against contamination: Not clear Drop outs: end of intervention 3% [1/70], follow up at 6 months: 3% [1/70] (intervention group 1, control group 0)
Participantsn= 70 randomised, 68 completedAge range (mean): 7 to 9 years (intervention group 8.1 ± 0.9, control group 8.0 ± 0.8) % Male: 40% Weight entry criteria: Weight for height 120-200% Weight on entry (mean): Intervention group 43.1 ±  8.7 kg, control group 40.4 ±  6.7 kg Setting: School Geographic Region: Kuopio, Finland
InterventionsInterventions: Two weight-management interventions: family based group treatment (FBT) vs routine treatment (C) Intervention: family based group treatment (FBT) Target of intervention: Parents, but separate program for children Behavioural or psychological component: The group program for parents consisted of 15 sessions covering behavioral, dietetic and physical activity topics. Themes included: benefits and sacrifices of weight management., ABC's of behavior modification, parenting skills, dealing with stress, goal-setting, parents as models, problem solving, self-monitoring, how to continue. Dietary topics included: regular meals, physical activities and sleep, healthy breakfast and school lunch, label reading, decreasing excessive intake of high-energy food, how to choose fats, increase consumption of fruits and vegetables, acceptance of new foods, portion control and emotional eating, snacks, festive seasons, usage of spices, light cooking. Physcial activity topics covered why, how and when to play and how to reduce sedentary activities. A separate program took place for children with similar topics. Physical activity: The children's sessions were adjusted to children's cognitive development and thus consisted of functional activities. Most sessions included non-competitive physical activities aimed to develop children's motor skills and to motivate them to increase recreational physical activity. Nutritional advice: No. The recommended  meal pattern and quality of the diet were in line with recommendations given for Finnish families. Other: Homework was provided to both parents and children to give a chance to practice between sessions. Parents were provided with treatment models and children with workbooks. Material was modified from national 'Magnificent kids' and 'Magnificent Teens' material, from behavioral therapy workbook and self-developed material. Usual care/ alternative intervention: routine treatment (C) Target of intervention: Child, but parents could attend sessions Behavioural or psychological component: Two individual appointments for children by school nurses where held at the end of fall and spring terms. The themes were self-knowledge and physical activity. The children fulfilled workbooks partly with the nurses and partly at home with the parents. Physical activity: No Nutritional advice: No Other: The program consisted of booklets for families, based on the national ‘Magnificent kids’ material and on a cognitive behaviour therapy workbook.. The booklets contained information about weight management, eating habits and physical activities. At the two individual appointments with children the heights and weights were measured.
OutcomesEstimates of % fat content e.g. BMI, ponderal index, skin-fold thickness, height, weight, participants views of the intervention (parents ratings of sessions).
Notes 
Risk of bias
ItemAuthors' judgementDescription
Allocation concealment?YesTelephone numbered, opaque sealed envelopes. Stratified on basis of weight for height in 4 blocks. Siblings (3 pairs in the study) were randomized together, based on the higher weight for height percentile.
McCallum 2007
MethodsRandom allocation: Telephone numbered, opaque sealed envelopes. Randomisation was stratified by GP and overweight versus obese status (classified according to International Obesity Taskforce cut-points).  Randomisation was performed by a third-party biostatistician using a pre-generated computerised sequence. Blinding was maintained throughout allocation and data collection. Blinding: Children: No. By the nature of the intervention, care-givers and most of the patients were aware that they were either receiving an intervention (GP consultations and counselling) or not being seen by the GP. Providers: No. By the nature of the intervention, care-givers and most of the patients were aware that they were either receiving an intervention (GP consultations and counselling) or not being seen by the GP. Outcome assessors: Yes. Blinding was maintained throughout allocation and data collection. Length of intervention and follow up: Four GP consultations over a 12 week period. Follow-up at 9 and 15 months post-randomisation. Unit of allocation: Individual child and family Unit of analysis: Individual child and family Protection against contamination: Not done BUT assessed. General practice record audit to assess the extent of possible contamination (i.e., attendances by the control families for discussion of weight) showed minimal contamination. Drop outs: end of intervention 2% [3/163], follow up at 9 months: 6% [10/163] and follow up at 15 months 10% [17/163]
Participantsn= 163 randomised, 146 completedAge range (mean): 5.0 to 9.9 years (intervention group 7.5±1.6, control group 7.4±1.6) % Male: 48% Weight entry criteria: Identified as overweight or mildly obese on the BMI survey (IOTF cut-points). Weight on entry (mean): intervention group BMI 20.5±2.2 , control group 20.0±1.8 Setting: General practitioner clinics Geographic Region: Melbourne, Australia
InterventionsIntervention: Behavioral program, delivered by general practitioners Target of intervention: Child & family Behavioural or psychological component: Parents were asked to attend 4 consultations over a 12 week period. GPs used brief solution-focused counselling to set and record appropriate healthy lifestyle goals with the family, assisted by a personalised 20 page "Family Folder". This included 7 topic sheets, each targeting one area of behavioural change required to reduce overweight, and comprising a brief summary of supporting evidence, modelled solutions to challenges and additional suggestions as to how each goal might be achieved. The 7 topic areas were: Childhood overweight -what are the issues?; Water - the drink for children; Importance of breakfast, regular meals and snacks; Choosing the lower fat options; Healthy food for the family: avoiding battles; More Active - It's easy!; Doing Nothing: not a good option. Physical activity: The topic areas that GPs and parents could focus upon included two with a specific physical activity or sedentary behaviour focus: More Active ? It's easy!; Doing Nothing: not a good option. Nutritional advice: The topic areas that GPs and parents could focus upon included four with a specific nutrition focus: Water ? the drink for children; Importance of breakfast, regular meals and snacks; Choosing the lower fat options; Healthy food for the family: avoiding battles. Other: No Usual care/ alternative intervention: Standard care. Target of intervention: Child & family Behavioural or psychological component: No Physical activity: No Nutritional advice: No Other: Control families were notified of their status via letter and were not identified to the GPs at any time. General practice records of children in the control group were subsequently audited to assess the extent of possible contamination (i.e. attendances for discussion of weight).
OutcomesHeight (cm), weight (kg), BMI (kg/m2), BMI z-score, behaviour changes (% time in moderate to vigorous activity ,daily physical activity, daily nutrition score, measures of self esteem, health status, QOL (PedsQL Parent Proxy, PedsQL Child Self-Report, body satisfaction, physical appearance and global self-worth).
NotesThe first reported RCT of a GP intervention to treat overweight and mild obesity in pre-pubertal children. The study was carefully performed. The fact that patients were identified as overweight or obese by the study team and NOT by either the GP or the families (i.e. they were not treatment-seeking families) may make the findings more difficult to generalise to usual clinical situations.  The "dose" of the intervention was low (4 sessions over 12 weeks) and this may also have contributed to the null findings.
Mellin 1987
MethodsRandom allocation: No description of randomisation process Blinding: Children: No Providers: No Outcome assessors: Unclear Length of intervention and follow up: 3 month intervention and 12 follow up Unit of allocation: Children Unit of analysis: Children Protection against contamination: Unclear Drop outs: end of intervention 5% [3/66], follow up at 15 months: 16% reported in paper [unclear how this figure was reached, 7/14 sessions were attended by 97% of the subjects. 16% attrition would be 10/11 subjects i.e. 3 or 4/37 in test group so 7 or 8 /29 in control group]
Participantsn= 66 randomised [37/66 intervention group and 29/66 in control group], 55? completedAge range (mean): 12 to 18 years (15.6 years) % Male: 21% Weight entry criteria: No details Weight on entry (mean): 78kg and 33% overweight for age, sex and height Setting: No details Geographic Region: US
InterventionsInterventions: Shapedown program: Cognitive, behavioural, and affective and interactional techniques adapted to make successive small modifications in diet, exercise, communication and affect, that are sustainable vs no-treatment control group Intervention: Shapedown program - Target of intervention: child and parent - Behavioural or psychological component: The program employs a variety of cognitive, behavioral, affective, and interactional techniques adapted to the needs of adolescents. Using a self-directed change format, the program encourages adolescents to make successive, sustainable, small modifications in diet, exercise, relationships, lifestyle, communications, and attitudes. Very-low calorie or restrictive diets were avoided in the program. Parents are instructed on strategies for supporting their adolescents weight loss, including altering family dietary and activity patterns and improving parenting and communication skills. Group leaders conducted 14 weekly sessions for the adolescents and 2 parents sessions utilizing the materials (leaders guide, and two workbooks - parents and adolescent version) of the Shapedown program. Each 90-minute sessions included voluntary weigh-in, leader-facilitated group interaction, and an exercise period.   - Physical activity: See behavioral component, not further described. - Nutrional advice: See behavioral component, not further described. - Other: Fees for the intervention were consistent with each site's normal charges for such services. Usual care/ alternative intervention: No-treatment control group - Target of intervention: child and parent - Overall: Control group subjects received no treatment initially and were charged no fees but were informed they could enrolls in the next program that would commence in 6 months.
OutcomesWeight status: Weight (kg) presented at 3, 6 and 15 months. Others: relative weight (%), weight-related behavior, affect, weight management knowledge
Notes 
Risk of bias
ItemAuthors' judgementDescription
Allocation concealment?UnclearNo description of randomisation process
Munsch 2008
MethodsRandom allocation: Yes. Families were randomly assigned according to a permuted block design to either the mother-child (condition A) or the mother-only (condition B) cognitive behavioural therapy (CBT). Blinding: Children: No Providers: Not clear, not specified                                        Outcome assessors: Not clear, not specified                                        Length of intervention and follow up: 10 weekly sessions followed by 6 monthly sessions = ˜8.5 months Unit of allocation: Families (parent-child dyads) Unit of analysis: Families (parent-child dyads) Protection against contamination: Done. Two independent raters (students of clinical psychology holding a bachelor's degree) separately judged group leaders' adherence to treatment protocol to assess whether the two interventions were different. The results showed that the progressive muscle relaxation training intervention received by children in condition B could be distinguished from the CBT received by children in condition A. Drop outs: end of intervention 34% [16/56] (intervention group 6/31, 13/25 control group), follow up at ca. 9 months: 52% [29/56] (intervention group 11/31, control group 18/25)
Participantsn= 56 randomised, 39 completedAge range (mean): 8 to 12 years (intervention group: children 10.3 + 1.4 (n=28), mothers 40.9 + 4.4 (n=29), control group: children 10.6 + 1.5 (n=21), mothers 38.8 + 6.0 (n=25)) % Male: children 39.62% Weight entry criteria: Body mass index >85th percentile adjusted for gender and age Weight on entry (mean): Only % overweight given: intervention group: children 55.4 + 17.9 (n=28), mothers 29.6 + 7.5 (n=21), control group: children 62.4 + 27.2 (n=21), mothers 26.9 + 3.9 (n=17) Setting: Outpatient clinic Geographic Region: Basel & Bruderholz, Switzerland
InterventionsInterventions: Mother Cognitive Behavioral Therapy versus Mother-Child Cognitive Behavioral Therapy Intervention: Condition A: Mother-Child Cognitive Behavioural Therapy (CBT) Target of intervention: Mother & child Behavioural or psychological component: Mothers and children received CBT. The TAKE Program/Protocol was developed according to the guidelines of Barlow & Dietz (1998) & Summerbell et al (Cochrane, 2003). Treatment was tailored to the specific problems in the mother-child dyad according to the individual-treatment-in-group approach (Fiedler, 1996). Physical activity: Sessions 4, 5 and 6 were aimed at encouraging mothers to model physical activity in daily family life. Nutritional advice: During two sessions, the basic rules of regular and balanced nutrition were introduced using the stoplight diet, which categorises food as  low, medium, or high fat and  instructs users to eat freely from the low-fat category, cautiously from the middle category, and only rarely from the high-fat foods. To implement a functional feeding style, mothers were encouraged to follow three basic food rules for family meals (1) any food on the table may be eaten by all family members; (2) offer only restricted amounts of high-fat foods; and (3) offer a sufficient amount of low-fat food so that the child can eat until satiated. Other: No Usual care/ alternative intervention: Condition B (Control): Mother-only Cognitive Behavioural Therapy (CBT) Target of intervention: Mother only Behavioural or psychological component: Mothers received CBT. Children attended relaxation training (progressive muscle relaxation training, PMR) of equal frequency and duration to the disorder-specific CBT of children in condition A. This condition was chosen because PMR was shown to account for possible nonspecific effects of ‘attention’ in other studies. PMR for children. Followed Speck's Manual (2005), in which overweight or obesity or the management of these conditions were not targeted. The treatment took place in separate but parallel groups with up to 6 children and 6-12 mothers in each group. The treatment phase consisted of 10 weekly 120 minute sessions and 6 monthly sessions. Physical activity: As above. Nutritional advice: As above. Other: No
OutcomesWeight, height, estimates of % fat content e.g.. BMI, ponderal index, skin-fold thickness (child: percent overweight, mother: BMI), behaviour changes (children's behavioural problems and competencies), views of the intervention, measures of harm (depression and anxiety ratings).
NotesOnly brief information on the randomisation process is given. The process is of particular interest because there are difference in numbers enrolled in each condition (i.e. 31 vs 25). There was a high drop-out rate, in the mothers only intervention at the 6 month follow up vs mother-child intervention (71% vs 31%). The majority of participants were low/medium SES. It appears that the rate of psychological (mental) disorders in the population is rather high but no comparative data is given on rates in the general population. Both interventions resulted in a significant decrease in children's mean % overweight (this measure accounted for age and gender) but there was no difference between groups. The reduction was greatest during the first 10 weeks. Note: absolute height and weight data were not presented.
Risk of bias
ItemAuthors' judgementDescription
Allocation concealment?UnclearFamilies were randomly assigned according to a permuted block design to either the mother-child (condition A) or the mother-only (condition B) cognitive behavioural therapy (CBT).
Nemet 2005
MethodsRandom allocation: Telephone numbered, opaque sealed envelopes. We allocated intentionally an unequal number of participants to each group, on the basis of our previous experience (with higher dropout in the intervention). Assigned with a computerized random number generator. Blinding: Children: Not clear, not specified                                          Providers: Not clear, not specified Outcome assessors: Not clear, not specified                                          Length of intervention and follow up: Intervention 3 months. Follow up 12 months. Unit of allocation: Individual child (+ family) Unit of analysis: Individual child (+ family) Protection against contamination: Not clear Drop outs: end of intervention 15% [8/54], follow up at 12 months: 26% [14/54] (intervention group 10, control group 4)
Participantsn= 54 randomised, 40 completedAge range (mean): 6 to 16 years (intervention group 10.9 ± 1.9, control group 11.3 ± 2.8) % Male: 56.52% Weight entry criteria: Obesity (no organic cause) Weight on entry (mean): intervention group 63.8 ±  19.1 kg, control group 63.4 ±  22.8 kg Setting: Child health and sports training center, Meir General hospital Tel Aviv Geographic Region: Tel Aviv, Israel
InterventionsIntervention: Combined dietary-behavioral-physical activity intervention Target of intervention: Parent and child Behavioural or psychological component: Four evening lectures were held; on childhood obesity, general nutrition, a therapeutic nutritional approach for childhood obesity and exercise and childhood obesity. Physical activity: All intervention subjects participated in a twice-weekly training program (1 hour per session). The intervention was designed to  mimic the type and intensity of exercise that elementary and high school children would perform normally. The physicians who worked in the program participated regularly to encourage the children and provide examples. Participants were instructed to add an extra 30-45 min of walking or other weight-bearing sport activities  at least once per week. Throughout the program subjects were encouraged to reduce sedentary behaviours. Nutritional advice: The participants met with the dietician 6 times during the 3-month program. The first appointment (45-60min) was dedicated to becoming acquainted. Learning about the reasons for childhood obesity, receiving information on food choices and dietary and cooking habits, understanding the motivation of weight loss and trying to enrol the whole family in the battle against overweight. The subsequent appointments (30-45min) were devoted mainly to nutritional education (food pyramid, food choices, food labels, food preparation and cooking, eating habits, regular meals, and controlling environments that stimulate overeating. The children received dietary information through sheets and flyers on important nutritional issues. The subjects received a balanced hypocaloric diet, with a caloric deficit of 30% less than the reported intake or 15% less than the estimated daily required intake. Other: No Usual care/ alternative intervention: Routine care Target of intervention: Parent and child Behavioural or psychological component: No Physical activity: Control group participants were instructed to perform physical activity 3 times per week on their own. Nutritional advice: Control subjects were referred to an ambulatory nutritional consultation at least once. Other: No
OutcomesHeight, weight, estimates of % fat content e.g. BMI, ponderal index, skin-fold thickness, metabolic health outcomes (total cholesterol, HDL, LDL, triglycerides).
Notes 
Risk of bias
ItemAuthors' judgementDescription
Allocation concealment?YesTelephone numbered, opaque sealed envelopes. We allocated intentionally an unequal number of participants to each group, on the basis of our previous experience (with higher dropout in the intervention). Assigned with a computerized random number generator.
Nova 2001
MethodsRandom allocation: No description of randomisation process. Blinding: Children: Not clear, not specified                                         Providers: Not clear, not specified                                         Outcome assessors: No; Family paediatrician aware of protocol and application to participants. Length of intervention and follow up: Final follow-up at 24 months in both groups. Intervention duration not clearly reported. Unit of allocation: Individual family paediatricians (and enrolled children under each FP) Unit of analysis: Child Protection against contamination: Not clear Drop outs: end of intervention not reported, follow up at 6 months: 23% [43/186], follow up at 12 months 30% [56/186]
Participantsn= 18 family paediatricians randomised, enrolling 186 children, 130 completedAge range (mean): 3 to 12 years (intervention group 8.6 ± 1.9, control group 8.6 ± 2.1) % Male: 55.91% (intervention group 52.8% , control group 54.48%) Weight entry criteria:>20% of ideal body weight Weight on entry (mean): mean (SD) BMI intervention group: 23.75 (2.65); mean (SD) BMI control group: 22.37 (1.85). Setting: Family paediatricians of certain local health units Geographic Region: Lombardy, Northern Italy
InterventionsIntrventions: Two different treatment groups: Enhanced Approach (Group B, intervention group) and Routine Approach (Group A, control group) Intervention: Enhanced Approach Target of intervention: Family Behavioural or psychological component: In addition to food diaries, a subjective evaluation regarding the accuracy of filling in the diary was undertaken by the family paediatrician (good/sufficient/poor), intended to reinforce the family's compliance with the proposed changes in eating behaviour. This was to help judge the degree of parental commitment to the changes, as were interviews with the participating families at the end of the follow-up visits. Physical activity: Detailed guidelines regarding physical activity was provided for Group B. Nutritional advice: In Group B, a specific diet (only one scheme suitable in composition and caloric input - approximately 1400 calories - for all the enrolled children). An alimentary diary with instructions for use was also given to this group. Other: No Usual care/ alternative intervention: Routine Approach Target of intervention: Family Behavioural or psychological component: No Physical activity: As part of general information-based leaflets, involving an 'invitation to practice some physical activity'. Nutritional advice: General advice on healthy eating as part of information leaflets given to Group A participants. Other: No
OutcomesHeight, weight, BMI, , percentage overweight, BMI SD score, behaviour changes (alimentary diaries given to Group B participants ).
NotesThis trial reports on a 24 month intervention. Data are only presented including 12 month follow up.
Rodearmel 2007
MethodsRandom allocation: Telephone numbered, opaque sealed envelopes  Blinding: Children: No  Providers: No  Outcome assessors: No  Length of intervention and follow up: 6 months, families in both groups met with study staff 6 times during the intervention period, follow-up 6 months. Unit of allocation: Family Unit of analysis: Family Protection against contamination: Not clear Drop outs: end of intervention 16% [34/218], follow up at 6 months: 16% [34/218]
Participantsn= 218 randomised, 184 completedAge range (mean): 7 to 14 years (mean age 11.11 in intervention group and 11.28 in control group) % Male: Not clear Weight entry criteria: Families with at least 1 child ho was overweight or at risk fro overweight = BMI > or equal to 85th centile Weight on entry (mean): zBMI: intervention group: 1.76 (0.45), control group: 1.68 (0.42) Setting: Not clear Geographic Region: Denver, Colorado, USA
InterventionsIntervention: 2 small behaviour changes. 1. increase steps/day by 2000. 2. replace sugar with sweeteners Target of intervention: Family Behavioural or psychological component/physical activity/nutritional advice: Families in both groups met staff on 6 occasions over the 6 month interventions (after a 2 week baseline period). AOM families got pedometers to wear, and a lot of support and education around replacement of dietary sugars alone or in food with Splenda replacement products (study was funded in part by the company who makes these products - McNeil Nutritionals) Other: No Usual care/ alternative intervention: Control group Target of intervention: Family Behavioural or psychological component: No Physical activity: No Nutritional advice: No Other: a self monitoring group. This group were asked to use pedometers and record their pa, but they were not asked to change their pa levels or dietary habits.
OutcomesHeight, mean BMI z score (95% CIs), mean %body fat and waist circum(95% CIs), change BMI z score (95% CIs), change %body fat and waist circum (95% CIs), behaviour changes (steps).
Notes 
Risk of bias
ItemAuthors' judgementDescription
Allocation concealment?YesTelephone numbered, opaque sealed envelopes 
Rolland-Cachera 2004
MethodsRandom allocation: No description of randomisation process. Blinding: Children: Not clear, not specified Providers: Not clear, not specified                                           Outcome assessors: Not clear, not specified Length of intervention and follow up: 9 Months weight loss treatment within the clinic/boarding school. Follow-up: 2yr and 9 months from commencement of intervention. Unit of allocation: Individual child Unit of analysis: Individual child Protection against contamination: Not clear Drop outs: end of intervention 18% [22/121], follow up at 21 months 31% [38/121], and follow up at 33 months 41% [50/121]
Participantsn= 121 randomised, 71 completedAge range (mean): 11 years to 16 years (mean(SD) age PROT-: 14.1(1.2); mean(SD) age PROT+: 14.4(1.3) % Male: 26.4% Weight entry criteria: > or = 97th centile of French reference values Weight on entry (mean): Mean (SD) weight on entry PROT-: 96.1 (13.7); Mean (SD) weight on entry PROT+: 98.8 (14.3). Setting: 9 Month treatment in a medical centre (boarding school) plus a 2-year follow-up in free-living patients. Geographic Region: Not clear
InterventionsIntervention: inpatient program with low protein diet and physical activity vs high protein diet and physical activity. Intervention: inpatient program with low protein diet and physical activity Target of intervention: Child Behavioural or psychological component: No Physical activity: Physical activity consisted in 7 h/week of vigorous sports (swimming, tennis, handball, aerobic) and 7 h/week of outdoor activities (such as walking or playing). Children had no possibility to watch TV in the centre. They alternatively could spend time reading, acting, singing, talking or trolling in the centre. Advice was given to maintain the same nutritional intake and physical activity at home during weekends and holidays. Nutritional advice: Combination of dietary control and physical activity, consisting of 9-months of treatment with 2 year follow-up. Energy intake was restricted to 1750 kcal a day until reaching the body weight goal. Subsequently, daily energy intake was increased progressively, in 1-week steps, until about 2200 kcal on average (depending on age and sex). The maintenance diet was then followed during 4 weeks. The children and their parents were advised to maintain the same level of energy and nutrient intakes after leaving the centre. The nutrient content of the PROT- diet was 15% protein and 54% CHO. The respective values for PROT+ group were 19 and 50%. PROT+ diet was the habitual diet in the centre. The protein content in the PROT+ diet was 85 g/day. The protein content in PROT- diet (65 g/day when total energy was 1750 kcal) was decided taking into account the recommended dietary allowances (59 and 44 g in 15–18 y boys and girls, respectively). In the PROT+ diet, meat, fish or eggs were served twice a day, while in the PROT diet they were consumed only once a day. Fat content was identical in both diets (31%). The percentage of energy ingested over the four daily eating occasions was 20% at breakfast, 31% at lunch, 16% at the afternoon snack and 33% at dinner. Snacking out of these four main meals was very occasional in the centre. Other: No Usual care/ alternative intervention: inpatient program with high protein diet and physical activity. Target of intervention: Child Behavioural or psychological component: No Physical activity: As above. Nutritional advice:As above, but high protein diet Other: No
OutcomesHeight (m), weight (kg), BMI (kg/m2), BMI (sd. z score), subscapular & triceps skinfold (mm), SS/TRI, waist circumference & hip circumference (cm), waist/hip ratio, bioimpedance analysis (FM (kg), FFM (kg), FM (%), FFM (%)), behaviour changes (nutritional intake (kcal/day), physical activity (hr/week), daily energy distribution (%)), GH assays (pg/µl).
Notes 
Rooney 2005
MethodsRandom allocation: Yes. No description of randomisation process.       Blinding: Children: Not clear, not specified                                         Providers: Not clear, not specified                                         Outcome assessors: Not clear, not specified                                         Length of intervention and follow up: Walk 10,000 steps daily for 12 weeks, follow-up 9 months. Unit of allocation: Families Unit of analysis: Families Protection against contamination: Not clear Drop outs: not clearly reported 10-29%
Participantsn= 98 families and 353 people randomised, number completed unclear Age range (mean): 5 to 12 years (intervention group (PE) 10.1, intervention group 2 (P) 9.4 ,control group 9.6) % Male: Proportion not given Weight entry criteria: Included were families with at least one child between the age of 5 and 12 with a BMI over the 84th percentile. Weight on entry (mean): average Child BMI percentile 82.2 Setting: Based in a University Geographic Region: USA
InterventionsInterventions: pedometer plus education (PE), pedometer (P), or control (C) Intervention: pedometer plus education (PE), pedometer (P) Target of intervention: Family Behavioural or psychological component: No Physical activity: Participants in the PE and P groups received a Digi-Walker pedometer and were told to wear it and encouraged to walk 10,000 steps daily for 12 weeks. To measure activities that the pedometer registers poorly (swimming) families received a minutes-to-steps conversion table. Families kept track of their steps and returned step logs every 2 weeks. PE group participants attended 6 one-hour, biweekly sessions concerning physical activity. Participants were surveyed about their knowledge and attitudes about physical activity prior to randomisation, at the end of the intervention and 9 months later. Their heights and weights were measured and BMI calculated. Nutritional advice: PE group participants attended 6 one-hour, biweekly sessions concerning nutrition. Participants were surveyed about their knowledge and attitudes about healthy eating prior to randomisation, at the end of the intervention and 9 months later. Their heights and weights were measured and BMI calculated. Other: Both the P and PE groups received a bi-weekly newsletter that complimented the educational theme and included fun activity tips. Families returning for assessment at interventions end were eligible to win a trip to Walt Disney World (valued around $4000). Families participating in the 9-month follow-up received a $25 stipend. Control families also received a pedometer for each participating member at this follow-up. Usual care/ alternative intervention: control (C) Target of intervention: Family Behavioural or psychological component: No. Physical activity: No. Nutritional advice: No. Other: Families returning for assessment at interventions end were eligible to win a trip to Walt Disney World (valued around $4000). Families participating in the 9-month follow-up received a $25 stipend. Control families also received a pedometer for each participating member at this follow-up.
OutcomesHeight, weight, estimates of % fat content e.g.. BMI, ponderal index, skin-fold thickness (BMI percentile), participants views of the intervention.
NotesNumbers of children are not reported.
Risk of bias
ItemAuthors' judgementDescription
Allocation concealment?UnclearNo description of randomisation process.
Saelens 2002
MethodsRandom allocation: Opaque sealed envelopes  Blinding: Children: Not clear, not specified Providers: Not clear, not specified                                         Outcome assessors: Not clear, not specified                                         Length of intervention and follow up: Four-month treatment period. Post-treatment (median 4.1 months after clinic visit) and follow-up (actual median = 7.2 months after paediatric clinic visit).Unit of allocation: Individual adolescents Unit of analysis: Individual adolescents Protection against contamination: Not clear Drop outs: end of intervention 11% [5/44], follow up at 7 months: 16% [7/44]
Participantsn= 44 randomised, 37 completedAge range (mean): 12 to 16 years (14.2y) % Male: 59.09% Weight entry criteria: >20% over above median BMI for height and age Weight on entry (mean): intervention group 87.5 ± 16.0kg, typical care group 85.8 ± 14.6 kg Setting: Primary care setting Geographic Region: Southern California, US
InterventionsIntervention: Multiple component behavioural weight control intervention (Healthy Habits) Target of intervention: Child Behavioural or psychological component: Self-monitoring: writing down specific foods, amounts, calories, food categories (green, red, no colour) daily, weighing weekly, writing down type and amount of physical activity Goal setting: weekly establishment of goals for calories, green and red foods, and amount of physical activity Problem solving: identifying specific problems/barriers that prevent goal attainment, brainstorming solutions and ways to implement modified plan Stimulus control: modifying the food and physical activity environment to make healthy choices more available and less healthy choices more difficult to obtain Self-reward: rewarding self for achieving goals Pre-planning: establishing plans for high-risk situations (e.g.. parties) to decrease likelihood of unhealthy eating or lack of physical activity. Physical activity: Beginning at the fifth call, the 'Healthy Habits' intervention had a physical activity goal consisting a minimum of 60 mins of at least moderate physical activity on 5 days per week with gradual increases from baseline levels. Nutritional advice: Stoplight Diet, 1200-1500 kcal's daily, although flexible depending on initial weight. Food categorised and colour coded: green = foods <150 cals per serving, red = >5 grams of fat per serving or were diet version of high fat foods. Other: Financial incentives: Points system to award adolescents for meeting set goals and targets, with points converting to tickets for a 'lottery' - one randomly selected ticket receiving $50. In addition, adolescents received $25 for post-treatment and $25 for follow-up. Usual care/ alternative intervention: Single session of physician weight counselling (Typical Care TC) Target of intervention: Child Behavioural or psychological component: Typical Care (TC) group ? comprised of a single-session of physician weight counselling. Physical activity: Paediatricians conducted a review as part of the consultation based on recommended physical activity levels for adolescents (60 min/d of at least moderate intensity physical activity). Nutritional advice: Recommendations for more healthy eating consisting with the 'Food Guide Pyramid'. Other: No
OutcomesHeight (cm), weight (kg), estimates of % fat content e.g.. BMI, ponderal index, skin-fold thickness (BMI), behaviour changes (self-report questionnaire measuring sedentary behaviour), participants views of the intervention (rating intervention components via Likert scale items), physical work capacity, prediction of relative weight.
Notes 
Risk of bias
ItemAuthors' judgementDescription
Allocation concealment?YesOpaque sealed envelopes 
Satoh 2007
MethodsRandom allocation: No description of randomisation process. Blinding: Children: No Providers: No Outcome assessors: Not clear, not specified                                         Length of intervention and follow up: 6 Months Intervention, follow-up 6 months. Unit of allocation: Individual patients Unit of analysis: Individual patients Protection against contamination: Not clear Drop outs: end of intervention 33% [14/43], follow up at 6 months: 33% [14/43]
Participantsn= 43 randomised, 29 completedAge range (mean): 8 to 14 years (intervention group 11.0±1.5, control group 12.4±1.6) % Male: 29 completers: 17 female and 12 male (41.4%) Weight entry criteria: Body weight exceeds 120% of standard body weight (corresponding to the height for age and sex obtained from national statistics for Japanese school children). Weight on entry (mean): intervention group 50±22, control group 49±16 Setting: In general clinical research center of the children's hospital. Geographic Region: Oodate city, Akita Prefecture, Japan.
InterventionsIntervention: Model nutritional balance chart (MNBC) Target of intervention: Child & family Behavioural or psychological component: No Physical activity: No Nutritional advice: Before starting dietary guidance, both the intervention and control subjects and their parents received conventional dietary guidance from nutritionists at the hospitals. Subsequently dietary guidance using MNBC once per month for 6 months. The MNBC is designed to outline a 6697kj intake according to recommendation by the Japan Obesity Society and demonstrates the ideal dietary distribution of 11 categories of food: meat, fish, eggs and milk (including dairy products), beans, green and yellow vegetables, light-coloured vegetables, fruits, grains (including potatoes), oil and sugar. The number of times a food category was consumed was marked with black dots; the foods eaten were recorded by category, but not amount. The MNBC includes food for 3 days. Other: No Usual care/ alternative intervention: control Target of intervention: Child & family Behavioural or psychological component: No Physical activity: No Nutritional advice: Conventional dietary guidance once a month (such as restriction of KJ and nutritional balance of carbohydrates, proteins and fat by nutritionist at hospital). Other: It states the controls received conventional treatment, in contrast it also states they only provided data and did not receive any intervention.
OutcomesHeight, weight (kg), percentage overweight, participants views of the intervention (describe), blood examinations (total cholesterol (mg/dL), triglycerides (mg/dL), LDL-C (mg/dL), HDL-C (mg/dL), serum glucose (mg/dL), serum protein (g/dL), hemoglobin (g/dL)), food intake data.
NotesVarious data was not presented though stated that measurements were taken. Analysis based on completers only. No comparisons between groups are made.
Savoye 2007
MethodsRandom allocation: No description of randomisation process Blinding: Children: No Providers: No Outcome assessors: Unclear Length of intervention and follow up: Intervention: 12 months. Follow-up from commencement of intervention: 12 months Unit of allocation: Child Unit of analysis: Child Protection against contamination: Unclear Drop outs: end of intervention (= 12 months) 43% [90/209], follow up at 6 months: 35% [74/209] 32% One study arm was discontinued (n=35) at six months follow up. (total number of dropouts: n = 55; Intervention: n = 30, Control group: n = 25, discontinued study arm n= 35)
Participantsn= 209 randomised, 119 completed (drop outs n = 55 and discontinued arm n = 35) Age range (mean) 8-16 years % Male: 39% Weight entry criteria: BMI > 95th percentile based on the CDC growth chart Weight on entry (mean): Weight management group: 87.0 (25.1). Control group: 91.2(23.3). BMI: weight management group: 35.8 (7.6), control group: 36.2 (6.2). Setting: Outpatient clinic Geographic Region: Yale, New Haven
InterventionsIntervention: Bright Bodies Weight Management Group - Target of intervention: family - Behavioural or psychological component: The behavior modification component was facilitated by the registered dietitian or social worker. Topics were provided from the Smart Moves Workbook, a curriculum developed for overweight children. Techniques included self-awareness, goal setting, stimulus control, coping skills training, cognitive behavior strategies and contingency management. Behavior classes for caregivers included topics that reflected the challenges parents verbalized. Coping skills training was the primary technique used as it has been used for the treatment of other chronic conditions, including diabetes. The classes emphasised the importance of the parents role in modelling healthy behavior change. - Physical activity: The exercise component of the weight management program was facilitated by exercise physiologists. Each class consisted of a warm-up, high-intensity aerobic exercise, and a cool-down. The main objective of the high-intensity exercise was to sustain 65% to 80% of the age-adjusted maximal heart rate for the duration of the exercise. To ensure this, a heart rate monitor was worn by all participants and Borg's Perceived Exertion Scale was use to monitor exertion. Participants were also encouraged to exercise 3 additional days at home per week and to decrease sedentary behaviours. The minimum activity that each participant completed was 100 minutes per week for the first 6 months and 100 minutes twice per months for the last 6 months.  - Nutrional advice: The nutrition education component of the weight management program used a nondiet approach that emphasized low-fat, nutrient-dense foods of moderate portion sizes. The registered dietitians used the Smart Movies Workbook, which provided consistent structure for all class topics. - Other: No Usual care/ alternative intervention: Control group - Target of intervention: family - Behavioural or psychological component: Brief psychosocial counselling by a social worker - Physical activity: Exercise counselling included decreasing sedentary activities and finding an activity the participant enjoyed enough to engage in regular basis. - Nutrional advice: Nutrition counselling included decreasing intake of juice, switching to diet beverages, switching from whole to low-fat milk, and bringing lunch to school vs choosing hot lunch. - Other: No
OutcomesHeigth, weight, BMI, total body fat (% and kg), SBP, DPB, glucose, insulin, HOMA, total cholesterol, HDL, LDL and triglycerides.
Notes 
Risk of bias
ItemAuthors' judgementDescription
Allocation concealment?UnclearNo description of randomisation process
Schwingshandl 1999
MethodsRandom allocation: No description of randomisation process Blinding: Children: Unclear Providers: Unclear Outcome assessors: Unclear Length of intervention and follow up: 12 week treatment and dietary re-education at 6 and 12 months. Follow up at one year after treatment commencement Unit of allocation: Child Unit of analysis: Child Protection against contamination: Unclear Drop outs: 33% [10/30]
Participantsn= 30 randomised, 20 available for follow up Age range (mean): 6 to 16 years (11.6 years) % Male: 43% Weight entry criteria: Non given Weight on entry (mean): 66.25 kg Setting: Unclear Geographic Region: Austria
InterventionsInterventions: Physical training program and dietary advice vs dietary advice alone Intervention: Physical training program and dietary advice - Target of intervention: child - Behavioural or psychological component: No. - Physical activity: Training sessions took place twice weekly (for 12 weeks) in a public gym , with a duration of approximately 60-70 minutes for each session. After a warm up period on either a stationary bike, treadmill, or rowing ergometer, and a light stretch, each child performed two sets out of the following exercises: lying leg press; seated leg extensions and leg curls; seated bench press; pulldown to the front and long pulley row; seated shoulder press; triceps pushdowns and triceps extensions at the dips machine; dumbbell biceps curls; calf raises seated and crunches. The volume (number of sets performed during training sessions) increased after two weeks, working up to as many as three to four sets for each exercise. Intensity was adapted during the time course of a strength gain. Sets were pyramided: starting with a light set, with each following set using a slightly higher load. Only the last set was performed until muscle failure. If the child was able to perform more than 10 repetitions in the final set, the resistance was increased for the next training session. - Nutrional advice: Both groups participated in the same dietary education programme. General dietary advice was given by group teaching. This included: energy requirements; relation of the different nutrients in a balanced diet; and the importance of fibre, vitamins, minerals and fluids. Energy intake was restricted to 4180 kJ/day in both groups; children older than 14 years were restricted to 5016 kJ/day (girls) and 5852 kJ/day (boys). All participants received written information regarding an energy restricted, balanced diet, and detailed information of the daily allowance of each food component to avoid over consumption. At each visit each participant received dietary re-education on an individual basis. - Other: No. Usual care/ alternative intervention: dietary advice alone - Target of intervention: child - Behavioural or psychological component: No. - Physical activity: No. - Nutrional advice: Both groups participated in the same dietary education programme. General dietary advice was given by group teaching. This included: energy requirements; relation of the different nutrients in a balanced diet; and the importance of fibre, vitamins, minerals and fluids. Energy intake was restricted to 4180 kJ/day in both groups; children older than 14 years were restricted to 5016 kJ/day (girls) and 5852 kJ/day (boys). All participants received written information regarding an energy restricted, balanced diet, and detailed information of the daily allowance of each food component to avoid over consumption. At each visit each participant received dietary re-education on an individual basis. - Other: No.
OutcomesWeight status: Weight (kg) and BMI-SDS (Mean standard score for BMI) presented at baseline, 4, 8 and 12 weeks. No outcome data presented. Others: fat free mass (kg).
Notes 
Risk of bias
ItemAuthors' judgementDescription
Allocation concealment?UnclearNo description of randomisation process
Senediak 1985
MethodsRandom allocation: No description of randomisation process Blinding: Children: Yes Providers: Yes Outcome assessors: Unclear Length of intervention and follow up: 4 weeks (15 weeks for gradual behavioural group) and 21 week follow up (10 weeks for gradual behavioural group) Unit of allocation: Children Unit of analysis: Children Protection against contamination: Unclear Drop outs: 31% [11/35 = 4/12 rapid group, 3/12 gradual group and 4/11 non specific control]
Participantsn= 45 randomised, 10 excluded from 26 week follow up (waiting list control) 25 completed. Age range (mean): 72 to 150 months (123.61 months) % Male: Approximately 66% Weight entry criteria: >20% overweight for height, age and sex Weight on entry (mean): 37.22% Setting: No details given Geographic Region: Australia
InterventionsInterventions: Four conditions: rapid behavioural group (1) vs gradual behavioural procedure (2) vs non-specific control condition (3) vs a waiting list control group (4) Intervention: Rapid behavioural group (1) - Target of intervention: child and parent - Behavioural or psychological component: Group basis, with 5 or 6 parent-child pairs attending each session. 2 therapists, a qualified clinical psychologist and a masters student in clinical psychology. Lifestyle changes such as minimising the use of energy-saving devices (e.g.. walking instead of riding in the car) Subjects recorded caloric intake and exercise activity each day during the treatment phase, with parents and children being encouraged to complete this task jointly when possible to increase the accuracy of self-monitoring. Behavioural contracting was used between parents and children with targets relating to improvement in eating and exercise habits as well as weight loss. Parents were instructed to serve as appropriate models for their children regarding eating and exercise activities and to use praise to reinforce desirable behaviour. Children were taught to use self-reinforcement skills for achievement of eating and exercise targets. Stimulus control techniques (Stuart and Davis) were encouraged, and attempts were made to modify negative cognitions which may contribute to obesity. Children were trained to engage in 'counter statements' in response to maladaptive thoughts relating to overeating or failure to exercise. The rapid behavioural group had 8 sessions conducted twice weekly for four weeks, 90 minutes duration. - Physical activity: Aerobic exercise as outlined by Epstein and Wing (1980), subjects were instructed to engage in at least four, 30 min aerobic exercise sessions per week. Basic conditioning exercises were introduced to prepare subjects for the more strenuous aerobic exercises (Gatchell). - Nutrional advice: Diet based on the food exchange system (Langeluddecke) and the traffic light system (Epstein).  - Other: Parents were required to deposit $30 at the beginning of the programme with $3 being returned at each of the sessions and follow up contacts, contingent upon attendance and completion of homework assignments.  Intervention: Gradual behavioural procedure (2) - Target of intervention: child and parent - Behavioural or psychological component: Group basis, with 5 or 6 parent-child pairs attending each session. 2 therapists, a qualified clinical psychologist and a masters student in clinical psychology. Lifestyle changes such as minimising the use of energy-saving devices (e.g.. walking instead of riding in the car) Subjects recorded caloric intake and exercise activity each day during the treatment phase, with parents and children being encouraged to complete this task jointly when possible to increase the accuracy of self-monitoring. Behavioural contracting was used between parents and children with targets relating to improvement in eating and exercise habits as well as weight loss. Parents were instructed to serve as appropriate models for their children regarding eating and exercise activities and to use praise to reinforce desirable behaviour. Children were taught to use self-reinforcement skills for achievement of eating and exercise targets. Stimulus control techniques (Stuart and Davis) were encouraged, and attempts were made to modify negative cognitions which may contribute to obesity. Children were trained to engage in 'counter statements' in response to maladaptive thoughts relating to overeating or failure to exercise. For the gradual behavioural group, the 8 sessions were spaced so as to gradually fade out therapist contact, with increasingly extended intervals between meetings, over a 15 week period.  Sessions 1 to 4 occurred weekly, sessions 5 and 6 fortnightly and sessions 7 and 8 occurring after a three week interval. This group received only one follow up assessment, occurring 11 weeks after termination (week 26) which corresponded with the 21 week follow-up for the rapid group and non-specific control condition. - Physical activity: As above. - Nutrional advice: As above. - Other: As above. Usual care/ alternative intervention: Non-specific control condition (3) - Target of intervention: child and parent - Behavioural or psychological component: The non-specific control group (3) were scheduled in the same manner as (1) i.e.. twice a week over four weeks. Same therapists were involved. Content of sessions involved a social support procedure which encouraged parents and children to discuss matters related to weight control amongst themselves, with the therapist facilitating discussion in a non-directive manner. Participants were also trained in progressive relaxation techniques (Bernstein and Borkovec), mood monitoring and will-power training (Jeffrey and Christensen). - Physical activity: No. - Nutrional advice: No. - Other: A monetary deposit was also required, contingent on attendance and completion of homework tasks.  At the final follow-up assessment, participants were provided with dietary and exercise information for use by those who had not lost weight. Usual care/ alternative intervention: Waiting list control group (4) - Target of intervention: child - Overall: Subjects in the waiting list control group were informed that,  because of their overwhelming response to the programme, there would be a delay in the commencement of therapy. Assessments were carried out at weeks 1 and 4, before and after onset of (1). No contact was made between these occasions. For ethical reasons, the waiting list period was not extended beyond a 4 week interval. Members of the waiting list group received a behavioural programme after week 4 but ceased to form part of the present study.
OutcomesWeight Status: Weight and % overweight presented at 1, 4, 15 and 26 weeks. % overweight based on the average weight for children of the same sex, age and height (Jones et al 1973) Others: subscapular skinfold thickness, % normel subscapular skinfold thickness, caloric intake and activity output.
NotesWait list control were only followed up for 4 weeks, thereafter they received a behavioural program and ceased to take part in the study.
Risk of bias
ItemAuthors' judgementDescription
Allocation concealment?UnclearNo description of randomisation process
Wadden 1990
MethodsRandom allocation: Method not described Blinding: Children: Unclear Providers: Unclear Outcome assessors: Unclear Length of intervention and follow up: 16 weeks treatment plus 6 monthly follow up meetings in which participants were weighed and attended group sessions. Final follow up at 10 months from commencement of intervention. Unit of allocation: Child Unit of analysis: Child Protection against contamination: Unclear Drop outs: 23% [11/47] at end of intervention and 40% [19/47] at 10 months follow up.
Participantsn= 47 randomised, 36 completed treatment and 28 completed the follow up Age range (mean): 12 to 16 years (13.8y) % Male: All female Weight entry criteria: > 10kg overweight for age, sex and height Weight on entry (mean): 95.1kg Setting: Unclear Geographic Region: US
InterventionsInterventions: Parent-involved behavioural program: girls alone without mothers present (1) vs mothers and daughters together (2) vs daughters alone with mothers attending a concurrent, separate group meeting(3). Intervention: Girls alone without mothers present (1) - Target of intervention: child - Behavioural or psychological component: Treatment was delivered in groups of 8 to 10 persons; sessions were held on Wednesdays after school and Saturdays. All subjects received the same treatment with the exception of parental involvement. Weekly 1hr sessions followed treatment principles described in the manual for the Weight Reduction and Pride program, a 16 week program developed specifically for these children. All subjects received a copy of the 100 page manual, which instructed them in the subcomponents below. Each weekly lesson from the manual was accompanied by a homework assignment and quiz, which were reviewed in the following week's session. Subjects were weighed at the monthly follow-up visits and invited to discuss during their group meetings any difficulties or successes related to weight control. In addition, therapists briefly reviewed pertinent materials from previous treatment sessions. Limiting times and places of eating; slowing their rate of eating; modifying self-defeating thoughts concerning weight and food. Children were rewarded with stars for completing the assignments; stars could be exchanged on a monthly basis for small prizes or saved toward a big prize to be awarded at the end of the program.  (1) Girls alone: girls in this condition attended all sessions alone and received the treatment program described above. They were encouraged to discuss the treatment materials with their parents, who did not otherwise participate in the program. - Physical activity: Increasing physical activity by walking and other lifestyle behaviours.  - Nutrional advice: Measuring foods and beverages; recording their food and calorie intake; consuming low-fat well-balanced meals of 4200 to 6300kJ (1000-1500kcal)daily; understanding macronutrients, vitamins and minerals; limiting their consumption of high-calorie snacks and fast-foods.   - Other: In addition, subjects received $1 for each treatment session they attended and 50 cents for each half pound they lost. The $35 deposit was used to pay these costs. Usual care/ alternative intervention: Mothers and daughters together (2) - Target of intervention: child and parent - Behavioural or psychological component: As above. (2) Mothers and daughters together: Children and mothers attended all sessions together (with four or five children and mothers per group).  They were told that this was a useful approach that would teach mothers to understand their daughters's weight problem and help them with it. Mothers were given weekly reading materials and homework assignments, which included modelling appropriate eating and exercise habits, praising their daughters homework assignments with them (if asked), preparing low-calorie snacks, and limiting their purchases of high calorie beverages and snacks. This was summarised in a 16 week mothers manual. Mothers were given the option of losing weight and weighing-in each week. - Physical activity: Increasing physical activity by walking and other lifestyle behaviours. - Nutrional advice: Measuring foods and beverages; recording their food and calorie intake; consuming low-fat well-balanced meals of 4200 to 6300kJ (1000-1500kcal)daily; understanding macronutrients, vitamins and minerals; limiting their consumption of high-calorie snacks and fast-foods. - Other: As above. Usual care/ alternative intervention: Daughters alone with mothers attending a concurrent, separate group meeting(3) - Target of intervention: child and parent - Behavioural or psychological component: As above. (3) Daughters alone with mothers attending a concurrent, separate group meeting: The mothers and children met concurrently in separate groups. They were told that separate meetings would allow both parties to freely express their thoughts and feelings. Children and mothers received th treatment manuals previously described, and group sessions were structured accordingly. The mother's meeting was for social support and discussion of daughter's eating and exercise habits. - Physical activity: Increasing physical activity by walking and other lifestyle behaviours. - Nutrional advice: Measuring foods and beverages; recording their food and calorie intake; consuming low-fat well-balanced meals of 4200 to 6300kJ (1000-1500kcal) daily; understanding macronutrients, vitamins and minerals; limiting their consumption of high-calorie snacks and fast-foods. - Other: As above.
OutcomesWeight status: Weight (kg) and BMI presented at 0, 1, 2, 3 and 4 months and outcome weight presented at 6 months. Others: % fat, fat free mass, self esteem, cholesterol and blood pressure, and depression.
Notes 
Risk of bias
ItemAuthors' judgementDescription
Allocation concealment?UnclearNo description of randomisation process
Warschburger 2001
MethodsRandom allocation: No description of randomisation process Blinding: Children: Unclear Providers: Unclear Outcome assessors: Unclear Length of intervention and follow up: 6 weeks treatment, 6 and 12 months follow up Unit of allocation: Child Unit of analysis: Child Protection against contamination: Unclear Drop outs: No details given
Participantsn=197 (121/197 experimental group, 76/197 comparison group) Age range (mean): 9 to 19 years (13.8 years SD 1.1) in experimental group, (13.1, SD 1.1) in the control group) % Male: No details Weight entry criteria: >20% overweight for height Weight on entry (mean): % overweight experimental group 63.8+/- 25.4, control group 64.6 +/- 23.7 Setting: rehabilitation hospital Geographic Region: Germany
InterventionsInterventions: Six week in-patient rehabilitation + cognitive-behavioural treatment program vs six week in-patient rehabilitation + muscle relaxation training Intervention: Six week in-patient rehabilitation + cognitive-behavioural treatment program - Target of intervention: child - Behavioural or psychological component: The programme included specific skills to facilitate behaviour change and also behaviour management skills to encourage habit change. Self-monitoring, contract-managment, stimulus-control, modelling, eating-managment and reinforcement principles were used. OVer 6 sessions the children and adolescents learned to understand why they had become overweight and what they could do to lose weight and feel better. In groups with around 8-10 children of the same sex and age they talked about psychosocial problems associated with obesity and how to change their eating and activity habits. The primary goal was to increase their self-managment skills in order to handle the different requirements. Children and adolescents were given written material (completed by the participants) and were asked to inform their parents at home about the main aspects of the training programme (e.g. what to eat, how to do sports). - Physical activity: Both groups stayed for 6 weeks in a rehabilitation hospital. They received a calorie-reduced diet and took part in an exercise programme. - Nutrional advice: Both groups stayed for 6 weeks in a rehabilitation hospital. They received a calorie-reduced diet and took part in an exercise programme. - Other: No. Usual care/ alternative intervention: Six week in-patient rehabilitation + muscle relaxation training - Target of intervention: child - Behavioural or psychological component: Muscle relaxation training. - Physical activity: Both groups stayed for 6 weeks in a rehabilitation hospital. They received a calorie-reduced diet and took part in an exercise programme. - Nutrional advice: Both groups stayed for 6 weeks in a rehabilitation hospital. They received a calorie-reduced diet and took part in an exercise programme. - Other: No.
OutcomesWeight status: % overweight and BMI presented at pre-treatment, post-treatment and 6 and 12 months follow-up. Others: Obesity-specific self-efficacy scale, quality of life questionnaire and an eating behaviour scale.
Notes 
Risk of bias
ItemAuthors' judgementDescription
Allocation concealment?UnclearNo description of randomisation process
Weintraub 2008
MethodsRandom allocation: After completing baseline assessments, children were randomised 'using a computer by the database manager'. Blinding: Children: No                                     Providers: It is not possible to blind carers or children to this type of group allocation Outcome assessors: No. Owing to limited staffing for this pilot study, data collectors were not blinded at follow up assessment. Length of intervention and follow up: 6 months intervention. Follow-up 6 months. Unit of allocation: Individual child Unit of analysis: Individual child Protection against contamination: Not clear Drop outs: zero dropouts reported
Participantsn= 21 randomised, 21 completedAge range (mean): intervention group 9.50±0.58 years, control group 10.34±0.84 years % Male: Gender distribution not given. Weight entry criteria: BMI >85th centile for age (USCDC 2000 growth reference). Weight on entry (mean): intervention group BMI 27.17±4.96 , control group 29.01±4.77. Setting: Schools Geographic Region: A low-income community in northern California, USA.
InterventionsIntervention: Randomised controlled trial of a six-month school-based soccer program. Target of intervention: Child Behavioural or psychological component: There was an emphasis on respect for self and others, inclusion and teamwork. At the conclusion of the program, children received certificates of accomplishment and medals. Physical activity: Soccer program, initially offered 3 days per week, and then increased to 4 days per week during month 5 of the 6 month intervention. One day per week was game day, with the other days being practice days.  Sessions were approximately 2¼ hours long and started with a homework period followed by ˜75 minutes of activity. The activity period began with a supportive team-building check-in followed by 15 minutes of warm-up and stretching. The remainder of the practice session was devoted to learning soccer skills (fun skill-building exercises, concluding with a scrimmage). There was an emphasis on respect for self and others, inclusion and teamwork. Shin guards, uniforms and water bottles given to each player. Matches were held quarterly. At the conclusion of the program, children received certificates of accomplishment and medals. Nutritional advice: No Other: Shin guards, uniforms and water bottles were given to each player. Usual care/ alternative intervention: Six-month health and education intervention. Target of intervention: Child Behavioural or psychological component: As above. In the 'active placebo' control intervention, children received a 25 session, state-of-the-art, information-based nutrition and health education intervention consisting of weekly after-school meetings conducted by trained volunteer undergraduate and medical students. Program content included materials and activities promoting healthful nutrition and physical activity produced by federal health agencies and national nongovernmental health organisation. Physical activity: No. Nutritional advice: See behavioural component. Other: No
OutcomesHeight (cm), weight (kg), estimates of % fat content e.g. BMI, ponderal index, skin-fold thickness (mean±SD), BMI (kg/m2), BMI z-score, behaviour changes (10-item Children's Depression Inventory, overconcerns with Weight sub-scale of the McKnight Risk Factor Survey , 10-item Rosenberg Self-esteem Scale), participants views of the intervention, measures of harm (parent reports of adverse events), total activity, 7am-10pm (counts/min), moderate physical activity, 7am-10pm, 3000-5200 counts/min (minutes), vigorous physical activity, 7am-10pm, >5200 counts/min (minutes), television and other screen time (hours per week).
Notes 
Risk of bias
ItemAuthors' judgementDescription
Allocation concealment?YesAfter completing baseline assessments, children were randomised 'using a computer by the database manager'.
Weyhreter 2003
MethodsRandom allocation: No description of randomisation process Blinding: Children: No Providers: No Outcome assessors: No Length of intervention and follow up: Intervention: 6 months. Follow-up from commencement of intervention: 28.76 (10.49) months from end of intervention (35 months after commencement of intervention. Unit of allocation: Child Unit of analysis: Child and parent Protection against contamination: Done. Participants in the two treatment arms never met together and there was very little opportunity for contamination across the treatment arms. Drop outs: 37% (total: n = 26)
Participantsn= 70 randomised, 44 completedAge range (mean) 2-16 years (10.3 years, SD 3.3) % Male: 0% Weight entry criteria: BMI at or exceeding the 97th percentile for age and gender Weight on entry (mean): BMI-SDS 4.78 + 1.16 for the whole group of children Setting: clinic-based Geographic Region: Germany
InterventionsInterventions: 3 different behavioral treatments Intervention: Behavioral treatment, with parent meeting and cooking classes - Target of intervention: family - Behavioural or psychological component: Behaviourally oriented strategies. One parent evening education meeting (C). - Physical activity: physical activity advice based on diaries kept by children (supervised by parents) - Nutrional advice: nutritional advice based on diaries kept by children (supervised by parents). Cooking classes for parents and children. - Other: No. Usual care/ alternative intervention: Behavioral treatment, with parent meeting (B) - Target of intervention: family - Behavioural or psychological component: As above. - Physical activity: As above. - Nutrional advice: As above, but no cooking classes. - Other: No Usual care/ alternative intervention: Standard behavioral treatment (A) - Target of intervention: family - Behavioural or psychological component: As above. - Physical activity: As above. - Nutrional advice: As above, but no cooking classes. - Other: No
Outcomes 
NotesFollow up self reported height and weight data over telephone.
Risk of bias
ItemAuthors' judgementDescription
Allocation concealment?UnclearNo description of randomisation process
Williamson 2005
MethodsRandom allocation: Participants were randomly assigned to the treatment arms using a stratified randomisation strategy based on BMI percentile and age. Blinding: Children: No Providers: No Outcome assessors: No Length of intervention and follow up: Intervention: 24 months. Follow-up from commencement of intervention: 24 months Unit of allocation: Child Unit of analysis: Child and parent Protection against contamination: Done. Participants in the two treatment arms never met together and there was very little opportunity for contamination across the treatment arms. Drop outs: 30% (total: n = 17; Intervention: n = 10, Control group: n = 7)
Participantsn= 61 randomised, 40 completedAge range (mean) 11-15 years (13.2 years, SD 1.4) % Male: 0% Weight entry criteria: BMI at or exceeding the 85th percentile for age and gender Weight on entry (mean): 93.3 (22.5) kg, BMI 36.4 (7.9) Setting: Community Geographic Region: Baton Rouge, LA, Unites States of America
InterventionsIntervention: Interactive behaviour therapy - Target of intervention: family- Behavioural or psychological component: The website provided nutrition education and behavior modification for adults and adolescents using a family-oriented format, i.e., a program that invited the parents, the child, and other members of the family to be involved using mutual problem solving and behavioral contracting. Counseling for behavior modification was accomplished primarily via asynchronous email communications. The behavioral condition incorporated behavior modification techniques and heavy emphasis on email communication with as case manager who had at least graduate level clinic psychology training specializing in weight management. Specific weekly topics in the behavioral condition included self-monitoring, goal setting for eating and physical activity, problem solving, behavioral contracting, and relapse prevention. - Physical activity: Participants were encouraged to engage in regular physical activity. In the behavioural group, participants established physical activity goals that were incorporated into behavioural contracts. - Nutrional advice: Participants were instructed to complete daily food records and submit them using an automated form housed on the Web site. Food records were submitted to the project dietitian, who recorded them for accuracy and compliance with the recommended calorie levels. In addition automated feedback was provided such that after submission of the forms, a computer program embedded in the form generated an image of the Food Guide Pyramid and indicated the extent to which the food record complied with the recommended nutritional values. - Other: The adolescent participant and her overweight parent (in both treatment conditions) were scheduled to attend four face-to-face counselling sessions during the first 12 weeks of the program, at weeks 1, 3, 6, and 12. Participants in both arms were reinforced (with small gifts) for attendance at face-to-face therapy sessions. For the behavioural group these 4 sessions focused on: 1. introduction to food monitoring and goal setting for nutrient intake 2. introduction to monitoring of exercise and goal setting to yield a minimum of 150 minutes of exercise per week by week 20; 3. introduction to Behavioural Contracting with a goal of modelling appropriate strategies for behavioural contracting; and 4. review of progress and problem-solving to address poor adherence. Usual care/ alternative intervention: Passive health education - Target of intervention: family- Behavioural or psychological component: No. Participants in the control group received nutrition education from a registered dietitian, but were not prescribed behavioural tasks to yield weight loss. - Physical activity: The control condition was primarily educational in nature and provided basic information about nutrition and physical activity. Participants were encouraged to engage in regular physical activity. - Nutrional advice: Participants in the control group were provided health education in a coordinated program between face-to-face sessions and links to a variety of websites promoting healthy lifestyle. The control website did not provide explicit prescriptions for behaviour change, behavioural contracts, or opportunities for self-monitoring. The control condition was primarily educational in nature and provided basic information about nutrition and physical activity. Participants in the control condition logged in to a separate Web site and were managed by registered dietitian. In the control condition, topics include lessons pertaining to serving sizes, the food guide pyramid, hidden calories and understanding food labels. - Other: As above.
OutcomesHeigth, weight, BMI, % body fat, Weight Loss Behavior Scale, Measure of exercise confidence, total daily energy intake, fat intake, protein intake and carbohydrate intake (all measured in adolescents en parents)
Notes 
Risk of bias
ItemAuthors' judgementDescription
Allocation concealment?UnclearNo description of randomisation process
Woo 2004
MethodsRandom allocation: No description of randomisation process Blinding: Children: No Providers: Yes. Both groups (children and parents) participated in the same diet education program and were interviewed by the same dietitian, who was blinded to the exercise program allocation. Outcome assessors: Unclear Length of intervention and follow up: Intervention: 6 weeks and subsequently 1 year. Follow-up: 1 year Unit of allocation: Child Unit of analysis: Child Protection against contamination: Unclear Drop outs: Not reported
Participantsn= 82 randomised, 82 completed (n = 41 diet + exercise and n =41 diet for 6 weeks. Thereafter: n = 22 continued exercise + diet; n = 41 diet, and n = 19 diet + detraining) Age range (mean) 9-12 years % Male: 66% Weight entry criteria: BMI ≅ 21 Weight on entry (mean): Diet only: 50.3 (8.5). Diet + exercise: 54.6 (9.5). BMI: Diet only: mean (SD) 24.5 (2.9), Diet + exercise: mean (SD) 25.4 (3.1) Setting: Outpatient clinic Geographic Region: probably Hong Kong, China
InterventionsIntervention: Diet + exercise - Target of intervention: child and parent - Behavioural or psychological component: No - Physical activity: A fitness assessment test was carried out before commencement of the program. Each child's exercise ability was measured, and customized training was prescribed by trained physiotherapists. The exercise sessions were all carried out in the hospital and supervised by the same physiotherapist team and were of circuit style, with a preset sequence of 18 workout stations; each child had to go through 9 stations in each sessions, twice a week for 6 weeks and then once weekly for 1 year (for a subgroup). Aerobic exercise including dance was incorporated into the training. Each training sessions lasted 75 minutes, including 10 minutes of warm up, 30 minutes of resistance training, 10 minutes of aerobic exercise, 10 minutes of agility training, 5 minutes of cool-down, and short rest-periods between stations. All children maintained an exercise intensity at 60 to 70% of predicted maximum heart rate during the aerobic exercise. - Nutrional advice: Both groups (children and parents) participated in the same diet education program and were interviewed by the same dietitian, who was blinded to the exercise program allocation, 2 weekly for the first 6 weeks and 2 monthly subsequently. The diet prescribed was a balanced hypocaloric diet that provided 900 to 1200 kcal daily. The menu varied according to the child's age and eating habits. It was low in fat (20-25%), high in complex carbohydrate (50-60%) , and sufficient in protein (25-30%) to support growth. A 3-day dietary recording was done by the children with the help of their parents at baseline and before each scheduled follow-up. - Other: No Usual care/ alternative intervention: Diet only - Target of intervention: child and parent - Behavioural or psychological component: No - Physical activity: No - Nutrional advice: As above. - Other: No
OutcomesHeight, weight, BMI, waist-to-hip ratio, body fat %, fat free mass (kg), total cholesterol, triglycerides, HDL, LDL, LDL/HDL ratio, glucose, arterial reactivity and IMT.
Notes 
Risk of bias
ItemAuthors' judgementDescription
Allocation concealment?UnclearNo description of randomisation process
Freemark 2001
MethodsRandom allocation: Computer-generated randomisation tables. Blinding: Children: Yes.                        Providers: yes Outcome assessors: Yes. States that both the subject and research staff were blinded to the intervention.      Length of intervention and follow up: Intervention 6 months, follow-up 6 months. Unit of allocation: Individual adolescent Unit of analysis: Individual adolescent Protection against contamination: Done. Drop outs: 9% [3/32] (intervention group 1, control group 2) end of intervention and 6 months follow up.
Participantsn= 32 randomised, 29 completedAge range (mean): 12 to 19 years (intervention group 14.4±0.6, control group 15.4±0.5) % Male: 37.93% Weight entry criteria: BMI >30 kg/m2Weight on entry (mean): BMI: intervention group BMI 41.5±0.9 , control group 38.7±1.3 (P<0.05). Setting: Both inpatient and outpatient clinic of a (University School of Medicine) Geographic Region: Durham, North Carolina, USA
InterventionsIntervention: Metformin Target of intervention: Child Behavioural or psychological component: No Physical activity: No Nutritional advice: No Medication: Describe: Patients were randomised to either metformin 500 mg twice a day or 6 months, or placebo twice a day for 6 months. Other: No Usual care/ alternative intervention: Placebo Target of intervention: Child Behavioural or psychological component: No Physical activity: No Nutritional advice: No Medication: Yes, as above. Other: No
OutcomesHeight, weight, estimates of % fat content e.g.. BMI, ponderal index, skin-fold thickness (kg/m 2 ), BMI SD score (means ±SE given), measures of harm (metformin toxicity assessed by clinical review each month for 6 months, fasting blood tests at baseline and monthly for 6 months (liver and renal function tests), lactate, rapidly sampled intravenous glucose tolerance test, liver function tests.
NotesLifestyle intervention was not included. This is one of the first RCTs to suggest a role for metformin in this group of insulin resistant severely obese adolescents.
Srinivasan 2006
MethodsRandom allocation: Telephone numbered, opaque sealed envelopes. Computer-generated random number allocation, with both caregivers and investigators blinded to allocation. Blinding: Children: Yes   Providers: Yes  Outcome assessors: Yes (not for scoring of acanthosis nigricans) Length of intervention and follow up: 6 months each for metformin and placebo, in a randomised crossover design, with a 2 week washout period in between. Follow-up 12 months from commencing either metformin or placebo (although active or placebo therapy only given for 6 months each). Unit of allocation: Individual child Unit of analysis: Individual child Protection against contamination: Done. Drop outs: concerning BMI data 23% [1/13] group A (Metformin first), 20% [3/15] group B (Placebo first)
Participantsn= 28 randomised, 24 completedAge range (mean): 9 to 18 years (12.5±2.2) % Male: 46.43% Weight entry criteria: Obesity (as defined by the International Obesity Taskforce criteria). Weight on entry (mean): 89.9±17.6 kg Setting: Outpatient clinic of a tertiary paediatric hospital (University teaching hospital) Geographic Region: Sydney, Australia
InterventionsInterventions: Metformin or placebo + "standardised information on healthy eating and exercise" Intervention: Metformin first - Target of intervention: Child - Behavioural or psychological component: No - Physical activity: All patients received "standardised information" on exercise - Nutritional advice: All patients received "standardised information" on diet - Medication: Metformin or placebo for 6 months each, in a cross-over design, with a 2 week washout period in between. Both metformin and placebo doses were built up over 3 weeks to 1 g twice daily. - Other: No Usual care/ alternative intervention: Placebo first - Target of intervention: Child - Behavioural or psychological component: No. - Physical activity: As above. - Nutritional advice: As above. - Medication: Metformin and placebo for 6 months each, in a cross-over design, with a 2 week washout period in between. Both metformin and placebo doses were built up over 3 weeks to 1 g twice daily. Other: No
OutcomesHeight (cm, z-score), weight (kg, z-score), BMI and BMIz-score (CDC2000 growth reference), measures of harm (several different units of measurement), fasting insulin and glucose and parameters derived form the frequently sampled intravenous glucose tolerance test (IVGTT) (insulin (mU/L), glucose (mmol/L), insulin sensitivity ([mU/L]-1.min-1), glucose effectiveness (min-1), acute insulin response (mU/L-1.min), disposition index, glucose disposal), measures derived from magnetic resonance imaging (subcutaneous abdominal adipose tissue (cm2), visceral abdominal adipose tissue (cm2), body composition (percentage body fat).
NotesPatients received “standardised information on diet and exercise” but otherwise did not have a detailed lifestyle intervention.
Chanoine 2005
MethodsRandom allocation: Participants were randomised at a 2 to 1 ratio to receive Orlisat or placebo. Patients were randomised centrally according to a computer generated randomisation schedule prepared by the study's sponsor, with stratification of body weight (<80kg or > 80kg) on day 1 and by weight loss during the lead-in period <1 kg or > 1 kg). The allocation process was triple-blind; the allotted treatment group was obtained through an automated telephone system. Blinding: Children: Yes Providers: Yes. First 2 weeks: single blind, placebo lead-in period. Next 52 weeks: double blind treatment period. Outcome assessors: Yes Length of intervention and follow up: 54 weeks (August 2000- October 2002), 2 week single blind, placebo lead-in period, 52 week double blind treatment period, follow up 52 weeks. Unit of allocation: Individual adolescents Unit of analysis: Individual adolescents Protection against contamination: Done. Drop outs: 35% [190/539] (intervention group: 125, control group: 65)
Participantsn= 539 randomised, 349 completedAge range (mean): 12-16 years (intervention group 13.6 + 1.3, control group 13.5 + 1.2) % Male: 33% Weight entry criteria: BMI 2 units or higher than US weighted mean for the 95th percentile based on age and sex (this was requested by the USFood and Drug Administration to ensure that only patients with the greatest potential for benefiting from the study were included) Weight on entry (mean): intervention group: 13.6 + 1.3, control group: 13.5 + 1.2 Setting: Clinical, 32 centres, institutions with established obesity treatment programs and clinical research expertise Geographic Region: US and Canada
InterventionsInterventions: Orlistat + diet + exercise + behaviour therapy vs Placebo + diet + exercise + behaviour therapy Intervention: Orlistat + diet + exercise + behaviour Target of intervention: Child. It is unclear as to what extent parents were involved in supporting the intervention. Although it is one of the inclusion criteria that subjects had to have a parent or guardian prepared to attend study visits with them. Behavioural or psychological component: All study centres had behavioral modification programs in place, but used a study-specific manual as a guideline. Programs generally involved recording food intake and activity; limiting high-calorie and high-fat foods in the household; restricting food intake to the dining area at meal times; eating slowly; avoiding snacking; encouraging participants to understand their cues for overeating; and substituting new behaviours for overeating. Staff at the study centres were to support and reinforce behavioral modification techniques regularly. Physical activity: Guidelines were provided to encourage regular physical activity and reduce sedentary behavior. Strength, flexibility, and aerobic activities were included as part of the exercise plan wherever possible. A behavioral psychologist spoke with patients about compliance with the exercise program at each study visit. Nutritional advice: Participants were maintained on a nutritionally balanced, hypocaloric diet designed to produce an initial weight loss of 0.5 to 1.0kg per week. The caloric distribution of the diet was 30%as fat (10% saturated, 10% monounsaturated, and 10% polyunsaturated;  <70 g/d maximum), 50% as carbohydrate, and 20% as protein. Maximum intakes of cholesterol and calcium were 300 mg/d and 1300 mg/d, respectively. The caloric intake prescribed in this study was calculated to provide a reduction in estimated caloric requirements of approximately 40%. Caloric requirements were determined by sex and baseline body weight, using estimates of total energy requirements based on the World Health Organization's equations for basal metabolic rate and corrected for ... activity. Assigned caloric intake ranged from 1400 kcal/d (body weight <70 kg) to 1800 kcal/d (bodyweight >100kg) in boys and from 1200 to 1600 kcal/d in girls. The daily caloric intake was adjusted during the double-blind treatment period if the participant reached a BMI of 22 or if the participant was losing weight too rapidly (> 1 kg per week). At each study visit, the dietician spoke with the patient about compliance with diet. Medication: 120 mg of orlistat 3 times daily. Placebo and orlistat capsules looked identical and, except for the active ingredient, had exactly the same composition. Participants in both treatment groups received a commercially available daily multivitamin supplement (Centrum Kids Extra Calcium; Wyeth Consumer Healthcare, Madison, NJ) throughout the active period of the study. Other: No Usual care/ alternative intervention: Placebo + diet + exercise + behaviour therapy Target of intervention: As above. Behavioural or psychological component: As above. Physical activity: As above. Nutritional advice: As above. Medication: As above, but 120 mg of placebo medication 3 times daily. Other: No
OutcomesHeight (cm), weight (kg), Estimates of % fat content e.g. BMI, ponderal index, skin-fold thickness (BMI: kg/m2, BMC: g, BMD: g/cm2, fat-free body mass (FFM): g, fat mass (FM): g), waist (cm), hip circumference (cm), secondary efficacy end-points: clinical laboratory test (total cholesterol; HDL; LDL; HDL to LDL ratio;triglycerides; glucose (mg/dL); insulin ( µIU/ml)), vital signs (include blood pressure) (mm Hg), drug compliance rates, drug safety parameters, cardiac function, gall bladder and renal structure, tanner stage (graded 1 to 5), sex hormone levels (Estradiol (pg/mL), free testosterone,  sex hormone-binding globulin), vitamin levels (A, D, E and beta carotine).
NotesThis study was funded by F. Hoffmann-La Roche LTD. An independent statistical review of the raw data was conducted by Department of Statistics at the British Columbia Children's Hospital. Baseline and change data for diet, exercise and behaviour measures were not reported. This paper presents a thorough report of the safety outcomes of using orlistat in an adolescent population (majority female). It is not completely clear how often (possibly each visit) or how much time was allocated to the various lifestyle interventions. It is unclear as to what extent parents were involved in supporting the intervention.
Risk of bias
ItemAuthors' judgementDescription
Allocation concealment?YesThe allocation process was triple-blind; the allotted treatment group was obtained through an automated telephone system.
Maahs 2006
MethodsRandom allocation: Telephone numbered, opaque sealed envelopes. The GCRC statistician generated the randomisation sequence before the start of the study. The list of randomisation assignments was sealed and sent to the study pharmacist, who had contact with the study subjects. Two sets of subjects (a sister-sister pair and a girlfriend-boyfriend pair) were assigned to the same cohort, as determined by the order of entry of the first member of the pair; the next paired subject was blocked into the same cohort and given the next available number in the cohort. Blinding: Children: Yes. Study subjects, parents, and all study personnel were blinded to treatment condition. Only the research pharmacist was aware of treatment status. In addition, orlistat was placed within an opaque sealed capsule identical to the capsule used for placebo, which was filled with an inert substance. Providers: Yes. Study subjects, parents, and all study personnel were blinded to treatment condition. Only the research pharmacist was aware of treatment status. Outcome assessors: Yes Length of intervention and follow up: 26 weeks (all subjects were recruited between Dec 2002 and Feb 2003 and completed the trial by Sept 2003). Monthly visits to the outpatient clinic involved BMI assessment, dietary and exercise counselling, pill counting, and screening for adverse events. At the 3 and 6-month visits, a fasting blood sample was obtained for determination of the same variables at baseline, and BIA was repeated. Follow-up 26 weeks. Unit of allocation: Individual adolescents, although two sets of subjects (a sister-sister pair and a girlfriend-boyfriend pair) were assigned to the same cohort, as determined by the order of entry of the first member of the pair; the next paired subject was blocked into the same cohort and given the next available number in the cohort. Unit of analysis: Individual adolescents, although two sets of subjects (a sister-sister pair and a girlfriend-boyfriend pair) were assigned to the same cohort, as determined by the order of entry of the first member of the pair; the next paired subject was blocked into the same cohort and given the next available number in the cohort. Protection against contamination: Done. Drop outs: 15% [6/40] (intervention group 4, control group 2)
Participantsn= 40 randomised, 34 completedAge range (mean): 14 to 18 years (intervention group 15.8 + 1.5, control group 15.8 + 1.4) % Male: 32.5% Weight entry criteria: BMI > 85th percentile for age and sex Weight on entry (mean): intervention group 111.1 + 22.9 kg, control group 114.3 + 38.4 kg Setting: Overnight inpatient stay for baseline measures, followed by monthly visits to the outpatient clinic for 6 months. The study was conducted in the General Clinical Research Center at the University of New Mexico Hospital. Geographic Region: Albuquerque, US
InterventionsIntervention: orlistat + diet & exercise therapy Target of intervention: Child. It is unclear to what extent parents were involved in supporting the intervention. Behavioural or psychological component: No. Physical activity: Subjects in both study groups received the same exercise counselling. During the inpatient stay subjects were instructed to increase activity by using a paediatric activity pyramid (Park Nicollet HealthSource, Minneapolis, MN) and encouraged to exercise at least 3 times per week for at least 30 minutes on each occasion. At each monthly follow-up visit, all subjects met with a dietitian to reinforce the exercise plan. Nutritional advice: Subjects in both study groups received the same dietary counselling. The goal caloric intake was calculated using the Harris-Benedict equation with ambulating activity factor. From this expected caloric need, we subtracted 500 calories to determine daily calorie level for weight loss for each subject. During the inpatient stay, the subjects were instructed to consume a low-fat (30%) exchange diet and were give weekly log sheets to complete. At each monthly follow-up visit, all subjects met with a dietitian to reinforce the low-fat diet. Additional log sheets and dietary. Medication: Orlistat (120 mg orally 3 times a day). All subjects received a multivitamin to be taken daily. Other: All subjects were reimbursed $20 per subject visit. Additionally, Subjects in both arms of the study were offered incentive pay of $10 per kilogram of weight lost at 6 months in comparison with baseline weight. The incentive payment was capped for a maximal weight loss of 10%. Usual care/ alternative intervention: placebo + diet & exercise therapy Target of intervention: Child. It is unclear to what extent parents were involved in supporting the intervention. Behavioural or psychological component: No. Physical activity: As above. Nutritional advice:  As above. Medication: Placebo (120 mg orally 3 times a day). The placebo capsule was filled with an inert substance. All subjects received a multivitamin to be taken daily. Other: As above.
OutcomesHeight, weight (mean kg + SE), estimates of % fat content e.g. BMI, ponderal index, skin-fold thickness (BIA, BMI), behaviour changes (diet, exercise), Measures of self esteem, health status, QOL (QOL questionnaires: brief symptom inventory (Derogatis et al, 1983), Parents and Children's KINDL (Ravens-Sieberer et al, 2001), IWQOL-Kids (based on Impact of Weight on Quality of Life (Kolotkin et al, 1997 & 2001), Global Ratings scale (no other details given) + change in health status questionnaire), measures of harm (screening for adverse effects), laboratory measurements (fasting: serum glucose, serum free insulin, c-peptide, A1C, high sensitivity CRP, lipids, vitamin D (25-hydroxyvitamin D), vitamin A (retinol) & E (alpha-tocopherol).
NotesThe authors state this is the first non-industry-sponsored, randomised, double-blind, placebo controlled trial of its kind. This research was sponsored by various grants from the University of New Mexico. The financial incentive for weight loss may have ultimately influenced the success that the authors attribute to the diet and exercise intervention. This type of incentive may have promoted potentially unhealthy weigh loss practices prior to monthly weight assessments. It is unclear to what extent parents were involved in supporting the intervention. This independent study found no difference between the orlistat group and placebo group in terms of decreased levels of weight, BMI and body fat. Although, measures of diet and exercise change were not reported in this study the authors attribute weight and body fat loss in both groups to these lifestyle interventions.  It is important to acknowledge that a modest financial reward was given to adolescents for weight loss and the effect of this intervention is unknown. This study highlights that there are many unpleasant GIT side-effects associated with orlistat use.
Ozkan 2004
MethodsRandom allocation: Yes. Allocation not concealed. Randomisation was done by alternation of successive patients, who met the inclusion criteria, to receive conventional treatment alone or orlistat in addition to conventional treatment. This study was a prospective, open-label, randomised, controlled pilot trial. However, it is also specified in the methods that the control group consisted of 20 obese patients matched for age, sex, pubertal stage and the degree of obesity?? Blinding: Children: No. This was an open-label trial. Providers: No. This was an open-label trial. Outcome assessors: Not clear, not specified    Length of intervention and follow up: The duration of treatment is not exactly clear. The intervention group was followed for 5-15 months (average duration of treatment 11.7± 3.7 months). In the control group, duration of follow-up was 6-17 months; mean ± SD 10.2±3.7 months. Unit of allocation: Individuals Unit of analysis: Individuals Protection against contamination: Not done, also open label trial Drop outs: 29% [12/42] (intervention group 7, control group 5)
Participantsn= 42 randomised, 30 completedAge range (mean): 10 to 16 years (intervention group 12.9±2.4, control group 12.5±2.2) % Male: 33,3% (excludes dropouts) Weight entry criteria: Severe exogenous obesity, described as weight for height index >140% in otherwise healthy subjects, not associated with endocrinopathy, genetic syndromes or medications. Weight on entry (mean): Initial median BMI (kg/m2) in intervention group: 32.5, in control group: 31.2 Setting: Outpatient clinic Geographic Region: Erzurum & Istanbul, Turkey
InterventionsIntervention: Conventional treatment (nutritional and lifestyle modification programmes) + 120 mg three times a day of orlistat Target of intervention: Not specified Behavioural or psychological component: No. A behavioural or psychological component was not specifically mentioned but it is possible this was part of the lifestyle modification program. Physical activity: The lifestyle modification programme promoted an increase in activity level throughout the study period (at least 30 minutes of moderate exercise per day). Lifestyle modification was reinforced at each visit. Nutritional advice: The lifestyle modification programme promoted a 20% reduction in daily calories calculated for age and sex throughout the study period. The subjects were seen by the dietitian monthly and in the outpatient clinic every 2 months. Lifestyle modification was reinforced at each visit. Medication: Orlistat (120 mg three times a day) and a daily multivitamin preparation. Other: No. Usual care/ alternative intervention: Conventional treatment: nutritional and lifestyle modification programmes Target of intervention: Not specified Behavioural or psychological component: As above. Physical activity: As above. Nutritional advice: As above. Medication: None, no placebo was given; this was an open label study. Other: No
OutcomesHeight (cm), weight (kg), BMI (kg/m2), BMI change from baseline (kg/m2), percentage change in initial weight change since baseline (%), measures of harm (side effects).
NotesWhen the authors state “The control group consisted of 20 obese patients matched for age, sex, pubertal stage and the degree of obesity” presumably the authors mean that post-randomisation the groups were similar in these characteristics. However, this is not quite true as the control group had a significantly lower median weight for height (%) and BMI at baseline. There was scant reporting of participant demographic characteristics. Compliance with orlistat was not assessed. Pathology data (including vitamin levels) and measures of dietary intake & physical activity were not reported. Individual length of treatment, for non-drop outs, varied substantially from 5 to 17 months. However the mean length of treatment between groups was not significantly different. The conventional treatment was of low intensity and parents rated compliance as poor-fair. The authors acknowledge in the discussion that a more vigorous and frequently monitored lifestyle intervention program could have resulted in better outcomes for both groups.
Berkowitz 2003
MethodsRandom allocation: No description of randomisation process Blinding: Children: Yes Providers: Yes Outcome assessors: Unclear Length of intervention and follow up: 52 Weeks and 12 Months Unit of allocation: Individual adolescent Unit of analysis: Individual adolescent Protection against contamination: Done Drop outs: 10% [8/82] at 6 months (end of double-blind phase; n = 5 in Behavior therapy + placebo group and n = 3 in Behavior therapy + sibutramine group). At 12 months 15% [12/82] (n = 5 in Behavior therapy + placebo group and n = 7 in Behavior therapy + sibutramine group)
Participantsn= 82 randomised, 62 completedAge range (mean) 13-17 years (mean±SD 14.1±1.2 year) % Male: 33% Weight entry criteria: BMI of 32-44 Weight on entry (mean): mean (SD) 103.6 (15.4), BMI mean (SD) 37.8 (3.8) Setting: Conducted at the Weight and Eating Disorders Program at the University of Pennsylvania School of Medicine Geographic Region: Philadelphia, Pennsylvania, USA
InterventionsIntervention: Behavioral program + sibutramine - Target of intervention: family - Behavioural or psychological component: Comprehensive family-based behavioral weight loss (also described as a "therapeutic lifestyle change") program delivered following detailed treatment manuals. In phase 1 (first 6 months): 13 weekly group sessions followed by 6 biweekly group sessions. In phase 2 (second 6 months): group sessions held biweekly from months 7 to 9 and monthly from months 10 to 12. Parent group sessions held separately, but simultaneously, and on the same schedule as the adolescent group sessions. Parent sessions paralleled adolescents' session and used a companion protocol that was intended to promote parental behaviour changes and designed to enhance the adolescent's behavior change. ("Weight Reduction and Pride [WRAP] Program Parents' Edition" by Wadden & Berkowitz). Groups were led by dietitians, psychologists or psychiatrists. Diet and activity goals were set (see below). Participants were encouraged to self-monitor, through daily eating and activity logs, which were submitted at each session. - Physical activity: Adolescents were prescribed an eventual goal of walking or engaging in similar aerobic activity for 120 minutes per week or more. - Nutrional advice: Instructed to consume a 1200-1500 kcal/day diet of conventional foods, with approximately 30% from fat and 15% from protein, and the remainder from carbohydrate. - Medication: During Phase 1 (first 6 months), all participants received placebo (single blind) for week 1. From week 2, for the rest of Phase 1, they were randomised to either placebo or 5 mg/day of sibutramine. In medication-treated participants, sibutramine was increased to 10mg/day at week 3, and to 15 mg/day at week 7. Both drug and placebo were supplied by Knoll Pharmaceutical Company and Abbott Laboratories. Placebo capsules looked exactly like sibutramine capsules and were dispensed in the same way. During Phase 2 (second 6 months), all participants were treated with sibutramine following the dose titration scheduled used in Phase 1. Participants whose systolic or diastolic blood pressure increased from baseline by 10 mm Hg or more (or who had increases in pulse rate >15%) for 2 or more consecutive visits had their medication dose reduced in 5 mg decrements until acceptable BP and pulse rate values were obtained. Sibutramine was discontinued if the dose reductions did not reverse the 10 mm Hg or more increase, or in whom systolic or diastolic BP increased 20 mm Hg or more at any single visit. . - Other: No Usual care/ alternative intervention: Behavioural program + placebo - Target of intervention: family - Behavioural or psychological component: As above. - Physical activity: As above. - Nutrional advice: As above. - Medication: As above, but placebo. - Other: No
OutcomesHeight, weight, BMI, waist circumference; fasting blood tests (lipids, lipoproteins, insulin, glucose); systolic and diastolic BP and pulse rate; Eating Inventory (hunger); Maternal level of education; Medication adherence (by pill counts)
NotesThe Behavioral Therapy program was reasonably intensive and may not be equivalent to what is offered in usual weight management clinical practice. 
Berkowitz 2006
MethodsRandom allocation: yes, telephone numbered, opaque sealed envelopes Blinding: Children: Yes Providers: Yes Outcome assessors: Unclear Length of intervention and follow up: 12 month intervention with major assessments performed at 3, 6, 9, and 12 months from baseline. Unit of allocation: Child Unit of analysis: Child Protection against contamination: Done. Drop outs: 28% [137/498] (intervention group: 87, control group: 50)
Participantsn= 498 randomised, 361 completedAge range (mean): 12-16 years (intervention group: 13.7 + 1.3, control group: 13.6 + 1.3) % Male: 35.7% (intervention group: 34.2%, control group: 38.5%) Weight entry criteria: BMI at least 2 units more than the US weighted mean of the 95th percentile based on age and sex, and not more than 44 kg/m2Weight on entry (mean): intervention group: 97.9 kg ±14.7, control group: 97.8 kg ±14.6 Setting: 33 U.S weight loss clinics , outpatient clinic based in a University School of Medicine. Geographic Region: US
InterventionsIntervention: Behavioral program + sibutramine Behavioural or psychological component: A centre-specific behavior therapy program. Centers implemented flexible lifestyle modification approaches that were specific to the participant's needs. This included self-monitoring of eating habits and physical activity, stress management, stimulus control, problem solving, contingency management, cognitive restructuring and social support. Physical activity: Counselling at each visit promoted increased physical activity and reduced sedentary behaviours. Nutrional advice: Nutritional counselling encouraged development of healthy eating habits and promoted dietary consumption based on a 500 kcal/day deficit. Medication: Participants were randomised at baseline to receive either 10 mg sibutramine or placebo daily. At month 6, doses of all participants who had not lost more than 10% of their initial BMI were uptitrated (blinded) to 15mg sibutramine or placebo. Abbott (previously Knoll Pharmaceuticals) manufactured and provided all capsules. Placebo and sibutramine capsules appeared identical and were dispensed similarly. Therapy was discontinued, or closely monitored, in participants whose systolic BP, diastolic BP or pulse rate increased at a single visit to more than 150 mm Hg or by more than 20 mm Hg, to 95 mm Hg or by more than 15 mm Hg, or to 110 beats per min or by more than 20 beats per min, respectively, until acceptable values returned. A protocol-driven algorithm was used for repeating visits or withdrawing participants whose values did not return to specified limits. In the case of intolerance, participants were to be withdrawn from the study Other: No Usual care/ alternative intervention: Behavioural program + placebo Behavioural or psychological component: As above. Physical activity: As above. Nutrional advice: As above. Medication: As above, but placebo. Other: No
OutcomesHeight (cm), weight (kg), BMI (%), Adverse events (%), body weight (%), waist circumference (cm), triglyceride level (mmol/L, mg/dL), HDL cholesterol level (mmol/L, mg/dL), insulin level (pmol/L, microU/mL).
NotesOne of the first multi-center RCTs of sibutramine use in adolescents, with detailed safety monitoring. The use of center-specific behavioural programs, and the large number of centers (n=33), emphasises the applicability of the findings of this study to a range of weight loss clinic settings that treat adolescents. The study findings cannot be extrapolated to less severely obese adolescents, to adolescents treated without the benefit of a behavioral therapy program, and for treatment periods longer than 12 months.
Garcia-Morales 2006
MethodsRandom allocation: Participants were block-randomized by using a computer generated list. All the materials for a patient were identified by the participant number. The placebo and drug capsules were identical in appearance and smell. The trial medications were prepared by one author (A.B.), who did not know the identity of the patients. Another author (L.M.G.-M.) received the trial materials without any knowledge of the procedures or order in the random number list. Blinding: Children: Yes Providers: Yes Outcome assessors: Not clear, not specified. It is not clear which author collected the outcome measures. Note: The trial medications were prepared by one author (A.B.), who did not know the identity of the participants. Another author (L.M.G.-M.) received the trial materials without any knowledge of the procedures or order in the random number list. Length of intervention and follow up: 6 months with a run in period (duration not reported). The first patient entered the trial in August 2001 and the last participant finished the trial in August 2003. Monthly individual consultations with dietitian (nutrition advice) and endocrinologist (monitoring). Follow-up 6 months. Note: there was a run-in period Unit of allocation: Individuals Unit of analysis: Individuals Protection against contamination: N/A Drop outs: 22% [11/51] (intervention group 5, control group 6)
Participantsn= 51 randomised, 40 completedAge range (mean): 14 to 18 years (intervention group 15.2 (1.3) , control group 14.7 (1.1)) % Male: 43.48% (20/46, total not reported) Weight entry criteria: Sex-specific BMI for age and sex >95th percentile (obesity) Weight on entry (mean): Intervention group 92.6 (14.6) , control group 98.9 (22.7) Setting: Outpatients attending the Endocrinology Department of the Federico Gomez Children's Hospital of Mexico. Geographic Region: Mexico City, Mexico.
InterventionsIntervention: Sibutramine + diet + exercise Target of intervention: Child Behavioural or psychological component: No Physical activity: All participants were advised to perform at least 30 minutes of aerobic physical activity per day. Exercise advice was individually tailored for each patient. Nutritional advice: participants were advised to adopt a diet supplying 30 kcal/kg of the current body weight; ˜50% of the diet's energy was derived from carbohydrates, 30% from lipids, and 20% from proteins. All participants received a list of recommended food portions and possible  combinations. Diet advice was individually tailored for each patient. participants received the dietetic advice 15 days before the beginning of the medications and dietetic supervision during the treatment phase of the trial each month. Each participant attended individual consultation sessions with a registered paediatric nutritionist. Medication: Sibutramine 10 mg QD Other: No Usual care/ alternative intervention: Placebo + diet + exercise Target of intervention: Child Behavioural or psychological component: No Physical activity: As above Nutritional advice: As above. Medication: Placebo 10 mg QD Other: No
OutcomesHeight (cm), weight (kg), estimates of % fat content e.g. BMI, ponderal index, skin-fold thickness, BMI (kg/m2), %BMI (% kg/m2), waist circumference (cm), % waist (% cm), behaviour changes (diet, exercise), measures of self esteem, health status, QOL (quality of life, 36-Item Short-Form Health Survey (SF-36) questionnaire), measures of harm (blood pressure, heart rate, and electrocardiograms), blood cytology, blood chemistry, and urinalysis, adverse events.
NotesFew demographic details are given about the participants and it is not known to what extent parents were involved in the lifestyle intervention. The study has collected detailed data relating to the safety of sibutramine. There was no follow up after the intervention ceased.
Risk of bias
ItemAuthors' judgementDescription
Allocation concealment?YesPatients were block-randomized by using a computer generated list. All the materials for a patient were identified by the patient number. The placebo and drug capsules were identical in appearance and smell. The trial medications were prepared by one author (A.B.), who did not know the identity of the patients. Another author (L.M.G.-M.) received the trial materials without any knowledge of the procedures or order in the random number list.
Godoy-Matos 2005
MethodsRandom allocation: Yes. No description of randomisation process. This was the only information given on randomisation: “Subjects who completed the run-in period and returned less than 25% of the prescribed capsules were randomised to receive sibutramine (10 mg/d) or matching placebo capsules without regard to weight loss during the run-in period.” Blinding: Children: Yes. Providers: Yes. Outcome assessors: Not clear, not specified. The paper reports that a baseline echocardiogram was performed at visits 2 (week 0) and 8 (week 24) by an examiner who was blinded to group assignment. It is not clear whether the person collecting the primary and secondary outcomes was blinded to group allocation. Length of intervention and follow up: In the first month, all patients received placebo and a hypocaloric diet plus exercise orientation. For the next 6 months, participants received either sibutramine + diet + exercise or placebo + diet + exercise. Visits were scheduled for every 4 week; total 8 visits. These visits appeared to be for monitoring adverse events, drug compliance and conducting measurements. Follow-up 7 months (includes 1 month run-in period). Unit of allocation: Not specified Unit of analysis: Not specified Protection against contamination: Done. Drop outs: 17% [10/60] end of intervention and 6 months follow up.
Participantsn= 60 randomised, 50 completedAge range (mean): 14 to 17 years (Intervention group: females: 15.0 + 1.1, males: 16.7 + 0.6 control group: females: 16.3 + 1.16, males: 16.7 + 0.6) % Male: approximately 20% Weight entry criteria: BMI of 30-45 Weight on entry (mean): Intervention group: females: 100.5 + 14.2, males: 94.0 + 13.6 control group: females: 117.1 + 11.7, males: 113.4 + 10.0 Setting: Regular clinical setting Geographic Region: Rio De Janeiro, Brazil
InterventionsIntervention: Sibutramine + hypocaloric diet + exercise Target of intervention: Not specified Behavioural or psychological component: No. Because this study was designed to reproduce a regular clinical setting practice, we did not use structured behavioral counselling. Physical activity: Physical activity instructions were delivered by the attendant doctor in a brief written protocol aimed to obtain mainly aerobic moderate exercises for at least 30 min/d. Nutritional advice: All patients received dietary counselling to achieve an energy deficit of 500 kcal/d at the start of the run-in phase. No additional visits to the dietitian were allowed. The recommended diet composition was approximately 30% from fat, 20% from protein, and 50% from carbohydrates. Medication: During the single-blind run-in period, all participants received a placebo capsule. Subjects who completed the run-in period and returned less than 25% of the prescribed capsules were randomised to receive sibutramine (10 mg/d) or matching placebo capsules without regard to weight loss during the run-in period. Subjects were instructed to take their capsule in the morning. Knoll Pharmaceutical, subsequently Abbott Laboratories (Chicago, IL), provided and manufactured both placebo and sibutramine capsules. Visits were scheduled for every 4 weeks; subjects were attended by the same doctor throughout the study whenever possible. Other: No Usual care/ alternative intervention: Placebo + hypocaloric diet + exercise Target of intervention: Not specified Behavioural or psychological component: As above. Physical activity: As above. Nutritional advice: As above. Medication: As above, but placebo. Other: No
OutcomesHeight (m), weight & Weight Change (kg), estimates of % fat content e.g. BMI, ponderal index, skin-fold thickness: BMI (kg/m2), waist (cm), hip (cm), waist to hip ratio (ratio), measures of harm, adverse events, echocardiogram (cm or %), routine blood test (lipids, total Chol, HDL , LDL, TG, serum glucose, insulin), pregnancy test in females.
NotesThis work was supported by a grant from Abbott Laboratories. The role of the company in reviewing the results was not explained. Few details were given about participant demographic characteristics, recruitment, randomisation process and sample size calculations. It is not known to what extent parents were involved in the interventions. Approximately 80% of participants were females. The reason for this is not explained and no comment is made about differences in outcomes by gender. Mean weight loss in the 4 week run-in period in both groups was 2-3 kg, although it appears that the reported changes in parameters are those from 0-24 weeks only.
Risk of bias
ItemAuthors' judgementDescription
Allocation concealment?UnclearNo description of randomisation process.
Van Mil 2007
  1. d: day; h: hour; sd: standard deviation; kcal: kilocalories; kj: kilojoules.

MethodsRandom allocation: Knoll Pharmaceuticals BV[currently Abbott Laboratories (Hoofddorp, The Netherlands)], manufactured and provided code-numbered placebo and sibutramine capsules. Subjects received their trial and medication code according to order of entrance into the study, without stratification. Blinding: Children: Yes. Providers: Yes. Outcome assessors: Not clear, not specified Length of intervention and follow up: 12 weeks treatment with sibutramine or placebo, and diet + exercise. Then 12 weeks follow up including continuation of diet + exercise but no medication. Follow-up 24 weeks. Unit of allocation: Child. The only details given about parental involvement was: the subjects with parent(s) were seen by the study dietician for dietary evaluation. The dietician reviewed the record with the parent(s) and subject and calculated the energy intake and macronutrients. Unit of analysis: Child. Protection against contamination: Done. Drop outs: 4% [1/24] end of intervention and 17% [4/24] at 6 months follow up (intervention group 1, control group 3).
Participantsn= 24 randomised, 20 completedAge range (mean): 12 to 18 years (intervention group 14.1, control group 13.8) % Male: 45.83% Weight entry criteria: BMI greater than or equal to the 97th percentile, and further selected for triceps skinfold thickness greater than or equal to the 97th. Weight on entry (mean): intervention group 80.8 (SD 15.6), control group 89.2 (SD 16.4) Setting: Out-patient clinic Geographic Region: Maastricht, The Netherlands
InterventionsIntervention: sibutramine (Meridia) in combination with an energy-restricted diet and exercise plan for 12 weeks, followed by an identical, but medication-free, treatment period (follow-up). Target of intervention: Child. The only details given about parental involvement was: the subjects with parent(s) were seen by the study dietician for dietary evaluation. The dietician reviewed the record with the parent(s) and subject and calculated the energy intake and macronutrients. Behavioural or psychological component: No Physical activity: Exercise Plan:  In the first phase (12 weeks), physical activity was prescribed, based on individual preferences as well as information obtained by the activity questionnaire. The prescription contained a daily bout of exercise of at least 30 minutes of moderate to vigorous levels of exertions; however, the participants were encouraged to do more. Furthermore, emphasis was put on the implementation of additional physical activities, regardless of intensity, in the daily routine (14). The second phase consisted of a follow-up period of 12 week with continuation of the exercise plan. Throughout the study, the emphasis was put on lifestyle modification. Nutritional advice: Energy-restricted diet: In the first phase (12 weeks), dietary advice was based on energy requirements. The energy prescription was calculated from measured basal metabolic rate (BMR) multiplied by an estimated physical activity level (PAL) minus 500 kcal. The dietary intake could not be lower than 18-20 kcal per kilogram of ideal body weight with a minimum of 25% of calories provided by fat. The estimated PAL was determined using an activity questionnaire (13). The second phase consisted of a follow-up period of 12 week with continuation of the diet plan. Throughout the study, the emphasis was put on lifestyle modification. Medication: Study phase 1 (12 weeks): 5 mg sibutramine, taken once daily in the morning. After 2 weeks, the dose was increased to 10mg daily. Knoll Pharmaceuticals BV [currently Abbott Laboratories (Hoofddorp, The Netherlands)], manufactured and provided code-numbered placebo and sibutramine capsules. In the second study phase (12 weeks): consisted of a follow-up period of 12 week with continuation of the diet and exercise plan, however, without the study medication. Throughout the study, the emphasis was put on lifestyle modification. Other: No Usual care/ alternative intervention: placebo in combination with an energy-restricted diet and exercise plan for 12 week, followed by an identical, but medication-free, treatment period (follow-up). Target of intervention: As above. Behavioural or psychological component: No Physical activity: As above. Nutritional advice: As above. Medication: As above, but placebo. Other: No
OutcomesHeight (cm), weight (kg), estimates of % fat content e.g. BMI, ponderal index, skin-fold thickness (change in: BMI (kg/m2), BMI-SDS, FFM (kg), FM (%), measures of harm (safety (blood pressure, heart rate, electrocardiographical changes)/adverse events), energy expenditure (change MJ/day: SMR, BMR, TEE, BMRadj, TEE Res, PAL was a ratio (i.e. TEE/BMR))
NotesCompliance with the medication, diet and exercise regimes were not reported. It is important to note that all participants had persisting obesity despite previous professionally supervised weight loss attempts. Therefore this group may have been particularly difficult to treat. Duration of the medication intervention was relatively short (i.e. 2 weeks at 5 mg/day and 10 weeks at 10 mg/day) The cumulative change in BMI-SDS from baseline to end of follow up at 6 months was not reported.
Risk of bias
ItemAuthors' judgementDescription
Allocation concealment?YesKnoll Pharmaceuticals BV [currently Abbott Laboratories (Hoofddorp, The Netherlands)], manufactured and provided code-numbered placebo and sibutramine capsules. Subjects received their trial and medication code according to order of entrance into the study, without stratification.

Characteristics of excluded studies [ordered by study ID]

  1. Criteria for study inclusion:

  2. 1) Is it an RCT?

  3. 2) Is it an RCT in children only?

  4. 3) Is the intervention plus follow-up 1 year or more? if not, 6 months or more?

  5. 4) Is the aim of the trial to TREAT childhood obesity?

  6. Papers were excluded if pre 1985. This is because these papers were included in a systematic review by Glenny 1997.

Abu-Abeid 2003Not a randomised controlled trial. Note: surgical intervention.
Adamson 2004Aim of the study was to prevent childhood obesity
Al-Qahtani 2007Not a randomised controlled trial. Note: surgical intervention.
Alexy 2006Not a randomised controlled trial.
Allen 2005Not relevant to question: aim to treat polycistic ovary syndrome
Ames 2005Included participants other than children
Anand 2007Aim of the study was to prevent childhood obesity
Anderson 1991Not a randomised controlled trial. Included participants other than children. Aim of the study was other than to treat childhood obesity
Angrisani 2005Not a randomised controlled trial. Note: surgical intervention.
Annesi 2007Aim of the study was to prevent childhood obesity
Balagopal 2005Intervention plus follow up less than 6 months. Note: meeting abstracts to the same study are listed under this study as well
Ball 2000Meeting abstract. Study not published.
Ball 2002Not relevant for question; no intervention
Barnett 2005Not a randomised controlled trial. Note: surgical intervention.
Barnow 2003Not a randomised controlled trial.
Bauer 2006Included participants other than children
Becque 1988Intervention plus follow up less than 6 months Aim of the study was other than to treat childhood obesity
Bialokoz-Kalinowska 2005Not a randomised controlled trial.
Bonet 2007Not a randomised controlled trial.
Braet 1997Not a randomised controlled trial. Included participants other than children.
Braet 2003Not a randomised controlled trial.
Brown 2007Aim of the study was to prevent childhood obesity
Brownell 1983This paper is pre- the 1985 search strategy criteria and so is not included. It is included in systematic review by Glenny 1997.
Bustos 1997Not a randomised controlled trial. Included participants other than children.
Cairella 1991Not a randomised controlled trial. Included participants other than children. Aim of the study was other than to treat childhood obesity
Capella 2003Not a randomised controlled trial. Note: surgical intervention.
Carrasco 2007Review type paper
Carrel 2007Not relevant to question: aim to identify predictors of weightloss, succes, maintenance
Casado-Martinez 1993Included participants other than children. Intervention plus follow up less than 6 months Aim of the study was other than to treat childhood obesity
Celio 2005Intervention plus follow up less than 6 months.
Ceratti 1990Not a randomised controlled trial.
Chang 2008Not a randomised controlled trial. By their own choice, a considerate proportion (16%; 5/32) of participants were moved from control to intervention group.
Chen 2001Not a randomised controlled trial.
Coates 1982This paper is pre- the 1985 search strategy criteria and so is not included. Not a randomised controlled trial.
Collins 2007Not a randomised controlled trial. Note: surgical intervention.
Danielzik 2007Aim of the study was to prevent childhood obesity
Davis 2006Aim of the study was other than to treat childhood obesity
Davis 2007Aim of the study was other than to treat childhood obesity
Deforche 2001Not a randomised controlled trial.
Deforche 2005Post-treatment maintenance.
DeJongh 2006Aim of the study was to prevent childhood obesity
DeWolfe 1984Included participants other than children Aim of the study was other than to treat childhood obesity This paper is pre- the 1985 search strategy criteria and so is not included. It is included in systematic review by Glenny 1997.
Dillard 2007Not a randomised controlled trial. Note: surgical intervention.
Dolan 2003Not a randomised controlled trial. Note: surgical intervention.
Dolan 2004Not a randomised controlled trial. Note: surgical intervention.
Dreimane 2007Not a randomised controlled trial.
Du 2002Not relevant to question; alternative therapy
Dupuis 2000Intervention plus follow up less than 6 months
Dämon 2005Aim of the study was to prevent childhood obesity
Ebbeling 2006Aim of the study was to prevent childhood obesity
Eliakim 2002Not a randomised controlled trial.
Eliakim 2004Not relevant to question: aim to identify predictors of weightloss, succes, maintenance. Not a randomsied controlled trial.
Epstein 1984This paper is pre- the 1985 search strategy criteria and so is not included. It is included in systematic review by Glenny 1997.
Epstein 1990aIntervention plus follow up less than 6 months Note in text as the paper is over 1 year follow up but does not present any 1 year data and the data would be pre search criteria.
Epstein 1990bOver 1 year follow up but does not present any 1 year data and the data would be pre search criteria anyway.
Epstein 1994bNot a randomised controlled trial. The paper is over 1 year follow up but does not present any 1 year data and the data were collected pre the 1985 search criteria anyway. This Paper is included in the Glenny 1997 systematic review.
Epstein 1996Not a randomised controlled trial.
Epstein 1997Intervention plus follow up less than 6 months
Epstein 2001aNot relevant to question; aim to treat eating disorders
Epstein 2001bReview type paper
Epstein 2007Review type paper
Epstein 2008bAim of the study was to prevent childhood obesity
Ezendam 2007Aim of the study was to prevent childhood obesity
Faden 2004Meeting abstract
Faith 2001Intervention plus follow up less than 6 months
Fernandez-Paredes 1986Not clear if study is a randomised controlled trial.
Fielding 2005Not a randomised controlled trial. Note: surgical intervention.
Figueroa-Colon 1993Not a randomised controlled trial. Included participants other than children.
Figueroa-Colon 1996Not a randomised controlled trial. Included participants other than children.
Foger 1993Not a randomised controlled trial. Duration of follow up not clear.
Foreyt 1991Not clear if studiy is a randomised controlled trial. Included participants other than children. Aim of the study was other than to treat childhood obesity.
Foster 1985Aim of the study was other than to treat childhood obesity.
Freemark 2000Meeting abstract. Note: drug intervention.
Frenn 2005Aim of the study was to prevent childhood obesity
Fu 2007Not a randomised controlled trial.
Fullerton 2007Dissertation abstract
Gale 2004Review type paper
Gately 2007Intervention plus follow up less than 6 months.
Germann 2006Not a randomised controlled trial.
Gidding 2006Aim of the study was to prevent childhood obesity
Goldfield 2000Intervention plus follow up less than 6 months.
Goldfield 2006Not relevant to question: aim to identify predictors of weightloss, succes, maintenance
Gottschalk 2007Not relevant to question: aim to treat type 2 diabetes.
Graf 2005bNot a randomised controlled trial.
Gutin 1995Not a randomised controlled trial. Included participants other than children. Intervention plus follow up less than 6 months. Aim of the study was other than to treat childhood obesity.
Gutin 1996Not a randomised controlled trial. Included participants other than children. Intervention plus follow up less than 6 months. Aim of the study was other than to treat childhood obesity.
Gutin 1999Intervention plus follow up less than 6 months. NOTE: 7 papers are cited for this study, although a number of others (at least 5) were identified as also, probably, from the same study - n randomised varied slightly between studies.
Hardin 1997Not a randomised controlled trial. Included participants other than children. Intervention plus follow up less than 6 months. Aim of the study was other than to treat childhood obesity.
Harrell 1998Intervention plus follow up less than 6 months
Haymond 2007Not relevant to question: aim to treat type 2 diabetes
Herrera 2004Not a randomised controlled trial.
Hoeger 2004Not relevant to question: aim to treat polycistic ovary syndrome
Holterman 2007Not a randomised controlled trial. Note: surgical intervention.
Hope 2002Dissertation abstract
Huang 2007Aim of the study was to prevent childhood obesity
Ildik¢ 2007Not a randomised controlled trial.
Inge 2004Not a randomised controlled trial. Note: surgical intervention.
Ippisch 2008Not a randomised controlled trial. Note: surgical intervention.
Jiang 1997Not a randomised controlled trial. Included participants other than children.
Johnson 1997Follow up data at 5 years was self reported.
Johnston 2004Aim of the study was other than to treat childhood obesity
Jones 2002Not relevant to question: aim to treat type 2 diabetes.
Kalarchian 2004Meeting abstract
Kay 2001Intervention plus follow up less than 6 months. Note: drug intervention.
Lake 2007Not a randomised controlled trial.
Lavine 2006Not relevant to question: aim to treat fatty liver
Lawson 2006Not a randomised controlled trial. Note: surgical intervention.
Lazaar 2007Aim of the study was to prevent childhood obesity
Le 2002Not relevant to question: aim to identify predictors of weightloss, succes, maintenance
Libman 2006Meeting abstract
Madan 2007Not a randomised controlled trial. Note: surgical intervention.
Maffeis 2007Review type paper
Malecka-Tendera 1996Intervention plus follow up less than 6 months.
McDuffie 2004Not a randomised controlled trial. Note: drug intervention.
McGarvey 2004Aim of the study was to prevent childhood obesity
Mo-suwan 1993Not a randomised controlled trial. Included participants other than children.
Mohn 2005Not a randomised controlled trial.
Mulkens 2007Intervention plus follow up less than 6 months.
Munguba 2008Not a randomised controlled trial.
Nadler 2007Not a randomised controlled trial. Note: surgical intervention.
Nuutinen 1992Not a randomised controlled trial. Included participants other than children.
Ong 2007Not relevant to question: aim to treat precocious pubarche
Pangrazi 2003Aim of the study was to prevent childhood obesity
Papadia 2007Not a randomised controlled trial. Note: surgical intervention.
Patrick 2006Aim of the study was to prevent childhood obesity
Peneau 2008Not relevant to question: aim to identify predictors of weightloss, succes, maintenance
Rand 1994Not a randomised controlled trial. Included participants other than children. Aim of the study was other than to treat childhood obesity.
Reinehr 2003Not a randomised controlled trial.
Reinehr 2006Not a randomised controlled trial.
Reybrouck 1990Not a randomised controlled trial. Included participants other than children. Intervention plus follow up less than 6 months.
Roemmich 2004Not a randomised controlled trial. Note: surgical intervention.
Rudolf 2006Not a randomised controlled trial.
Ryttig 1989Included participants other than children. Aim of the study was other than to treat childhood obesity.
Savoye 2005Not a randomised controlled trial.
Schwimmer 2005Not a randomised controlled trial. Note: drug intervention.
Silberhumer 2006Not a randomised controlled trial. Note: surgical intervention.
Sothern 1993Not a randomised controlled trial. Included participants other than children.
Stanford 2003Not a randomised controlled trial. Note: surgical intervention.
Stauber 2004Intervention plus follow up less than 6 months.
Stein 2006Not a randomised controlled trial.
Sternberg 2006Not a randomised controlled trial.
Strauss 2001Not a randomised controlled trial. Note: surgical intervention.
Sugerman 2003Not a randomised controlled trial. Note: surgical intervention.
Sung 2002Intervention plus follow up less than 6 months.
Suttapreyasri 1990Not a randomised controlled trial. Included participants other than children.
Taitano 1998Aim of the study was to prevent childhood obesity. Dissertation abstract.
Tanas 2007Not a randomised controlled trial.
Till 2008Not relevant to question: technique description
Tsai 2007Not a randomised controlled trial. Note: surgical intervention.
Tsiros 2008Intervention plus follow up less than 6 months.
Turabian 1989Included participants other than children. Intervention plus follow up less than 6 months. Aim of the study was other than to treat childhood obesity.
Umbehr 2008Aim of the study was to prevent childhood obesity
Van Dongen 1995Aim of the study was other than to treat childhood obesity.
Van Egmond-Frohlich 2006Posttreatment maintenance.
Vicente-Rodriguez 2007Aim of the study was to prevent childhood obesity
Vido 1993Intervention plus follow up less than 6 months.
Walker 2008Dissertation abstract
Webb 2006Review type paper
Weigel 2005Meeting abstract
Widhalm 2004Not a randomised controlled trial. Note: surgical intervention.
Wilfley 2007Posttreatment maintenance.
Willi 2004Not relevant to question: aim to treat type 2 diabetes
Williamson 2007Aim of the study was to prevent childhood obesity
Wrotniak 2004Not relevant to question: aim to identify predictors of weightloss, succes, maintenance
Wunsch 2006Not a randomised controlled trial.
Yitzhak 2006Not a randomised controlled trial. Note: surgical intervention.
Yoshinaga 2004Not a randomised controlled trial.
Young-Hyman 2002Aim of the study was to prevent childhood obesity
Yu 2005Aim of the study was other than to treat childhood obesity

Characteristics of ongoing studies [ordered by study ID]

Brennan 2008
Trial name or titleMotivational interviewing and cognitive behaviour therapy in the treatment of adolescent overweight and obesity: Study design and methodology
MethodsRandom allocation: Participants were asked to select a number and this was used to randomly allocate all participants to the treatment or wait-list control condition. Blinding: Children: No Providers: No Outcome assessors: Yes Length of intervention and follow up: The treatment phase consisted of 12 one-hour face-to-face sessions and one phone call session. The first ten treatment sessions were conducted weekly. The remaining sessions were conducted every second week.The maintenance phase consisted of two 1-hour maintenance clinic sessions and seven 15-minutes maintenance phone call sessions. Following the last treatment session, phone call sessions were completed every second week and a face-to-face session was scheduled three months after the last treatment session. This was followed by monthly phone call session and a final face-to-face session conducted six months after the last treatment sessions. Assessments were completed after the assessment interview and prior to randomisation, after the completion of the treatment phase of the intervention (or the end of wait-list), and after completion of the maintenance phase of the intervention (for those in the treatment condition). Unit of allocation: Child Unit of analysis: Child Protection against contamination: Unclear
ParticipantsParticipantsn= 63 randomisedAge range (mean): 11.5 to 18.9 years (Mean(SD) = 14.3(SD)) % Male: 46% Weight entry criteria: Overweight or obese according to the international cut-off points for body mass index in children Weight on entry (mean): not reported Setting: Intervention and assessment sessions were conducted in the Psychology Clinics at RMIT University, Melbourne and Bundoora campuses. Physical assessments were conducted in the Exercise Physiology and Body Composition laboratories at RMIT University, Bundoora campus. Geographic Region: Australia
InterventionsInterventions: Cognitive behavioural intervention vs wait-list control condition Intervention: Cognitive behavioural intervention - Target of intervention: child and parent - Behavioural or psychological component: The cognitive behavioural intervention, the CHOOSE HEALTH Program, consisted of 13 individual treatment sessions (12 face-to-face, 1 phone call) followed by 9 maintenance sessions (7 phone calls, 2 face-to-face). Each treatment session commenced with a review of the previous session and a discussion of homework, goal achievement and monitoring. The session material was then introduced with the opportunity for discussion, questions and practice of the strategies. Adolescents were encouraged to complete the exercises (e.g. identifying opportunities for physical activity, reading nutritional labels, problem solving) within the session and were then assisted to set their own goals (e.g. walk part of the way to school, read nutritional labels and select a low energy snack, use problem solving if exercise goals not achieved) regarding use of the strategies prior to the next session. Both parents and adolescents were required to attend the first six treatment sessions. Adolescents were then given the choice of attending the remaining sessions alone, or with the support of a parent. Sessios topics: Psycho-education, Eating behaviour, Physical Activity, Healthy food choices, Exercise, Behaviour charts and barriers, Recognising thoughts and emotions, Helpful thoughts and emotions, Assertive communication, Problem solving and planning, Staying on track, Maintaining change, Maintenance and closure. - Physical activity: The physical activity component of the intervention aimed to promote physical activity habits consistent with the Australian physical activity guidelines for children and young people which recommends adolescents achieve at least 60 minutes of moderate to vigorous physical activity per day and spend no more than two hours per day in noneducational screen activities. - Nutrional advice: The nutritional component of the intervention aimed to promote eating habits consistent with the Australian Guide to Healthy Eating which recommends the consumption of a variety of foods from each of the five food groups (cereals, vegetables, fruit, diary and meat products and alternatives), the selection of low-fat alternatives, and the consumption of water.. - Other: No. Usual care/ alternative intervention: Wait-list control condition - Target of intervention: child and parent - Overall: Participants in the wait-list control did not receive any intervention.
OutcomesImprovement in body composition was the primary outcome; secondary outcomes included improved cardiovascular fitness, eating and physical activity habits, family and psychosocial functioning.
Starting dateNot reported.
Contact informationCorresponding author: L. Brennan. Discipline of Exercise Sciences, RMIT University, PO Box 71, Bundoora Vic 3083, Australia. Tel.: +61 3 9925 6572;fax: +61 3 9467 8181. E-mail address: leah.brennan@rmit.edu.au
NotesThe first author was funded by a RMIT University Postgraduate Award and a VicHealth Postgraduate Scholarship. Supplementary funding was provided by the ATN Centre for Metabolic Fitness and the Parenting Research Centre.
Janicke 2008
Trial name or titleSensible Treatment of Obesity in Rural Youth (STORY): Design and methods.
MethodsRandom allocation: Method not described Blinding: Children: No Providers: No Outcome assessors: Unclear Length of intervention and follow up: Intervention: 4 month. Follow-up: 10 month. Unit of allocation: Family Unit of analysis: Child and parent Protection against contamination: Unclear
ParticipantsParticipantsn= 90 randomised (sample size estimation) Age range (mean): 8–13 years % Male: not reported Weight entry criteria: Body mass index equal to or above the 85th percentile for age and gender Weight on entry (mean): not reported Setting: Assessment and intervention sessions will be held at Cooperative Extension offices within each local participating county. Geographic Region: Four medically underserved rural counties in North Central Florida.
InterventionsInterventions: Family-Based Behavioral Group Intervention vs Parent-Only Behavioral Group Intervention vs Waitlist control condition Intervention: Family-Based Behavioral Group Intervention - Target of intervention: family - Behavioural or psychological component: Parent–child dyads in the Family-Based intervention and parents in the Parent-Only intervention will participate in weekly sessions for the first 8 weeks, then 4 biweekly sessions over the next 8 weeks for a total of 12 sessions across 16 weeks. Each parent and child dyad will participate in simultaneous, but separate, parent and child groups. As both children and parents will be targeted as “active agents of change”, the emphasis will be on modeling and providing support to work together to establish healthier eating and physical activity patterns. Each session will last 90 minutes. Both children and parents will be weighed every other group session to monitor weight status. During the parent group, the first portion of the meeting will involve a review of parent and child progress implementing the strategies developed for changing their eating or exercise habits during the previous session. Difficulties reported by the parents will be dealt with through group support and discussion. The second segment will focus on knowledge and skill training related to benefits of weight loss, basics of nutrition and the Stop-Light program, appropriate methods for increasing physical activity, behavior management, and positive parenting skills (e.g. goal setting, self-monitoring, stimulus control etc.). At the end of each session, children and parents will be brought together to develop specific goals, as well as plans to achieve these goals. The child group sessions will include four segments. Each session will begin with a review of the children's progress in completing their monitoring forms and achieving their dietary and physical activity goals. The second segment will use fun and educational activities to teach children about nutrition (e.g. recognizing calorie and fat content of foods via “signals” of the Stop-Light program), strategies to increase physical activity, behavioral management skills (selfmonitoring and goal settings), and strategies to cope with psychosocial concerns (i.e. building self-esteem). Third, all sessions will include a physical activity component to demonstrate strategies to help children keep physically active. This will include activities such as jumping rope, playing Frisbee, relay races, and participating in a mini-scavenger hunt. Finally, children will help prepare a healthy snack for taste testing during each session. - Physical activity: Increased physical activity will be encouraged through a pedometer-based step program. Children and parents will be encouraged to monitor their physical activity and gradually increase their steps per day. Program goals will be based on their baseline level of steps and will target an increase of at least 3000 steps per day by the end of the program for both children and parents. Goals will be set for gradually decreasing sedentary activities so that children will spend no more than 2 h per day watching television or playing video games. - Nutrional advice: Changes in dietary habits will be addressed via a modified version of the Stop-Light program. Child and parent participants will monitor everything they eat using a daily habit log. Daily dietary goals will be set each week, and will include limiting the consumption of high-fat/high-sugar “Red Foods” (with an absolute minimum goal of 2 red foods per day), and increasing fruit and vegetable intake. Children and adults will also be encouraged to eat a well-balanced diet based on the food guide pyramid. - Other: No. Usual care/ alternative intervention: Parent-Only Behavioral Group Intervention - Target of intervention: parent - Behavioural or psychological component: As above. Only the participating parent(s) will attend weekly group meetings. Each session will last 90 minutes and will include three segments, similar to the parent group previously described in the Family-Based intervention. Each week group interventionists will model the goal setting process with parents and suggest a general range of dietary and physical activity targets that might be appropriate for each child and parent. Parents will then be instructed to meet with their child at home and work together to set individual, achievable goals based on the previous weeks' progress. Parents will participate in role-play activities to practice negotiation of goals with their child. As children will not attend group sessions, an emphasis will be placed on teaching parents how to work with their children to set goals together. Parents will be encouraged to utilize praise, incentives, and modeling to encourage participation and goal achievement. Parents will be provided handouts to guide them in discussing program material and setting weekly goals with their children. Parents will be weighed every other group session to monitor their weight status. - Physical activity: Increased physical activity will be encouraged through a pedometer-based step program. Children and parents will be encouraged to monitor their physical activity and gradually increase their steps per day. Program goals will be based on their baseline level of steps and will target an increase of at least 3000 steps per day by the end of the program for both children and parents. Goals will be set for gradually decreasing sedentary activities so that children will spend no more than 2 h per day watching television or playing video games. - Nutrional advice: Changes in dietary habits will be addressed via a modified version of the Stop-Light program. Child and parent participants will monitor everything they eat using a daily habit log. Daily dietary goals will be set each week, and will include limiting the consumption of high-fat/high-sugar “Red Foods” (with an absolute minimum goal of 2 red foods per day), and increasing fruit and vegetable intake. Children and adults will also be encouraged to eat a well-balanced diet based on the food guide pyramid. - Other: No. Usual care/ alternative intervention: Waitlist control condition - Target of intervention: No intervention - Overall: Families assigned to the WLC condition will complete the assessment protocol at baseline, and at 4 and 10 months. After the follow-up period (month 10) families will be invited to participate in a 12-session behavioral-based intervention. No treatment will be delivered until after the final, 6-month follow-up assessment.
OutcomesPrimary outcome measure is change in child body mass index (BMI) z-score. Additional key outcome measures include child dietary intake, physical activity, self-esteem, body image, and parent BMI.
Starting dateNot reported
Contact informationCorresponding author: D.M. Janicke. Tel.: +1 352 273 6046; fax: +1 352 273 6156. E-mail address: djanicke@phhp.ufl.edu
NotesThe study is supported by a grant from the National Institute for Diabetes and Digestive and Kidney Diseases R34 DK071555-01. Additional supplemental funding for the preliminary pilot work for this study was supplied by the Institute for Child and Adolescent Research and Evaluation at the University of Florida.

Data and analyses

  1. Top of page
  2. Abstract
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Implications for research
  10. Acknowledgements
  11. Characteristics of studies
  12. Data and analyses
  13. Appendices
  14. What's new
  15. History
  16. Contributions of authors
  17. Declarations of interest
  18. Sources of support
  19. REFERENCES
Table Comparison 1.. Lifestyle interventions in children younger than 12 years
Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size
1 Change in BMI-SDS at six months follow up4301Mean Difference (IV, Fixed, 95% CI)-0.06 [-0.12, -0.01]
2 Change in BMI-SDS at twelve months follow up3264Mean Difference (IV, Fixed, 95% CI)-0.04 [-0.12, 0.04]
thumbnail image

Figure Analysis 1.1. Comparison 1 Lifestyle interventions in children younger than 12 years, Outcome 1 Change in BMI-SDS at six months follow up.

Download figure to PowerPoint

thumbnail image

Figure Analysis 1.2. Comparison 1 Lifestyle interventions in children younger than 12 years, Outcome 2 Change in BMI-SDS at twelve months follow up.

Download figure to PowerPoint

Table Comparison 2.. Lifestyle interventions in children 12 years and older
Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size
1 Change in BMI-SDS at six months follow up3291Mean Difference (IV, Fixed, 95% CI)-0.14 [-0.17, -0.12]
2 Change in BMI at six months follow up4362Mean Difference (IV, Fixed, 95% CI)-3.04 [-3.14, -2.94]
3 Change in BMI-SDS at twelve months follow up2231Mean Difference (IV, Fixed, 95% CI)-0.14 [-0.18, -0.10]
4 Change in BMI at twelve months follow up2231Mean Difference (IV, Fixed, 95% CI)-3.27 [-3.38, -3.17]
thumbnail image

Figure Analysis 2.1. Comparison 2 Lifestyle interventions in children 12 years and older, Outcome 1 Change in BMI-SDS at six months follow up.

Download figure to PowerPoint

thumbnail image

Figure Analysis 2.2. Comparison 2 Lifestyle interventions in children 12 years and older, Outcome 2 Change in BMI at six months follow up.

Download figure to PowerPoint

thumbnail image

Figure Analysis 2.3. Comparison 2 Lifestyle interventions in children 12 years and older, Outcome 3 Change in BMI-SDS at twelve months follow up.

Download figure to PowerPoint

thumbnail image

Figure Analysis 2.4. Comparison 2 Lifestyle interventions in children 12 years and older, Outcome 4 Change in BMI at twelve months follow up.

Download figure to PowerPoint

Table Comparison 3.. Drug interventions with Orlistat in children 12 years and older
Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size
1 Change in absolute BMI at six months follow up2579Mean Difference (IV, Fixed, 95% CI)-0.76 [-1.07, -0.44]
thumbnail image

Figure Analysis 3.1. Comparison 3 Drug interventions with Orlistat in children 12 years and older, Outcome 1 Change in absolute BMI at six months follow up.

Download figure to PowerPoint

Table Comparison 4.. Drug interventions with Sibutramine in children 12 years and older
Outcome or subgroup titleNo. of studiesNo. of participantsStatistical methodEffect size
1 Change in absolute BMI at six months follow up2111Mean Difference (IV, Fixed, 95% CI)-1.66 [-1.89, -1.43]
thumbnail image

Figure Analysis 4.1. Comparison 4 Drug interventions with Sibutramine in children 12 years and older, Outcome 1 Change in absolute BMI at six months follow up.

Download figure to PowerPoint

Appendices

  1. Top of page
  2. Abstract
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Implications for research
  10. Acknowledgements
  11. Characteristics of studies
  12. Data and analyses
  13. Appendices
  14. What's new
  15. History
  16. Contributions of authors
  17. Declarations of interest
  18. Sources of support
  19. REFERENCES

Appendix 1. 1999 search strategies

CENTRAL on The Cochrane Library (Issue 4, 1999)

#1 OBESITY*:ME

#2 OBESE

#3 OBESITY

#4 OVERWEIGHT

#5 ADIPOSITY

#6 OVEREATING

#7 OVERNUTRITION

#8 ADIPOSE-TISSUE*:ME

#9 ADIPOSE

#10 BODY-WEIGHT*:ME

#11 (WEIGHT near GAIN)

#12 (LEAN near WEIGHT)

#13 ((INCREASED or EXCESSIVE) near WEIGHT)

#14 (BODY next FAT)

#15 HYPERPHAGIA*:ME

#16 HYPERPHAGIA

#17 (EATING next HABIT)

#18 (BINGE next EATING)

#19 (EATING next DISORDER*)

#20 EATING-DISORDERS:ME

#21 APPETITE:ME

#22 APPETITE

#23 FEEDING-BEHAVIOR:ME

#24 (FEEDING next BEHAVIO*)

#25 (METABOLIC next SYNDROME)

#26 (((((((((#1 or #2) or #3) or #4) or #5) or #6) or #7) or #8) or #9) or #10)

#27 (((((((((#11 or #12) or #13) or #14) or #15) or #16) or #17) or #18) or #19) or #20)

#28 ((((#21 or #22) or #23) or #24) or #25)

#29 ((#26 or #27) or #28)

#30 CHILD*:ME

#31 CHILD

#32 CHILDREN

#33 PAEDIATRIC*

#34 PEDIATRIC*

#35 ADOLESCEN*

#36 (((((#30 or #31) or #32) or #33) or #34) or #35)

#37 PONDERAL

#38 SKINFOLD-THICKNESS:ME

#39 SKINFOLD

#40 ((SKIN near FOLD) near THICKNESS)

#41 BODY-WEIGHT*:ME

#42 WEIGHT-LOSS*:ME

#43 BODY-MASS-INDEX:ME

#44 (WEIGHT next REDUCTION)

#45 (BODY next MASS)

#46 (BODY next WEIGHT)

#47 (BODY next (COMPOSITION or WEIGHT))

#48 ((WEIGHT or FAT) next (((LOSS or MAINENANCE) or CONTROL) or REDUCTION))

#49 (WEIGHT next (GAIN or CHANGE))

#50 ((FAT next FREE) next MASS)

#51 (WAIST near HIP)

#52 (WAIST next SIZE)

#53 (ABDOMEN near HIP)

#54 ((((((((((#37 or #38) or #39) or #40) or #41) or #42) or #43) or #44) or #45) or #46) or #47)

#55 (((((#48 or #49) or #50) or #51) or #52) or #53)

#56 (#54 or #55)

#57 FAMILY-THERAPY:ME

#58 BEHAVIOR-THERAPY*:ME

#59 (GROUP next THERAPY)

#60 (MEDICAL next SUPERVISION)

#61 (FAMILY next THERAPY)

#62 (BEHAVIOUR next THERAPY)

#63 (COGNITIVE next THERAPY)

#64 (BEHAVIOUR next MODIFICATION)

#65 (BEHAVIOR next MODIFICATION)

#66 (BEHAVIOR next THERAPY)

#67 (BEHAVIOUR next MODIFYING)

#68 (GROUP next INTERVENTION*)

#69 (GROUP next PROGRAM*)

#70 (INDIVIDUAL next INTERVENTION*)

#71 (INDIVIDUAL next PROGRAM*)

#72 (INDIVIDUAL next THERAP*)

#73 (POPULATION next INTERVENTION*)

#74 (POPULATION next PROGRAM*)

#75 (POPULATION next THERAP*)

#76 (COMMUNITY next INTERVENTION*)

#77 (COMMUNITY next PROGRAM*)

#78 (COMMUNITY next THERAP*)

#79 ((WEIGHT near REDUCING) near DIET)

#80 (DIETARY near COMPOSITION)

#81 (LOW next CALOR*)

#82 (LOW next FAT)

#83 (CALOR* next RESTRICT*)

#84 (FOOD next DEPRIVAT*)

#85 (DIET near RESTRICT*)

#86 (FAT near RESTRICT*)

#87 (DIET next THERAP*)

#88 (HIGH next (FIBER next DIET))

#89 (HIGH next (FIBRE next DIET))

#90 DIET-THERAPY*:ME

#91 (DIABETIC next DIET)

#92 SLIMMING

#93 (WEIGHT next WATCHERS)

#94 (CORRESPONDENCE next PROGRAMME)

#95 EXERCISE*:ME

#96 (PHYSICAL next ACTIVITY)

#97 FASTING

#98 EXERCISE

#99 (PRIMARY next PREVENTION)

#100 (SECONDARY next PREVENTION)

#101 HEALTH-EDUCATION*:ME

#102 (HEALTH next EDUCATION)

#103 (FOOD next POLIC*)

#104 (NUTRITION* next POLIC*)

#105 (SCHOOL next (HEALTH next SERVICE))

#106 (HEALTH next PROTECTION)

#107 (HEALTH next PROMOTION)

#108 PROPHYLAXIS

#109 (SCHOOL next PROGRAM*)

#110 ALTERNATIVE-MEDICINE*:ME

#111 (COMPLEMENTARY next MEDICINE)

#112 (ALTERNATIVE next MEDICINE)

#113 (COMPLEMENTARY next THERAP*)

#114 ACUPUNCTURE

#115 HOMEOPATHY

#116 HYPNOSIS

#117 (HERBAL next MEDICINE)

#118 (CHINESE next DRUG)

#119 ANOREXIGENIC

#120 (SEROTONIN next AGONIST)

#121 (APPETITE next SUPPRESSANT*)

#122 (APPETITE next DEPRESSANT*)

#123 (BULKING next AGENT)

#124 FLUOXETINE

#125 ((((((((#57 or #58) or #59) or #60) or #61) or #62) or #63) or #64) or #65)

#126 (((((((((#66 or #67) or #68) or #69) or #70) or #71) or #72) or #73) or #74) or #75)

#127 (((((((((#76 or #77) or #78) or #79) or #80) or #81) or #82) or #83) or #84) or #85)

#128 (((((((((#86 or #87) or #88) or #89) or #90) or #91) or #92) or #93) or #94) or #95)

#129 (((((((((#96 or #97) or #98) or #99) or #100) or #101) or #102) or #103) or #104) or #105)

#130 (((((((((#106 or #107) or #108) or #109) or #110) or #111) or #112) or #113) or #114) or #115)

#131 ((((((((#116 or #117) or #118) or #119) or #120) or #121) or #122) or #123) or #124)

#132 ((((((#125 or #126) or #127) or #128) or #129) or #130) or #131)

#133 (ANOREXIA or BULIMIA)

#134 (#29 and #56)

#135 (#134 and #132)

#136 (#135 and #36)

#137 (#136 not #133)

MEDLINE

1 randomized controlled trial.pt.

2 randomized controlled trials/

3 random allocation/

4 double-blind method/

5 single-blind method/

6 clinical trial.pt.

7 exp clinical trials/

8 (clinical$ adj5 trial$).tw.

9 ((singl$ or doubl$ or trebl or tripl$) adj5 (blind$ or mask)).mp. [mp=title, abstract, registry number word, mesh subject heading]

10 placebos/

11 (placebo$ or random$).tw.

12 research design/

13 comparative study/

14 exp evaluation studies/

15 follow-up studies/

16 prospective studies/

17 (animal not (human and animal)).ti,ab,sh.

18 *obesity/

19 *obesity,morbid/

20 *pickwickian syndrome/

21 *prader-willi syndrome/

22 *weight gain/

23 obesity.ti.

24 obese.ti.

25 overweight.ti.

26 hyperphagia/

27 *bulimia/

28 or/18-27

29 or/1-16

30 29 and 28

31 30 not 17

32 exp behavior therapy/

33 (behavior adj (therapy or modification)).tw.

34 exp appetite depressants/

35 (appetite adj (suppressant? or depressant)).tw.

36 diet, fat-restricted/

37 diet, reducing/

38 (dieting or (low adj calorie) or diet?).tw.

39 food deprivation/

40 (food adj3 (deprivation or depriving)).tw.

41 exercise/

42 exercise therapy/

43 exertion/

44 (exercise or (physical adj therapy) or fitness).tw.

45 fasting/

46 fasting.tw.

47 (jaw adj3 (wiring or wired)).tw.

48 surgical staplers/

49 surgical stapling/

50 (stomach adj2 (stapling or banding or bypass)).ti,ab,sh.

51 gastric bypass/

52 (gastric adj bypass).tw.

53 health promotion/

54 health education/

55 (prevent or prevention of preventing).tw.

56 nutrition policy/

57 (food adj policy).tw.

58 food habits/ and health policy/

59 (program or programs or programme$ or intervention$).tw.

60 lipectomy/

61 liposuction.tw.

62 (guar adj gum).ti,ab,sh.

63 exp alternative medicine/

64 (acupuncture or hypnotism).tw.

65 advertising/

66 ((diet or dieting or slimming) adj club?).tw.

67 weightwatcher?.tw.

68 or/32-67

69 31 and 68

70 limit 69 to (newborn infant < birth to 1 month > or infant< 1 to 23 months > or preschool child < 2 to 5 years > or child < 6 to 12 years > or adolescence < 13 to 18 years >)

EMBASE

1 exp Obesity/

2 Overnutrition/

3 (obese or obesity or overweight or adiposity or

overeating).tw.

4 exp adipose tissue/

5 "weight gain".tw.

6 Lean body weight/

7 ((increased or excessive) adj weight).tw.

8 Body weight/

9 Body fat/

10 Hyperphagia/

11 hyperphagia.tw.

12 Eating habit/

13 (binge adj eating).tw.

14 (eating adj disorder$).tw.

15 Appetite/

16 Feeding behavior/

17 (metabolic adj syndrome).tw.

18 1 or 2 or 3 or 4 or 5 or 6

19 7 or 8 or 9 or 10 or 11 or 12

20 13 or 14 or 15 or 16 or 17

21 18 or 19 or 20

22 Randomized controlled trial/

23 Double blind procedure/

24 Single blind procedure/

25 Crossover procedure/

26 Multicenter study/

27 Clinical trial/

28 Meta analysis/

29 Controlled study/

30 ((intervention or clinical) adj (trial$ or stud$)).tw.

31 (random$ or placebo$).tw.

32 (control$ adj (trial$ or stud$ or group$)).tw.

33 22 or 23 or 24 or 25 or 26

34 27 or 28 or 29 or 30 or 31 or 32

35 33 or 34

36 Group therapy/

37 (medical adj supervision).tw.

38 ((group or individual or population or community) adj (intervention$ or program$ or therap$)).tw.

39 (unsupervised adj (intervention$ or program$)).tw.

40 Family therapy/

41 (family adj (therap$ or program$ or intervention$)).tw.

42 Behavior modification/

43 ((behaviour or behavior) adj (modification or modify)).tw.

44 Behavior therapy/

45 Cognitive therapy/

46 "weight reducing diet".tw.

47 "dietary composition".tw.

48 Low calory diet/

49 "low fat diet".tw.

50 Caloric restriction/

51 Food deprivation/

52 (food adj (deprivation or depriving)).tw.

53 Diet/

54 Diet restriction/

55 "fat restrict$".tw.

56 Diet therapy/

57 High fiber diet/

58 Diabetic diet/

59 ((slim or slimming) adj (plan$ or organisation$ or regimen$ or program$)).tw.

60 (weight adj watchers).tw.

61 (correspondence adj program$).tw.

62 Exercise/

63 Physical activity/

64 "fasting".tw.

65 Primary prevention/

66 Secondary prevention/

67 ((primary or secondary) adj prevention).tw.

68 exp health education/

69 ((food or nutrition$) adj polic$).tw.

70 School health service/

71 (health adj (protection or promotion or education)).tw.

72 Prophylaxis/

73 (school adj program$).tw.

74 exp alternative medicine/

75 (acupuncture or hypnotherapy or homeopathy or hypnotism or hypnosis).tw.

76 36 or 37 or 38 or 39 or 40 or 41 or 42 or 43 or 44 or 45

77 46 or 47 or 48 or 49 or 50 or 51 or 52 or 53 or 55

78 56 or 57 or 58 or 59 60.mp. or 61 or 62 or 63 or 64 or 65 [mp=title, abstract, heading word, trade name, manufacturer name]

79 66 or 67 or 68 or 69 or 70 or 71 or 72 or 73 or 74 or 75

80 76 or 77 or 78 or 79

81 Child/

82 School child/

83 child$.tw.

84 Adolescence/

85 adolescen$.tw.

86 81 or 82 or 83 or 84 or 85

87 21 and 35

88 87 and 86

89 88 and 80

CINAHL

1 randomised controlled trial.pt.

2 randomised controlled trials/

3 random allocation/

4 double-blind method/

5 single-blind method/

6 clinical trial.pt.

7 exp clinical trials/

8 (clinical$ adj5 trial$).tw.

9 ((singl$ or doubl$ or trebl or tripl$) adj5 (blind$ or mask)).mp. [mp=title, cinahl subject heading, abstract, instrumentation]

10 placebos/

11 (placebo$ or random$).tw.

12 research design/

13 comparative study/

14 exp evaluation studies/

15 follow-up studies/

16 prospective studies/

17 (animal not (human and animal)).ti,ab,sh.

18 *obesity/

19 *obesity, morbid/

20 *pickwickian syndrome/

21 *prader-willi syndrome/

22 *weight gain/

23 obesity.ti.

24 obese.ti.

25 overweight.ti.

26 hyperphagia/

27 *bulimia/

28 or/18-27

29 or/1-16

30 29 and 28

31 30 not 17

32 exp behavior therapy/

33 (behavior adj (therapy or modification)).tw.

34 exp appetite depressants/

35 (appetite adj (suppressant? or depressant)).tw.

36 diet, fat-restricted/

37 diet, reducing/

38 (dieting or (low adj calorie) or diet?).tw.

39 food deprivation/

40 (food adj3 (deprivation or depriving)).tw.

41 exercise/

42 exercise therapy/

43 exertion/

44 (exercise or (physical adj therapy) or fitness).tw.

45 fasting/

46 fasting.tw.

47 (jaw adj3 (wiring or wired)).tw.

48 surgical staplers/

49 surgical stapling/

50 (stomach adj2 (stapling or banding or bypass)).ti,ab,sh.

51 gastric bypass/

52 (gastric adj bypass).tw.

53 health promotion/

54 health education/

55 (prevent or prevention of preventing).tw.

56 nutrition policy/

57 (food adj policy).tw.

58 food habits/ and health policy/

59 (program or programs or programme$ or intervention$).tw.

60 lipectomy/

61 liposuction.tw.

62 (guar adj gum).ti,ab,sh

63 exp alternative medicine/

64 (acupuncture or hypnotism).tw.

65 advertising/

66 ((diet or dieting or slimming) adj club?).tw.

67 weightwatcher?.tw.

68 or/32-67

69 31 and 68

70 limit 69 to (newborn infant < birth to 1 month > or infant < 1 to 23 months > or preschool child < 2 to 5 years > or child < 6 to 12 years > or adolescence < 13 to 18 years >)

PsycLit

1 explode "Obesity"

2 overweight*

3 hyperphagia

4 weight

5 loss

6 reduc*

7 weight near (loss or reduc*)

8 adipos*

9 "Hyperphagia-" in DE

10 appetite

11 disorder*

12 appetite near disorder*

13 #1 or #2 or #3 or #7 or #8 or #9 or #12

14 explode "Food-Intake"

15 "Dietary-Restraint" in DE

16 dietary

17 dieting

18 weight

19 loss

20 reduc*

21 weight with (loss or reduc*)

22 weight

23 control

24 maintenance

25 weight with (control or maintenance)

26 fat

27 reduced

28 fat with reduced

29 "Weight-Control" in DE

30 weight

31 management

32 managing

33 manage

34 weight with (management or managing or manage)

35 explode "Behavior-Therapy"

36 "Behavior-Change" in DE

37 explode "Family-Therapy"

38 "Physical-Fitness" in DE

39 explode "Exercise"

40 explode "Self-Management"

41 "Individual-Psychotherapy" in DE

42 "Group-Psychotherapy" in DE

43 #14 or #15 or #16 or #17 or #21 or #25 or #28 or #29 or #34

44 #35 or #36 or #37 or #38 or #39 or #40 or #41 or #42

45 #43 or #44

46 "Followup-Studies" in DE

47 "Random-Sampling" in DE

48 random*

49 trial

50 random* near trial

51 crossover

52 "Experiment-Controls" in DE

53 followups

54 trial

55 trials

56 #46 or #47 or #48 or #49 or #50 or #51 or #52 or #53 or #54 or #55

57 #13 and #56

58 explode "Children"

59 "Adolescents-" in DE

60 #58 or #59

61 #57 and #60

62 adolescence

63 #60 or #62

64 children

65 #63 or #64

Science and Social Science Citation Indexes

1 (obesity,obese,overweight,adiposity,overeating,overnutrition)

2 (adipose//tissue,weight//gain,body//weight)

3 (increased//weight,excessive//weight,body//fat,hyperphagia)

4 (binge//eating,eating//disorder*,appetite,metabolic//syndrome)

5 #1 or #2 or #3 or #4

6 (child,children,adolescen*)

7 (intervention,interventions,program*,therap*)

8 (medical//supervision)

9 ( (behaviour,behavior) +modification)

10 (diet,diets,dieting,low//calorie,food/2/depriv*,slimming,fat//restrict*)

11 (high//fibre,high//fiber,weight//watchers,correspondence,exercise,physical//activit)

12 (fasting,prevention,preventative,health//education,food//policy,nutritional//policy)

13 (schools,school,health//promotion,prophylaxis)

14 (alternative//medicine,alternative//therap*,acupuncture)

15 (hypnotherapy,hypnosis,homeopath*,hypnotism)

16 #7 or #8 or #9 or #10 or #11 or # 12 or #13 or #14 or #15

17 (rats,rat,mice,mouse,hamster*,porcine,murine)

18 (ponderal//index,skinfold//thickness,skin//fold,weight)

19 (weight//reduction,body//mass,body//weight,body//composition)

20 (weight//loss,weight//maintenance,weight//control,weight//reduction)

21 (fat//loss,fat//control,fat//reduction,weight//change,weight//gain)

22 (fat//free,waist//hip,waist//size,abdomen//hip)

23 #18 or #19 or #20 or #21 or #22

24(random*,trial*,double//blind,single//blind,study,control,control//group*,controls,controlled,placaebo*)

25 (#5 and #6) not #17

26 (anorexia,bulemia)

27 (#25 and #16 and #23 and #24) not #26

Appendix 2. 2001 search strategies

CCTR

1 obesity*:me

2 weight-gain:me

3 weight-loss:me

4 obese or obesity

5 weight next gain or weight next loss

6 overweight or over next weight or overeat* or over next eat*

7 weight next change*

8 (bmi or body next mass next index) near (gain or loss or change)

9 #1 or #2 or #3 or #4 or #5 or #6 or #7 or #8

10 child:me

11 adolescence:me

12 child-preschool:me

13 infant:me

14 child* or adolescen* or infant*

15 teenage* or young next people or young next adult* or young next person

16 schoolchildren or school next children

17 paediatr* or pediatr*

18 boys or girls or youth or youths

19 #10 or #11 or #12 or #13 or #14 or #15 or #16 or #17 or #18

20 #9 and #19

MEDLINE

2explode "Obesity"/ all subheadings

3"Weight-Gain"/ all subheadings "Weight-Loss"/ all subheadings

4obesity or obese

5weight gain or weight loss

6overweight or over weight or overeat* or over eat*

7weight change*

8(bmi or body mass index) near2 (gain or loss or change)

9#1 or #2 or #3 or #4 or #5 or #6 or #7 or #8

10"Child-" in MIME,MJME

11"Adolescence"/ all subheadings

12"Child-Preschool"/ all subheadings

13"Infant-" in MIME,MJME

14child* or adolescen* or infant*

15teenage* or young people or young person or young adult*

16schoolchildren or school children

17p?ediatr* in ti,ab

18boys or girls or youth or youths

19#10 or #11 or #12 or #13 or #14 or #15 or #16 or #17 or #18

20explode "Behavior-Therapy"/ all subheadings

21"Social-Support" in MIME,MJME

22"Family-Therapy"/ all subheadings

23explode "Psychotherapy-Group"/ all subheadings

24(psychological or behavio?r*) adj (therapy or modif* or strateg* or intervention*)

25group therapy or family therapy or cognitive therapy

26(lifestyle or life style) adj (chang* or intervention*)

27counsel?ing

28social support

29peer near2 support

30(children near3 parent?) near therapy

31#20 or #21 or #22 or #23 or #24 or #25 or #26 or #27 or #28 or #29 or #30

32explode "Obesity"/ drug-therapy

33explode "Anti-Obesity-Agents"/ all subheadings

34lipase inhibitor*

35orlistat or xenical or tetrahydrolipstatin

36appetite adj (suppressant* or depressant*)

37sibutramine or (meridia in ti,ab)

38dexfenfluramine or fenfluramine or phentermine

39bulking agent*

40methylcellulose or celevac

41(antiobesity or anti obesity) adj (drug* or agent*)

42guar gum

43#32 or #33 or #34 or #35 or #36 or #37 or #38 or #39 or #40 or #41 or #42

44explode "Obesity"/ diet-therapy

45"Diet-Fat-Restricted"/ all subheadings

46"Diet-Reducing"/ all subheadings

47"Diet-Therapy"/ all subheadings

48"Fasting"/ all subheadings

49diet or diets or dieting

50diet* adj (modif* or therapy or intervention* or strateg*)

51low calorie or calorie control* or healthy eating

52fasting or modified fast*

53explode "Dietary-Fats"/ all subheadings

54fruit or vegetable*

55high fat* or low fat* or fatty food*

56formula diet*

57#44 or #45 or #46 or #47 or #48 or #49 or #50 or #51 or #52 or #53 or #54 or #55 or #56

58"Exercise"/ all subheadings

59"Exercise-Therapy"/ all subheadings

60exercis*

61aerobics or physical therapy or physical activity or physical inactivity

62fitness adj (class* or regime* or program*)

63aerobics or physical therapy or physical training or physical education

64dance therapy

65sedentary behavio?r reduction

66#58 or #59 or #60 or #61 or #62 or #63 or #64 or #65

67explode "Obesity"/ surgery

68"Surgical-Staplers"/ all subheadings

69"Surgical-Stapling"/ all subheadings

70"Lipectomy"/ all subheadings

71"Gastric-Bypass"/ all subheadings

72"Gastroplasty"/ all subheadings

73dental splinting or jaw wiring

74gastroplasty or gastric band* or gastric bypass

75intragastric balloon* or vertical band*

76stomach adj (stapl* or band* or bypass)

77liposuction

78#67 or #68 or #69 or #70 or #71 or #72 or #73 or #74 or #75 or #76 or #77

79explode "Alternative-Medicine"/ all subheadings

80alternative medicine or complementary therap* or complementary medicine

81hypnotism or hypnosis or hypnotherapy

82acupuncture or homeopathy or homoeopathy

83chinese medicine or indian medicine or herbal medicine or ayurvedic

84#79 or #80 or #81 or #82 or #83

85(diet or dieting or slim*) adj (club* or organi?ation*)

86weightwatcher* or weight watcher*

87correspondence adj (course* or program*)

88fat camp* or diet* camp*

89#85 or #86 or #87 or #88

90"Health-Promotion"/ all subheadings

91"Health-Education"/ all subheadings

92health promotion or health education

93media intervention* or community intervention*

94health promoting school*

95(school* near2 program*) or (community near2 program*)

96family intervention* or parent* intervention*

97parent* near2 (behavio?r or involve* or control* or attitude* or educat*)

98#90 or #91 or #92 or #93 or #94 or #95 or #96 or #97

99"Health-Policy"/ all subheadings

100"Nutrition-Policy"/ all subheadings

101health polic* or school polic* or food polic* or nutrition polic*

102#99 or #100 or #101

103explode "Obesity"/ prevention-and-control

104"Primary-Prevention"/ all subheadings

105primary prevention or secondary prevention

106preventive measure* or preventative measure*

107preventive care or preventative care

108obesity near2 (prevent* or treat*)

109#103 or #104 or #105 or #106 or #107 or #108

110explode "Controlled-Clinical-Trials"/ all subheadings

111"Random-Allocation" in MIME,MJME

112"Double-Blind-Method" in MIME,MJME

113"Single-Blind-Method" in MIME,MJME

114"Placebos"/ all subheadings

115explode "Research-Design"/ all subheadings

116(singl* or doubl* or trebl* or tripl*) near5 (blind* or mask*)

117exact{CONTROLLED-CLINICAL-TRIAL} in PT

118placebo*

119matched communities or matched schools or matched populations

120control* near (trial* or stud* or evaluation* or experiment*)

121comparison group* or control group*

122matched pairs

123outcome study or outcome studies

124quasiexperimental or quasi experimental or pseudo experimental

125nonrandomi?ed or non randomi?ed or pseudo randomi?ed

126#110 or #111 or #112 or #113 or #114 or #115 or #116 or #117 or #118 or #119 or #120 or #121 or #122 or #123 or #124 or #125

127#9 and #19

128#31 or #43 or #57 or #66 or #78 or #84 or #89 or #98 or #102 or #109

129#126 and #127 and #128

130animal in tg

131human in tg

132#130 not (#130 and #131)

133#129 not #132

134#133 and (PY >= "1997")

EMBASE

1 explode "obesity"/ all subheadings

2 "weight-gain"/ all subheadings

3 "weight-reduction"/ all subheadings

4 obesity or obese

5 weight gain or weight loss

6 overweight or over weight or overeat* or over eat*

7 weight change*

8 (bmi or body mass index) near2 (gain or loss or change)

9 #1 or #2 or #3 or #4 or #5 or #6 or #7 or #8

10 "child"/ all subheadings

11 "adolescence"/ all subheadings

12 "preschool-child"/ all subheadings

13 "infant"/ all subheadings

14 "school-child"/ all subheadings

15 child* or adolescen* or infant*

16 teenage* or young people or young person or young adult*

17 schoolchildren or school children

18 p?ediatr* in ti,ab

19 boys or girls or youth or youths

20 #10 or #11 or #12 or #13 or #14 or #15 or #16 or #17 or #18 or #19

21 "behavior-therapy"/ all subheadings

22 "social-support"/ all subheadings

23 "family-therapy"/ all subheadings

24 "group-therapy"/ all subheadings

25 "behavior-modification"/ all subheadings

26 "cognitive-therapy"/ all subheadings

27 (psychological or behavio?r*) adj (therapy or modif* or strateg* or intervention*)

28 group therapy or family therapy or cognitive therapy

29 (lifestyle or life style) adj (chang* or intervention*)

30 counsel?ing

31 social support

32 peer near2 support

33 (children near3 parent?) near therapy

34 #21 or #22 or #23 or #24 or #25 or #26 or #27 or #28 or #29 or #30 or #31 or #32 or #33

35 explode "obesity"/ drug-therapy

36 "antiobesity-agent"/ all subheadings

37 lipase inhibitor*

38 orlistat or xenical or tetrahydrolipstatin

39 appetite adj (suppressant* or depressant*)

40 sibutramine or (meridia in ti,ab)

41 dexfenfluramine or fenfluramine or phentermine

42 bulking agent*

43 methylcellulose or celevac

44 (antiobesity or anti obesity) adj (drug* or agent*)

45 guar gum

46 #35 or #36 or #37 or #38 or #39 or #40 or #41 or #42 or #43 or #44 or #45

47 "low-fat-diet"/ all subheadings

48 "low-calory-diet"/ all subheadings

49 "caloric-restriction"/ all subheadings

50 "diet-therapy"/ all subheadings

51 explode "fat-intake"/ all subheadings

52 diet or diets or dieting

53 diet* adj (modif* or therapy or intervention* or strateg*)

54 low calorie or calorie control* or healthy eating

55 fasting or modified fast*

56 fruit or vegetable*

57 high fat* or low fat* or fatty food*

58 formula diet*

59 #47 or #48 or #49 or #50 or #51 or #52 or #53 or #54 or #55 or #56 or #57 or #58

60 "exercise"/ all subheadings

61 "kinesiotherapy"/ all subheadings

62 exercis*

63 aerobics or physical therapy

64 fitness adj (class* or regime* or program*)

65 aerobics or physical therapy or physical training or physical education

66 dance therapy

67 sedentary behavio?r reduction

68 #60 or #61 or #62 or #63 or #64 or #65 or #66 or #67

69 explode "obesity"/ surgery

70 "stapler"/ all subheadings

71 "surgical-stapling"/ all subheadings

72 "lipectomy"/ all subheadings

73 "liposuction"/ all subheadings

74 "stomach-bypass"/ all subheadings

75 "gastroplasty"/ all subheadings

76 dental splinting or jaw wiring

77 gastroplasty or gastric band* or gastric bypass

78 intragastric balloon* or vertical band*

79 stomach adj (stapl* or band* or bypass)

80 liposuction

81 #69 or #70 or #71 or #72 or #73 or #74 or #75 or #76 or #77 or #78 or #79 or #80

82 "alternative-medicine"/ all subheadings

83 alternative medicine or complementary therap*

84 hypnotism or hypnosis or hypnotherapy

85 acupuncture or homeopathy or homoeopathy

86 chinese medicine or indian medicine or herbal medicine or ayurvedic

87 #82 or #83 or #84 or #85 or #86

88 (diet or dieting or slim*) adj (club* or organi?ation*)

89 weightwatcher* or weight watcher*

90 correspondence adj (course* or program*)

91 fat camp* or diet* camp*

92 #88 or #89 or #90 or #91

93 "health-promotion"/ all subheadings

94 "health-education"/ all subheadings

95 health promotion or health education

96 media intervention* or community intervention*

97 health promoting school*

98 (school* near2 program*) or (community near2 program*)

99 family intervention* or parent* intervention*

100 parent* near2 (behavio?r or involve* or control* or attitude* or educat*)

101 #93 or #94 or #95 or #96 or #97 or #98 or #99 or #100

102 "health-care-policy"/ all subheadings

103 health polic* or school polic* or food polic* or nutrition polic*

104 #102 or #103

105 explode "obesity"/ prevention

106 "primary-prevention"/ all subheadings

107 primary prevention or secondary prevention

108 preventive measure* or preventative measure*

109 preventive care or preventative care

110 obesity near2 (prevent* or treat*)

111 #105 or #106 or #107 or #108 or #109 or #110

112 explode "controlled-study"/ all subheadings

113 "randomisation"/ all subheadings

114 "double-blind-procedure"/ all subheadings

115 "single-blind-procedure"/ all subheadings

116 "placebo"/ all subheadings

117 (singl* or doubl* or trebl* or tripl*) near5 (blind* or mask*)

118 placebo*

119 matched communities or matched schools or matched populations

120 control* near (trial* or stud* or evaluation* or experiment*)

121 comparison group* or control group*

122 matched pairs

123 outcome study or outcome studies

124 quasiexperimental or quasi experimental or pseudo experimental

125 nonrandomi?ed or non randomi?ed or pseudo randomi?ed

126 #112 or #113 or #114 or #115 or #116 or #117 or #118 or #119 or #120 or #121 or #122 or #123 or #124 or #125

127 #9 and #20

128 #34 or #46 or #59 or #68 or #81 or #87 or #92 or #101 or #104 or #111

129 #126 and #127 and #128

130 explode "animal"/ all subheadings

131 "nonhuman"/ all subheadings

132 #130 or #131

133 explode "human"/ all subheadings

134 #132 not (#132 and #133)

135 #129 not #134

136 #135 and (PY >= "1998")

CINAHL

1 explode "Obesity"/ all topical subheadings / all age subheadings

2 "Weight-Control"/ all topical subheadings / all age subheadings

3 "Weight-Gain"/ all topical subheadings / all age subheadings

4 "Weight-Loss"/ all topical subheadings / all age subheadings

5 obesity or obese

6 weight gain or weight loss

7 overweight or over weight or overeat* or over eat*

8 weight change*

9 (bmi or body mass index) near2 (gain or loss or change)

10 #1 or #2 or #3 or #4 or #5 or #6 or #7 or #8 or #9

11 #10 in ti,ab,de

12 explode "Child"/ all topical subheadings / all age subheadings

13 "Infant"/ all topical subheadings / all age subheadings

14 "Child-Preschool"/ all topical subheadings / all age subheadings

15 "Adolescence"/ all topical subheadings / all age subheadings

16 child* or adolescen* or infant*

17 teenage* or young people or young person or young adult*

18 schoolchildren or school children

19 p?ediatr* in ti,ab

20 boys or girls or youth or youths

21 #12 or #13 or #14 or #15 or #16 or #17 or #18 or #19 or #20

22#21 in ti,ab,de

23explode "Behavior-Therapy"/ all topical subheadings / all age subheadings

24explode "Support-Psychosocial"/ all topical subheadings / all age subheadings

25"Family-Therapy"/ all topical subheadings / all age subheadings

26"Psychotherapy-Group"/ all topical subheadings / all age subheadings

27"Support-Groups"/ all topical subheadings / all age subheadings

28(psychological or behavio?r*) adj (therapy or modif* or strateg* or intervention*)

29group therapy or family therapy or cognitive therapy

30(lifestyle or life style) adj (chang* or intervention*)

31counsel?ing

32social support

33peer near2 support

34(children near3 parent?) near therapy

35#23 or #24 or #25 or #26 or #27 or #28 or #29 or #30 or #31 or #32 or #33 or #34

36#35 in ti,ab,de

37explode "Obesity"/ drug-therapy / all age subheadings

38explode "Antiobesity-Agents"/ all topical subheadings / all age subheadings

39lipase inhibitor*

40orlistat or xenical or tetrahydrolipstatin

41appetite adj (suppressant* or depressant*)

42sibutramine or (meridia in ti,ab)

43dexfenfluramine or fenfluramine or phentermine

44bulking agent*

45methylcellulose or celevac

46(antiobesity or anti obesity) adj (drug* or agent*)

47guar gum

48#37 or #38 or #39 or #40 or #41 or #42 or #43 or #44 or #45 or #46 or #47

49#48 in ti,ab,de

50"Diet-Fat-Restricted"/ all topical subheadings / all age subheadings

51"Diet-Reducing"/ all topical subheadings / all age subheadings

52"Diet-Therapy"/ all topical subheadings / all age subheadings

53"Fasting"/ all topical subheadings / all age subheadings

54diet or diets or dieting

55diet* adj (modif* or therapy or intervention* or strateg*)

56low calorie or calorie control* or healthy eating

57fasting or modified fast*

58fruit or vegetable*

59high fat* or low fat* or fatty food*

60formula diet*

61explode "Dietary-Fats"/ all topical subheadings / all age subheadings

62explode "Obesity"/ diet-therapy / all age subheadings

63#50 or #51 or #52 or #53 or #54 or #55 or #56 or #57 or #58 or #59 or #60 or #61 or #62

64#63 in ti,ab,de

65explode "Exercise"/ all topical subheadings / all age subheadings

66explode "Therapeutic-Exercise"/ all topical subheadings / all age subheadings

67exercis*

68aerobics or physical therapy

69fitness adj (class* or regime* or program*)

70aerobics or physical therapy or physical training or physical education

71dance therapy

72sedentary behavio?r reduction

73#65 or #66 or #67 or #68 or #69 or #70 or #71 or #72

74#73 in ti,ab,de

75explode "Obesity"/ surgery / all age subheadings

76"Surgical-Stapling"/ all topical subheadings / all age subheadings

77"Lipectomy"/ all topical subheadings / all age subheadings

78"Gastric-Bypass"/ all topical subheadings / all age subheadings

79"Gastroplasty"/ all topical subheadings / all age subheadings

80dental splinting or jaw wiring

81gastroplasty or gastric band* or gastric bypass

82intragastric balloon* or vertical band*

83stomach adj (stapl* or band* or bypass)

84liposuction

85#75 or #76 or #77 or #78 or #79 or #80 or #81 or #82 or #83 or #84

86#85 in ti,ab,de

87explode "Alternative-Therapies"/ all topical subheadings / all age subheadings

88hypnotism or hypnosis or hypnotherapy

89acupuncture or homeopathy or homoeopathy

90chinese medicine or indian medicine or herbal medicine or ayurvedic

91alternative medicine or complementary therap* or complementary medicine

92#87 or #88 or #89 or #90 or #91

93#92 in ti,ab,de

94(diet or dieting or slim*) adj (club* or organi?ation*)

95weightwatcher* or weight watcher*

96correspondence adj (course* or program*)

97fat camp* or diet* camp*

98#94 or #95 or #96 or #97

99#98 in ti,ab,de

100"Health-Promotion"/ all topical subheadings / all age subheadings

101"Health-Education"/ all topical subheadings / all age subheadings

102"Nutrition-Education"/ all topical subheadings / all age subheadings

103"School-Health-Education"/ all topical subheadings / all age subheadings

104health promotion or health education

105media intervention* or community intervention*

106health promoting school*

107(school* near2 program*) or (community near2 program*)

108family intervention* or parent* intervention*

109parent* near2 (behavio?r or involve* or control* or attitude* or educat*)

110#100 or #101 or #102 or #103 or #104 or #105 or #106 or #107 or #108 or #111

111#110 in ti,ab,de

112"Health-Policy"/ all topical subheadings / all age subheadings

113"Nutrition-Policy"/ all topical subheadings / all age subheadings

114health polic* or school polic* or food polic* or nutrition polic*

115#112 or #113 or #114

116#115 in ti,ab,de

117explode "Obesity"/ prevention-and-control / all age subheadings

118primary prevention or secondary prevention

119preventive measure* or preventative measure*

120preventive care or preventative care

121obesity near2 (prevent* or treat*)

122#117 or #118 or #119 or #120 or #121

123#122 in ti,ab,de

124explode "Clinical-Trials"/ all topical subheadings / all age subheadings

125"Random-Assignment"/ all topical subheadings / all age subheadings

126"Placebos"/ all topical subheadings / all age subheadings

127explode "Quasi-Experimental-Studies"/ all topical subheadings / all age subheadings

128(singl* or doubl* or trebl* or tripl*) near5 (blind* or mask*)

129placebo*

130matched communities or matched schools or matched populations

131control* near (trial* or stud* or evaluation* or experiment*)

132comparison group* or control group*

133matched pairs

134outcome study or outcome studies

135quasiexperimental or quasi experimental or pseudo experimental

136randomi?ed or non randomi?ed or pseudo randomi?ed

137 or #125 or #126 or #127 or #128 or #129 or #130 or #131 or #132 or #133 or #134 or #135 or #136

138 in ti,ab,de

#137 in ti,ab,de

#11 and #22

#36 or #49 or #64 or #74 or #86 or #93 or #99 or #111 or #116 or #123

#138 and #139 and #140

#141 and (PY >= "1997")

PsycINFO

#1 (obesity or obese) and (po=human)

#2 (weight gain or weight loss) and (po=human)

#3 (overweight or over weight or overeat* or over eat*) and (po=human)

#4 weight change* and (po=human)

#5 (bmi or body mass index) and (gain or loss or change) and (po=human)

#6 #1 or #2 or #3 or #4 or #5

#7 (child* or adolescen* or infant*) and (po=human)

#8 (teenage* or young people or young person or young adult*) and (po=human)

#9 (schoolchildren or school children) and (po=human)

#10 p?ediatr* and (po=human)

#11 (boys or girls or youth or youths) and (po=human)

#12 #7 or #8 or #9 or #10 or #11

#13 #6 and #12

#14 (singl* or doubl* or trebl* or tripl*) and (blind* or mask*) and (po=human)

#15 placebo* and (po=human)

#16 (matched communities or matched schools or matched populations) and

(po=human)

#17 control* and (trial* or stud* or evaluation* or experiment*) and (po=human)

#18 (comparison group* or control group*) and (po=human)

#19 matched pairs and (po=human)

#20 (outcome study or outcome studies) and (po=human)

#21 (quasiexperimental or quasi experimental or pseudo experimental) and (po=human)

#22 (nonrandomi?ed or non randomi?ed or pseudo randomi?ed) and (po=human)

#23 #14 or #15 or #16 or #17 or #18 or #19 or #20 or #21 or #22

#24 #13 and #23

#25 #6 and #12 and (po=human) and (pt=clinical-trial)

#26#24 or #25

DARE, NHS EED and HTA database

s1 obesity/kwo

s2 weight(w)gain/kwo

s3 weight(w)loss/kwo

s4 obese or obesity

s5 weight(w)gain or weight(w)loss

s6 overweight or over(w)weight or overeat$ or over(w)eat$

s7 weight(w)change$

s8 (bmi or body(w)mass(w)index) and (gain or loss or change)

s9 s1 or s2 or s3 or s4 or s5 or s6 or s7 or s8

s10 child/kwo

s11 adolescence/kwo

s12 child(w)preschool/kwo

s13 infant/kwo

s14 child$ or adolescen$ or infant$

s15 teenage$ or young(w)people or young(w)adult$ or young(w)person

s16 schoolchildren or school(w)children

s17 paediatr$ or pediatr$

s18 boys or girls or youth or youths

s19 s10 or s11 or s12 or s13 or s14 or s15 or s16 or s17 or s18

s20 s9 and s19

s21 (1997 or 1998 or 1999 or 2000 or 2001)/dat

s22 s20 and s21

Kings Fund database, HELM, DH-Data

1 obesity or obese

2 weight gain or weight loss

3 overweight or over weight or overeat* or over eat*

4 weight change*

5 (bmi or body mass index) near2 (gain or loss or change)

6 #1 or #2 or #3 or #4 or #5

7 child* or adolescen* or infant*

8 teenage* or young people or young person or young adult*

9 schoolchildren or school children

10 p?ediatr* in ti,ab

11 boys or girls or youth or youths

12 #7 or #8 or #9 or #10 or #11

13 (singl* or doubl* or trebl* or tripl*) near5 (blind* or mask*)

14 placebo*

15 matched communities or matched schools or matched populations

16 control* near (trial* or stud* or evaluation* or experiment*)

17 comparison group* or control group*

18 matched pairs

19 outcome study or outcome studies

20 quasiexperimental or quasi experimental or pseudo experimental

21 nonrandomi?ed or non randomi?ed or pseudo randomi?ed

22 #13 or #14 or #15 or #16 or #17 or #18 or #19 or #20 or #21

23 #6 and #12 and #22

24 #23 and (PY >= "1997")

Science and Social Science Citation Indexes

NB. Took out phrases 'over weight'/'over eat' because 'over' is a stop word, and so would not be searched by the search engine (obesity or obese or weight gain or weight loss or overweight or overeat* or weight change or bmi gain or bmi change or bmi loss) and (child* or adolescen* or infant* or teenage* or young people or young person or young adult* or schoolchildren or school children or pediatr* or paediatr* or boys or girls or youth or youths) and (((singl* or doubl* or trebl* or tripl*) and (blind* or mask*)) or control* group* or control* trial* or control* stud* or comparison group* or placebo* or matched communit* or matched school* or matched population* or nonrandomised or nonrandomized or non-randomized or non-randomised or quasiexperimental or quasi experimental or pseudo experimental)

Appendix 3. 2008 search strategies

The Cochrane Library, including CENTRAL (Issue 2, 2008)

#1 MeSH descriptor obesity explode all trees  3809 

#2 MeSH descriptor weight gain this term only  878  

#3 MeSH descriptor weight loss this term only  1556  

#4 (obese  or obesity )  6534  

#5 (weight next gain  or weight next loss )  6571  

#6 (overweight  or over next weight  or overeat*  or over next eat* )  1602  

#7 weight next chang*  755  

#8 (bmi  near/6 gain )  43  

#9 (bmi  near/6 loss )  84  

#10 (bmi  near/6 change )  268  

#11 (body next mass next index  near/6 gain )  65  

#12 (body next mass next index  near/6 loss )  111 

#13 (body next mass next index  near/6 change )  308  

#14 (#1 or #2 or #3 or #4 or #5 or #6 or #7 or #8 or #9 or #10 or #11 or #12 or #13)  11637  

#15 MeSH check word Child 31551  

#16 MeSH descriptor Adolescent this term only  55746  

#17 MeSH descriptor Infant explode all trees  9595  

#18 (child*  or adolescen*  or infant* )  108446  

#19 (teenage*  or young next people  or young next adult*  or young next person )  2711  

#20 schoolchildren  594  

#21 (paediatr*  or pediatr* )  24946  

#22 (boys  or girls  or youth  or youths )  4303  

#23 (#15 or #16 or #17 or #18 or #19 or #20 or #21 or #22)  112769  

#24 (#14 and #23)  3379

MEDLINE (on Ovid)

#1 exp Obesity/ (86668)

#2 Weight Gain/ (15116)

#3 Weight Loss/ (14429)

#4 obes$.tw. (91066)

#5 (weight gain or weight loss).tw. (56570)

#6 (overweight or over weight or overeat$ or over eat$).tw. (17401)

#7 weight change$.tw. (4450)

#8 ((bmi or body mass index) adj2 (gain or loss or change)).tw. (1005)

#9 or/1-8 (176730)

#10 exp Behavior Therapy/ (36740)

#11 Support Groups/ (6306)

#12 Family Therapy/ (6495)

#13 exp Psychotherapy, Group/ (19285)

#14 Behavior Modification/ (19393)

#15 Social support/ (32589)

#16 ((psychological or behavio?r$) adj (therapy or modif$ or strateg$ or intervention$)).tw. (13054)

#17 (group therapy or family therapy or cognitive therapy).tw. (5630)

#18 ((lifestyle or life style) adj (chang$ or intervention$)).tw. (3268)

#19 Counseling/ (21741)

#20 Directive counselling/ (303)

#21 counsel?ing.tw. (36645)

#22 social support.tw. (12238)

#23 (peer adj2 support).tw. (745)

#24 Motivation/ (35253)

#25 (children adj3 parent$ adj3 therap$).tw. (100)

#26 or/10-25 (179755)

#27 exp Obesity/dh [Diet Therapy] (4156)

#28 Diet Therapy/ (8812)

#29 Diet, Fat-Restricted/ (1901)

#30 Diet reducing/ (7687)

#31 Caloric restriction/ (1351)

#32 Fasting/ (23430)

#33 (diet or diets or dieting).tw. (164473)

#34 (low calorie or calorie control$ or healthy eating).tw. (2489)

#35 (fasting or modified fast$).tw. (47535)

#36 exp Dietary Fats/ (55935)

#37 exp Fruit/ (34339)

#38 exp Vegetables/ (58744)

#39 (fruit or vegetable$).tw. (30052)

#40 (high fat$ or low fat$ or fatty food$).tw. (13421)

#41 formula diet$.tw. (559)

#42 or/27-41 (347981)

#43 exp Exercise/ (59991)

#44 exercis$.tw. (134831)

#45 (aerobics or physical therapy or physical activity or physical inactivity).tw. (33786)

#46 (fitness adj3 (class$ or regime$ or program$)).tw. (744)

#47 exp "Physical Education and Training"/ (11468)

#48 physical education.tw. (1797)

#49 Dance Therapy/ (119)

#50 (dance or dancing).tw. (1626)

#51 Physical Activity/ (51407)

#52 sedentary behavio?r.tw. (318)

#53 ((slim$ or diet or dieting) adj2 (club$ or organi?ation$)).tw. (34)

#54 (weightwatcher$ or weight watcher$).tw. (47)

#55 (correspondence adj (course$ or program$)).tw. (79)

#56 (camp or camps).tw. (60053)

#57 or/43-56 (292790)

#58 exp Health Promotion/ (33804)

#59 exp Health Education/ (106002)

#60 (health adj2 (educat$ or promot$)).tw. (35865)

#61 ((media or community) adj2 intervention$).tw. (2160)

#62 School health services/ (11404)

#63 School nursing/ (3492)

#64 ((school$ or communit$) adj2 (program$ or intervention$)).tw. (9235)

#65 (family intervention$ or parent$ intervention).tw. (685)

#66 (parent$ adj2 (behavio?r or involve$ or control$ or attitude$ or educat$)).tw. (8280)

#67 or/58-66 (173931)

#68 exp Health Policy/ (55105)

#69 ((health or school$ or food or nutrition) adj2 (policy or policies)).tw. (12292)

#70 exp Obesity/pc [Prevention and Control] (5921)

#71 Primary prevention/ (9988)

#72 Preventive health services/ (8470)

#73 (primary prevention or secondary prevention).tw. (13545)

#74 ((preventive or preventative) adj2 (measure$ or care)).tw. (14655)

#75 (obesity adj2 (prevent$ or treat$)).tw. (5380)

#76 or/68-75 (113310)

#77 26 or 42 or 57 or 67 or 76 (1019691)

#78 Child/ (1104915)

#79 exp Infant/ (778916)

#80 Child, Preschool/ (612111)

#81 Adolescence/ (1259668)

#82 (child$ or adolescen$ or infant$).tw. (923147)

#83 (teenage$ or young people or young person or young adult$).tw. (53160)

#84 schoolchildren.tw. (7479)

#85 (boys or girls or youth or youths).tw. (72664)

#86 (paediatric$ or paediatric$).tw. (133744)

#87 or/78-86 (2474848)

#88 9 and 77 and 87 (14431)

#89 exp Anti-Obesity Agents/ (6755)

#90 Metformin/ (3454)

#91 ((anti-obes$ or antiobes$) adj2 (agent$ or drug$ or medicine$)).tw. (478)

#92 ((anti-obes$ or antiobes$) adj2 (agent$ or drug$)).tw. (475)

#93 sibutramine.tw. (558)

#94 rimonabant.tw. (388)

#95 metformin.tw. (3743)

#96 reductil.tw. (13)

#97 lipstatin.tw. (14)

#98 orlistat.tw. (621)

#99 xenical.tw. (57)

#100 acomplia.tw. (17)

#101 glucophage.tw. (67)

#102 (appetite adj2 (suppressant$ or depressant$)).tw. (518)

#103 (weight loss adj2 agent$).tw. (48)

#104 Anorexigenic Agent$.tw. (74)

#105 or/89-104 (12178)

#106 exp Bariatric Surgery/ (8328)

#107 gastroplast$.tw. (1501)

#108 bariatric surgery.tw. (2422)

#109 gastric bypass$.tw. (3092)

#110 (gastric adj2 band$).tw. (1612)

#111 (surgery adj2 obes$).tw. (769)

#112 exp Obesity/su [Surgery] (6220)

#113 Lap-band system.tw. (52)

#114 or/106-113 (11508)

#115 exp Obesity/th [Therapy] (8751)

#116 105 or 114 or 115 (30841)

#117 9 and 87 and 116 (3652)

#118 117 or 88 (16100)

#119 randomised controlled trial.pt. (257171)

#120 controlled clinical trial.pt. (78507)

#121 Randomized controlled trials/ (54762)

#122 random allocation/ (61472)

#123 double blind method/ (98005)

#124 single-blind method/ (12139)

#125 or/119-124 (434227)

#126 exp animal/ not humans/ (3314999)

#127 125 not 126 (406668)

#128 clinical trial.pt. (451614)

#129 exp Clinical Trials as Topic/ (205487)

#130 (clin$ adj25 trial$).ti,ab. (146475)

#131 ((singl$ or doubl$ or trebl$ or tripl$) adj (blind$ or mask$)).ti,ab. (94704)

#132 placebos/ (27373)

#133 placebo$.ti,ab. (110676)

#134 random$.ti,ab. (411848)

#135 research design/ (52826)

#136 or/128-135 (918397)

#137 136 not 126 (852755)

#138 127 or 137 (876380)

#139 118 and 138 (2518)

#140 limit 139 to yr="2001 - 2008" (1550)

EMBASE (on Ovid)

1 exp Obesity/ (89174)

2 Weight Gain/ (24911)

3 Weight reduction/ (35560)

4 obes$.tw. (73716)

5 (weight gain or weight loss).tw. (47379)

6 (overweight or over weight or overeat$ or over eat$).tw. (14658)

7 weight change$.tw. (3562)

8 ((bmi or body mass index) adj2 (gain or loss or change)).tw. (845)

9 or/1-8 (167541)

10 Behavior Therapy/ (20228)

11 Support Group/ (3704)

12 Family Therapy/ (4536)

13 Group Therapy/ (7151)

14 Behavior Modification/ (5063)

15 Social support/ (15422)

16 ((psychological or behavio?r$) adj (therapy or modif$ or strateg$ or intervention$)).tw. (13198)

17 (group therapy or family therapy or cognitive therapy).tw. (5179)

18 ((lifestyle or life style) adj (chang$ or intervention$)).tw. (2971)

19 exp Counseling/ (44293)

20 counsel?ing.tw. (30056)

21 social support.tw. (9726)

22 (peer adj2 support).tw. (511)

23 Motivation/ (17068)

24 (children adj3 parent$ adj3 therap$).tw. (85)

25 or/10-24 (128533)

26 exp Obesity/th [Therapy] (5608)

27 Diet Therapy/ (13785)

28 low fat diet/ (2907)

29 Low calory diet/ (1640)

30 Diet restriction/ (20425)

31 (diet or diets or dieting).tw. (121149)

32 (low calorie or calorie control$ or healthy eating).tw. (1950)

33 (fasting or modified fast$).tw. (41403)

34 exp Fat intake/ (16563)

35 dietary intake/ (30097)

36 exp Fruit/ (20920)

37 exp Vegetables/ (45258)

38 (fruit or vegetable$).tw. (22531)

39 (high fat$ or low fat$ or fatty food$).tw. (11804)

40 formula diet$.tw. (445)

41 or/26-40 (256022)

42 exp Exercise/ (82313)

43 exercis$.tw. (113167)

44 (aerobics or physical therapy or physical activity or physical inactivity).tw. (29641)

45 (fitness adj3 (class$ or regime$ or program$)).tw. (584)

46 exp Physical Education/ (1862)

47 physical education.tw. (1198)

48 (dance or dancing).tw. (1382)

49 exp Physical Activity/ (93042)

50 sedentary behavio?r.tw. (279)

51 ((slim$ or diet or dieting) adj2 (club$ or organi?ation$)).tw. (27)

52 (weightwatcher$ or weight watcher$).tw. (33)

53 (correspondence adj (course$ or program$)).tw. (23)

54 (camp or camps).tw. (51815)

55 or/42-54 (270711)

56 Health Promotion/ (24020)

57 Health Education/ (26626)

58 Nutrition education/ (549)

59 School health education/ (90)

60 (health adj2 (educat$ or promot$)).tw. (19243)

61 ((media or community) adj2 intervention$).tw. (1645)

62 School health service/ (1997)

63 School health nursing/ (45)

64 ((school$ or communit$) adj2 (program$ or intervention$)).tw. (5984)

65 (family intervention$ or parent$ intervention).tw. (643)

66 (parent$ adj2 (behavio?r or involve$ or control$ or attitude$ or educat$)).tw. (6061)

67 or/56-66 (66676)

68 exp Health Care Policy/ (54465)

69 Health program/ (50929)

70 ((health or school$ or food or nutrition) adj2 (policy or policies)).tw. (8327)

71 exp Obesity/pc, dm, rh [Prevention, Disease Management, Rehabilitation] (3675)

72 Primary prevention/ (9281)

73 Preventive health service/ (4334)

74 (primary prevention or secondary prevention).tw. (12960)

75 ((preventive or preventative) adj2 (measure$ or care)).tw. (10695)

76 (obesity adj2 (prevent$ or treat$)).tw. (4336)

77 or/68-76 (137986)

78 25 or 41 or 55 or 67 or 77 (774543)

79 exp Child/ (607372)

80 (child$ or adolescen$ or infant$).tw. (616520)

81 (teenage$ or young people or young person or young adult$).tw. (42974)

82 schoolchildren.tw. (4394)

83 (boys or girls or youth or youths).tw. (54357)

84 (paediatric$ or paediatric$).tw. (111854)

85 or/79-84 (925434)

86 9 and 78 and 85 (8999)

87 Antiobesity Agent/ (1180)

88 Sibutramine/ (2034)

89 exp Anorexigenic Agent/ (25367)

90 Rimonabant/ (2888)

91 Metformin/ (12294)

92 ((anti-obes$ or antiobes$) adj2 (agent$ or drug$ or medicine$)).tw. (506)

93 ((anti-obes$ or antiobes$) adj2 (agent$ or drug$)).tw. (501)

94 sibutramine.tw. (602)

95 rimonabant.tw. (499)

96 metformin.tw. (3979)

97 reductil.tw. (215)

98 lipstatin.tw. (17)

99 orlistat.tw. (931)

100 xenical.tw. (648)

101 acomplia.tw. (227)

102 glucophage.tw. (990)

103 (appetite adj2 (suppressant$ or depressant$)).tw. (372)

104 (weight loss adj2 agent$).tw. (42)

105 Anorexigenic Agent$.tw. (33)

106 or/87-105 (40391)

107 exp Bariatric Surgery/ (3885)

108 gastroplast$.tw. (1187)

109 bariatric surgery.tw. (1972)

110 gastric bypass$.tw. (2328)

111 (gastric adj2 band$).tw. (1127)

112 (surgery adj2 obes$).tw. (625)

113 exp Obesity/su [Surgery] (4982)

114 Lap-band system.tw. (30)

115 or/107-114 (7602)

116 exp Obesity/th [Therapy] (5608)

117 106 or 115 or 116 (50739)

118 9 and 85 and 117 (2167)

119 118 or 86 (9717)

120 controlled clinical trial/ (45910)

121 random$.tw. (369899)

122 randomised controlled trial/ (157804)

123 follow-up.tw. (333189)

124 double blind procedure/ (69280)

125 placebo$.tw. (105339)

126 placebo/ (113348)

127 factorial$.ti,ab. (7623)

128 (crossover$ or cross-over$).ti,ab. (37985)

129 (double$ adj blind$).ti,ab. (81997)

130 (singl$ adj blind$).ti,ab. (7143)

131 assign$.ti,ab. (102901)

132 allocat$.ti,ab. (32311)

133 volunteer$.ti,ab. (95107)

134 Crossover Procedure/ (20276)

135 Single Blind Procedure/ (7545)

136 or/120-135 (963194)

137 (exp animals/ or nonhuman/) not human/ (2588469)

138 136 not 137 (880257)

139 119 and 138 (1797)

140 limit 139 to yr="2001 - 2008" (1264)

CINAHL

1     "randomised controlled trial".pt. (0)

2     randomised controlled trials/ (42740)

3     random allocation/ (0)

4     double-blind method/ (0)

5     single-blind method/ (0)

6     clinical trial.pt. (28635)

7     exp clinical trials/ (55623)

8     (clinical$ adj5 trial$).tw. (13599)

9     ((singl$ or doubl$ or trebl or tripl$) adj5 (blind$ or mask)).mp. [mp=title, subject heading word, abstract, instrumentation] (15015)

10     placebos/ (4101)

11     (placebo$ or random$).tw. (53031)

12     research design/ (3536)

13     comparative study/ (43421)

14     exp evaluation studies/ (11780)

15     follow-up studies/ (68863)

16     prospective studies/ (68863)

17     (animal not (human and animal)).ti,ab,sh. (2971)

18     *obesity/ (7889)

19     *obesity, morbid/ (490)

20     *pickwickian syndrome/ (21)

21     *prader-willi syndrome/ (117)

22     *weight gain/ (928)

23     obesity.ti. (4229)

24     obese.ti. (1358)

25     overweight.ti. (1093)

26     hyperphagia/ (63)

27     *bulimia/ (828)

28     or/18-27 (10809)

29     or/1-16 (185254)

30     29 and 28 (2387)

31     30 not 17 (2379)

32     exp behavior therapy/ (5454)

33     (behavior adj (therapy or modification)).tw. (491)

34     exp appetite depressants/ (1449)

35     (appetite adj (suppressant? or depressant)).tw. (31)

36     diet, fat-restricted/ (966)

37     diet, reducing/ (1461)

38     (dieting or (low adj calorie) or diet?).tw. (12530)

39     food deprivation/ (0)

40     (food adj3 (deprivation or depriving)).tw. (23)

41     exercise/ (10978)

42     exercise therapy/ (6592)

43     exertion/ (1876)

44     (exercise or (physical adj therapy) or fitness).tw. (30895)

45     fasting/ (724)

46     fasting.tw. (2897)

47     (jaw adj3 (wiring or wired)).tw. (1)

48     surgical staplers/ (0)

49     surgical stapling/ (107)

50     (stomach adj2 (stapling or banding or bypass)).ti,ab,sh. (5)

51     gastric bypass/ (298)

52     (gastric adj bypass).tw. (160)

53     health promotion/ (14074)

54     health education/ (7717)

55     (prevent or prevention of preventing).tw. (17081)

56     nutrition policy/ (619)

57     (food adj policy).tw. (22)

58     food habits/ and health policy/ (12)

59     (program or programs or programme$ or intervention$).tw. (139125)

60     lipectomy/ (147)

61     liposuction.tw. (90)

62     (guar adj gum).ti,ab,sh. (24)

63     exp alternative medicine/ (52458)

64     (acupuncture or hypnotism).tw. (2977)

65     advertising/ (3012)

66     ((diet or dieting or slimming) adj club?).tw. (5)

67     weightwatcher?.tw. (0)

68     or/32-67 (257022)

69     31 and 68 (1183)

70     limit 69 to (newborn infant <birth to 1 month> or infant <1 to 23 months> or preschool child <2 to 5 years> or child <6 to 12 years> or adolescence <13 to 18 years>) (399)

71     limit 70 to yr="2001 - 2008" (323)

72     from 71 keep 1-323 (323)

PsychINFO

#32 #31 and (PY=2001-2008)(657 records)

#31 #17 and #30(972 records)

#30 #18 or #19 or #20 or #21 or #22 or #23 or #24 or #25 or #26 or #27 or #28 or #29 (225896 records)

#29 TREATMENT-OUTCOME-CLINICAL-TRIAL in MD(12341 records)

#28 "Clinical-Trials" in MJ,MN(1861 records)  Searches and results below from saved search history  RCT filter terms

#27 "Placebo-" in MJ,MN(1922 records)  Searches and results below from saved search history  9911 obesity 2 1 2008

#26 volunteer*(19028 records)

#25 prospectiv*(21076 records)

#24 (control or comparison) near group(45367 records)

#23 PROSPECTIVE-STUDY in MD(6986 records)

#22 LONGITUDINAL-STUDY in MD(48788 records)

#21 FOLLOWUP-STUDY in MD(28411 records)

#20 (clinical* stud*) or (single-blind) or (single blind) or (triple-blind) or (triple blind)(7553 records)

#19 (random*) or (clinical trial*) or (controlled study) or ((double-blind)or (double blind))(86179 records)

#18 TREATMENT-OUTCOME-CLINICAL-TRIAL in MD(12341 records)

#17 #10 and #16(4743 records)

#16 #11 or #12 or #13 or #14 or #15(601897 records)

#15 boys or girls or youth or youths(84169 records)

#14 pediatr* or paediatr*(27296 records)

#13 child* or adololescen* or infant*(471482 records)

#12 child* or adolescen*(507086 records)

#11 CHILDHOOD in AG(294367 records)

#10 #1 or #2 or #3 or #4 or #5 or #6 or #7 or #8 or #9(19171 records)

#9 (bmi or body mass) near (gain* or loss* or change*)(739 records)

#8 weight change*(864 records)

#7 overeat* or over eat*(997 records)

#6 overweight or over weight(3414 records)

#5 weight loss*(4492 records)

#4 weight gain*(4267 records)

#3 obes*(11040 records)

#2 "Weight-Control" in MJ,MN(2454 records)

#1 explode "Overweight-" in MJ,MN(7031 records)

Science and Social Science Citation Indexes on ISI Web of Science

#5 (#1 or #2 or #3 or #4); Timespan=2001-2008

#4 ts=((appetite adj2 (suppressant$ or depressant$)) or (rimonabant or metformin or reductil or lipstatin or orlistat or xenical or acomplia or glugophage) or ((anti-obes* or antiobes* or "weight loss") same (agent* or drug* or medicine*))) and ts=((child* or adolescen* or infant* or teenage* or "young people" or "young person" or "young adult*" or schoolchildren or pediatr* or paediatr* or boys or girls or youth or youths) and (Random* or trial* or placebo* or control* or ((singl* or doubl* or trebl* or tripl*) and (blind* or mask*)) or (comparison same group*) or (clinical same trial*)))

#3 ts=((bariatric same surgery) or gastroplas* or (gastric same (bypass* or band*)) or (lap same band same system) or (obes* same (surgery or surgical))) and ts=((child* or adolescen* or infant* or teenage* or "young people" or "young person" or "young adult*" or schoolchildren or pediatr* or paediatr* or boys or girls or youth or youths) and (Random* or trial* or placebo* or control* or ((singl* or doubl* or trebl* or tripl*) and (blind* or mask*)) or (comparison same group*) or (clinical same trial*)))

#2 TS=(((obesity or obese or "weight gain" or "weight loss" or overweight or overeat* or (weight same change) or (bmi same gain) or (bmi same change) or (bmi same loss)) and (child* or adolescen* or infant* or teenage* or "young people" or "young person" or "young adult*" or schoolchildren or pediatr* or paediatr* or boys or girls or youth or youths)) and (Random* or trial* or placebo* or control* or ((singl* or doubl* or trebl* or tripl*) and (blind* or mask*)) or (comparison same group*) or (clinical same trial*))) and TS=(therap* or support or modif* or training)

#1 TS=(((obesity or obese or "weight gain" or "weight loss" or overweight or overeat* or (weight same change) or (bmi same gain) or (bmi same change) or (bmi same loss)) and (child* or adolescen* or infant* or teenage* or "young people" or "young person" or "young adult*" or schoolchildren or pediatr* or paediatr* or boys or girls or youth or youths)) and (Random* or trial* or placebo* or control* or ((singl* or doubl* or trebl* or tripl*) and (blind* or mask*)) or (comparison same group*) or (clinical same trial*))) and TS=(Program* or manage* or intervention* or diet* or activity or counsel* or educat* or promot*)

What's new

  1. Top of page
  2. Abstract
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Implications for research
  10. Acknowledgements
  11. Characteristics of studies
  12. Data and analyses
  13. Appendices
  14. What's new
  15. History
  16. Contributions of authors
  17. Declarations of interest
  18. Sources of support
  19. REFERENCES

Last assessed as up-to-date: 10 October 2008.

11 October 2008New citation required and conclusions have changedThis review concludes that combined behavioural lifestyle interventions compared to standard care or self-help can produce a significant and clinically meaningful reduction in overweight in children and adolescents. The search was updated to May 2008. Some amendments were made to update the search strategies. No changes have been made to other aspects of the methodology. Forty-six new studies have been included. These included information on drug interventions for treating obesity in adolescents. The added evidence suggests that lifestyle interventions appear to have positive effects in the treatment of child and adolescent obesity. Furthermore, orlistat and sibutramine were found to have beneficial effects on adiposity in obese adolescents. However, a range of adverse effects was noted.
3 July 2008AmendedConverted to new review format. Authorship changed with new authors and new contact person.

Contributions of authors

  1. Top of page
  2. Abstract
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Implications for research
  10. Acknowledgements
  11. Characteristics of studies
  12. Data and analyses
  13. Appendices
  14. What's new
  15. History
  16. Contributions of authors
  17. Declarations of interest
  18. Sources of support
  19. REFERENCES

HOL: Co-ordinated the update of the review; Extracted and checked information from all included/excluded papers; Performed meta-analysis; Wrote the update of the review; Assisted in final editing of 2008 review.

LAB: Reviewed papers for inclusion/exclusion; Extracted and checked information from all included/excluded papers; Helped write text of review; Assisted in final editing of review.

HJ: Reviewed papers for inclusion/exclusion; Extracted and checked information from all included/excluded papers; Helped write text of review; Assisted in final editing of review.

VS: Reviewed papers for inclusion/exclusion; Extracted and checked information from all included/excluded papers; Helped write text of review; Assisted in final editing of review.

CO: Reviewed papers for inclusion/exclusion; Extracted and checked information from all included/excluded papers; Helped write text of review; Assisted in final editing of review.

RS: Reviewed papers for inclusion/exclusion; Checked information from all included/excluded papers; Performed meta-analysis; Helped write text of review; Assisted in final editing of review.

CS: Reviewed papers for inclusion/exclusion; Extracted and checked information from all included/excluded papers; Helped write text of review. Assisted in final editing of review.

Declarations of interest

  1. Top of page
  2. Abstract
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Implications for research
  10. Acknowledgements
  11. Characteristics of studies
  12. Data and analyses
  13. Appendices
  14. What's new
  15. History
  16. Contributions of authors
  17. Declarations of interest
  18. Sources of support
  19. REFERENCES

Louise Baur is a co-author on three of the papers included in the Cochrane Review (Srinivasan 2006; Golley 2007; McCallum 2007).

Hiltje Oude Luttikhuis and Ronald Stolk are involved in the design and conduct of a potentially eligible study for this review. The clinical trial registration number for this ongoing trial is ISRCTN47185691.

Sources of support

  1. Top of page
  2. Abstract
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Implications for research
  10. Acknowledgements
  11. Characteristics of studies
  12. Data and analyses
  13. Appendices
  14. What's new
  15. History
  16. Contributions of authors
  17. Declarations of interest
  18. Sources of support
  19. REFERENCES

Internal sources

  • University Medical Center, Groningen, Netherlands.

  • The Children's Hospital at Westmead, Sydney, Australia.

  • Centre for Food Physical Activity and Obesity Research, University of Teesside, UK.

  • The Wolfson Research Institute, University of Durham, UK.

  • Australian National Health & Medical Research Council, Australia. Postgraduate Research Scholarship for Ms Shrewsbury

External sources

  • No sources of support supplied

REFERENCES

  1. Top of page
  2. Abstract
  3. Background
  4. Objectives
  5. Methods
  6. Results
  7. Discussion
  8. Authors' conclusions
  9. Implications for research
  10. Acknowledgements
  11. Characteristics of studies
  12. Data and analyses
  13. Appendices
  14. What's new
  15. History
  16. Contributions of authors
  17. Declarations of interest
  18. Sources of support
  19. REFERENCES
  • References to studies included in this review
  • Berkowitz 2003 {published data only}
  • Berkowitz RI, Wadden TA, Tershakovec AM, Cronquist JL. Behavior therapy and sibutramine for the treatment of adolescent obesity: a randomized controlled trial. JAMA : the journal of the American Medical Association 2003;289(14):1805-12. [DOI: 10.1001/jama.289.14.1805]
  • Budd GM, Hayman LL, Crump E, Pollydore C, Hawley KD, Cronquist JL, et al.Weight loss in obese African American and Caucasian adolescents: secondary analysis of a randomized clinical trial of behavioral therapy plus sibutramine. The Journal of cardiovascular nursing 2007;22(4):288-96.
  • Berkowitz 2006 {published data only}
  • Berkowitz RI, Fujioka K, Daniels SR, Hoppin AG, Owen S, Perry AC, et al.Effects of sibutramine treatment in obese adolescents: a randomized trial. Annals of Internal Medicine 2006;145(2):81-90.
  • Daniels SR, Long B, Crow S, Styne D, Sothern M, Vargas-Rodriguez I, et al.Cardiovascular effects of sibutramine in the treatment of obese adolescents: results of a randomized, double-blind, placebo-controlled study. Pediatrics 2007;120(1):e147-57.
  • Berry 2007 {published data only}
  • Berry D, Savoye M, Melkus G, Grey M. An intervention for multiethnic obese parents and overweight children. Applied Nursing Research 2007;20(2):63-71.
  • Braet 2004 {published data only}
  • Braet C, Tanghe A, Decaluwe V, Moens E, Rosseel Y. Inpatient treatment for children with obesity: Weight loss, psychological well-being, and eating behavior. Journal of Pediatric Psychology 2004;29(7):519-29. [DOI: 10.193/jpepsy/jsh054]
  • Carrel 2005 {published data only}
  • Carrel AL, Clark RR, Peterson SE, Nemeth BA, Sullivan J, Allen DB. Improvement of fitness, body composition, and insulin sensitivity in overweight children in a school-based exercise program: a randomized, controlled study. Archives of Pediatrics & Adolescent Medicine 2005;159(10):963-8.
  • Chanoine 2005 {published and unpublished data}
  • * Chanoine J, Hampl S, Jensen C, Boldrin M, Hauptman J. Effect of orlistat on weight and body composition in obese adolescents: a randomized controlled trial. JAMA: Journal of the American Medical Association. June15, 2005;293(23):2873-83.
  • Daley 2006 {published data only}
  • * Daley AJ, Copeland RJ, Wright NP, Roalfe A, Wales JK. Exercise therapy as a treatment for psychopathologic conditions in obese and morbidly obese adolescents: a randomized, controlled trial. Pediatrics 2006;118(5):2126-34.
  • Daley AJ, Copeland RJ, Wright NP, Wales JKH. Protocol for: Sheffield Obesity Trial (SHOT): a randomised controlled trial of exercise therapy and mental health outcomes in obese adolescents [ISRCNT83888112]. BMC Public Health 2005;5:113.
  • De Mello 2004 {published data only}
  • de Mello ED, Luft VC, Meyer F. Individual outpatient care versus group education programs. Which leads to greater change in dietary and physical activity habits for obese children? [Atendimento ambulatorial individualizado versus programa de educacao em grupo: qual oferece mais mudanca de habitos alimentares e de atividade fisica em criancas obesas?]. Jornal de Pediatria 2004;80(6):468-74.
  • Duffy 1993 {published data only}
  • Duffy G, Spence SH. The effectiveness of cognitive self management as an adjunct to a behavioural intervention for childhood obesity: a research note. Journal of Child Psychology and Psychiatry 1993;34(6):1043-1050.
  • Ebbeling 2003 {published data only}
  • Ebbeling CB, Leidig MM, Sinclair KB, Hangen JP, Ludwig DS. A reduced-glycemic load diet in the treatment of adolescent obesity. Archives of Pediatrics & Adolescent Medicine 2003;157(8):773-9.
  • Epstein 1985a {published data only}
  • Epstein LH, Wing RR, Koeske R, Valoski A. A comparison of lifestyle exercise, aerobic exercise, and calisthenics on weight loss in obese children. Behaviour Therapy 1985;16:345-56.
  • Epstein 1985b {published data only}
  • Epstein LH, Wing RR, Penner BC, Kress MJ. Effect of diet and controlled exercise on weight loss in obese children. The Journal of Pediatrics 1985;107:358-61.
  • Epstein 1985c {published data only}
  • Epstein LH, Wing RR, Woodall K, Penner BC, Kress MJ, Koeske R. Effects of family-based behavioural treatment on obese 5-to-8-year-old children. Behaviour Therapy 1985;16:205-12.
  • Epstein 1994a {published data only}
  • Epstein LH, McKenzie SJ, Valoski A, Klein KR, Wing RR. Effects of mastery criteria and contingent reinforcement for family-based child weight control. Addictive Behaviours 1994;19(2):135-45.
  • Epstein 1995 {published data only}
  • Epstein LH, Valoski AM, Vara LS, McCurley J, Wisniewski L, Kalarchian MA, et al.Effects of decreasing sedentary behaviour and increasing activity on weight change in obese children. Health Psychology 1995;14(2):109-15.
  • Epstein 2000a {published data only}
  • * Epstein LH, Paluch RA, Gordy CC, Saelens BE, Ernst MM. Problem solving in the treatment of childhood obesity. Journal of Consulting and Clinical Psychology 2000;68(4):717-21.
  • Epstein LH, Paluch RA, Saelens BE, Ernst MM, Wifley DE. Changes in eating disorder symptoms with pediatric obesity treatment. Journal of Pediatrics 2001;139:58-65.
  • Epstein 2000b {published data only}
  • Epstein LH, Paluch RA, Gordy CC, Dorn J. Decreasing sedentary behaviors in treating pediatric obesity. Archives of Pediatrics and Adolescent Medicine 2000;154(3):220-26.
  • Epstein 2004 {published data only}
  • Epstein LH, Paluch RA, Kilanowski CK, Raynor HA. The effect of reinforcement or stimulus control to reduce sedentary behavior in the treatment of pediatric obesity. Health Psychology 2004;23(4):371-80. [DOI: 10.1037/0278-6133.23.4.371]
  • Epstein 2005 {published data only}
  • Epstein LH, Roemmich JN, Stein RI, Paluch RA, Kilanowski CK. The challenge of identifying behavioral alternatives to food: clinic and field studies. Annals of Behavioral Medicine 2005;30(3):201-9.
  • Epstein 2008a {published data only}
  • Epstein LH, Paluch RA, Beecher MD, Roemmich JN. Increasing healthy eating vs. reducing high energy-dense foods to treat pediatric obesity. Obesity 2008;16(2):318-26. [DOI: 10.1038/oby.2007.61]
  • Flodmark 1993 {published data only}
  • Flodmark CE, Ohlsson T, Ryden O, Sveger T. Prevention of progression to severe obesity in a group of obese schoolchildren treated with family therapy. Pediatrics 1993;91(5):880-4.
  • Freemark 2001 {published data only}
  • Freemark M. Liver dysfunction in paediatric obesity: A randomized, controlled trial of metformin. Acta Paediatrica, International Journal of Paediatrics 2007;96(9):1326-32.
  • Freemark M, Bursey D. The effects of metformin on body mass index and glucose tolerance in obese adolescents with fasting hyperinsulinemia and a family history of type 2 diabetes. Pediatrics 2001;107(4):E55.
  • Garcia-Morales 2006 {published data only}
  • Garc¡a-Morales LM, Berber A, Macias-Lara CC, Lucio-Ortiz C, Del-Rio-Navarro BE, Dorantes-Alv rez LM. Use of sibutramine in obese Mexican adolescents: a 6-month, randomized, double-blind, placebo-controlled, parallel-group trial. Clinical Therapeutics 2006;28(5):770-82. [DOI: 10.1016/j.clinthera.2006.05.O08]
  • Gillis 2007 {published data only}
  • Gillis D, Brauner M, Granot E. A community-based behavior modification intervention for childhood obesity. Journal of Pediatric Endocrinology & Metabolism 2007;20(2):197-203.
  • Godoy-Matos 2005 {published data only}
  • Corrêa LL, Platt MW, Carraro L, Moreira RO, Faria Júnior R, Godoy-Matos AF, et al.Evaluation of the sibutramine effect on satiety with a visual analogue scale in obese adolescents [Avaliação do Efeito da Sibutramina Sobre aSaciedade por Escala Visual Analógica emAdolescentes Obesos]. Arquivos Brasileiros de Endocrinologia e Metabologia 2005;49(2):286-90.
  • * Godoy-Matos A, Carraro L, Vieira A, Oliveira J, Guedes EP, Mattos L, et al.Treatment of obese adolescents with sibutramine: a randomized, double-blind, controlled study. Journal of Clinical Endocrinology and Metabolism 2005;90(3):1460-5. [DOI: 10.1210/jc.2004-0263]
  • Golan 1998 {published data only}
  • Golan M, Crow S. Targeting parents exclusively in the treatment of childhood obesity: long-term results. Obesity Research 2004;12(2):357-61.
  • * Golan M, Fainaru M, Weizman A. Role of behaviour modification in the treatment of childhood obesity with the parents as the exclusive agents of change. International Journal of Obesity and Related Metabolic Disorders 1998;22(12):1217-1224.
  • Golan M, Weizman A, Apter A, Fainaru M. Parents as the exclusive agents of change in the treatment of childhood obesity. American Journal of Clinical Nutrition 1998;67:1130-5.
  • Golan M, Weizman A, Fainaru M. Impact of treatment for childhood obesity on parental risk factors for cardiovascular disease. Preventive Medicine 1999;29:519-526.
  • Golan 2006 {published data only}
  • Golan M, Kaufman V, Shahar DR. Childhood obesity treatment: targeting parents exclusively v. parents and children. British Journal of Nutrition 2006;95(5):1008-15. [DOI: 10.1079/BJN20061757]
  • Goldfield 2001 {published data only}
  • Goldfield GS, Epstein LH, Kilanowski CK, Paluch RA, Kogut-Bossler B. Cost-effectiveness of group and mixed family-based treatment for childhood obesity. International Journal of Obesity and Related Metabolic Disorders 2001;25(12):1843-9.
  • Raynor HA, Kilanowski CK, Esterlis I, Epstein LH. A cost-analysis of adopting a healthful diet in a family-based obesity treatment program. Journal of the American Dietetic Association 2002;102(5):645-56.
  • Golley 2007 {published data only}
  • Golley RK, Magarey AM, Baur LA, Steinbeck KS, Daniels LA. Twelve-month effectiveness of a parent-led, family-focused weight-management program for prepubertal children: a randomized, controlled trial. Pediatrics 2007;119(3):517-25. [DOI: 10.1542/peds.2006-1746]
  • Graf 2005a {published and unpublished data}
  • Graf C, Koch B, Bjarnason-Wehrens B, Sreeram N, Brockmeier K, Tokarski W, et al.Who benefits from intervention in, as opposed to screening of, overweight and obese children?. Cardiology in the Young 2006;16(5):474-80.
  • Graf C, Rost SV, Koch B, Heinen S, Falkowski G, Dordel S, et al.Data from the StEP TWO programme showing the effect on blood pressure and different parameters for obesity in overweight and obese primary school children. Cardiology in the Young 2005;15(3):291-8.
  • Graves 1988 {published data only}
  • Graves T, Meyers AW, Clark L. An evaluation of parental problem solving training in the behavioral treatment of childhood obesity. Journal of Consulting and Clinical Psychology 1988;56(2):246-50.
  • Grey 2004 {published data only}
  • Grey M, Berry D, Davidson M, Galasso P, Gustafson E, Melkus G. Preliminary testing of a program to prevent type 2 diabetes among high-risk youth. The Journal of School Health 2004;74(1):10-5.
  • Gutin 2002 {published data only}
  • Barbeau P, Gutin B, Litaker MS, Ramsey LT, Cannady WE, Allison J, et al.Influence of physical training on plasma leptin in obese youths. Canadian Journal of Applied Physiology 2003;28(3):382-96.
  • * Gutin B, Barbeau P, Owens S, Lemmon CR, Bauman M, Allison J, et al.Effects of exercise intensity on cardiovascular fitness, total body composition, and visceral adiposity of obese adolescents. American Journal of Clinical Nutrition 2002;75(5):818-26.
  • Kang H, Gutin B, Barbeau P, Owens S, Lemmon CR, Allison J, et al.Physical training improves insulin resistance syndrome markers in obese adolescents. Medicine and Science in Sports and Exercise 2002;34(12):1920-7.
  • Hughes 2008 {published data only}
  • Hughes AR, Stewart L, Chapple J, McColl JH, Donaldson MD, Kelnar CJ, et al.Randomized, controlled trial of a best-practice individualized behavioral program for treatment of childhood overweight: Scottish Childhood Overweight Treatment Trial (SCOTT). Pediatrics 2008;121(3):e539-46. [DOI: 10.1542/peds.2007-1786]
  • Stewart L, Houghton J, Hughes AR, Pearson D, Reilly JJ. Dietetic management of pediatric overweight: development and description of a practical and evidence-based behavioral approach. Journal of the American Dietetic Association 2005;105(11):1810-5. [PUBMED: 16256768]
  • Israel 1985 {published data only}
  • Israel AC, Stolmaker L, Andrian CA. The effects of training parents in general child management skills on a behavioral weight loss program for children. Behaviour Therapy 1985;16:169-80.
  • Israel 1994 {published data only}
  • Israel AC, Guile CA, Baker JE, Silverman W. An evaluation of enhanced self-regulation training in the treatment of childhood obesity. Journal of Pediatric Psychology 1994;19(6):737-49.
  • Jelalian 2006 {published data only}
  • * Jelalian E, Mehlenbeck R, Lloyd-Richardson EE, Birmaher V, Wing RR. 'Adventure therapy' combined with cognitive-behavioral treatment for overweight adolescents. International Journal of Obesity 2006;30(1):31-9.
  • Jelalian E, Mehlenenbeck R, Mora K, Lloyd E, Frisch J, Wing R. Peer-based skills training to enhance teen weight loss (abstract No 0176). Obesity Research 2000;8:57S.
  • Jelalian E, Saelens BE. Empirically supported treatments in pediatric psychology: pediatric obesity. Journal of Pediatric Psychology 1999;24(3):223-488.
  • Jiang 2005 {published and unpublished data}
  • * Jiang JX, Xia XL, Greiner T, Lian GL, Rosenqvist U. A two year family based behaviour treatment for obese children. Archives of Disease in Childhood 2005;90(12):1235-8. [DOI: 10.1136/adc.2005.071753]
  • Johnston 2007a {published data only}
  • Johnston CA, Tyler C, Fullerton G, Poston WSC, Haddock CK, Mcfarlin B, et al.Results of an intensive school-based weight loss program with overweight Mexican American children. International Journal of Pediatric Obesity 2007;2(3):144-52. [DOI: 10.1080/1747716071305864]
  • Johnston 2007b {published data only}
  • Johnston CA, Tyler C, McFarlin BK, Poston WSC, Haddock CK, Reeves R, et al.Weight loss in overweight Mexican American children: A randomized, controlled trial. Pediatrics 2007;120(6):e1450-7.
  • Kalavainen 2007 {published data only}
  • Kalavainen MP, Korppi MO, Nuutinen OM. Clinical efficacy of group-based treatment for childhood obesity compared with routinely given individual counseling. International Journal of Obesity 2007;31(10):1500-8. [DOI: 10.1038/sj.ijo.0803628]
  • Maahs 2006 {published data only}
  • * Maahs D, de Serna DG, Kolotkin RL, Ralston S, Sandate J, Qualls C, et al.Randomized, double-blind, placebo-controlled trial of orlistat for weight loss in adolescents. Endocrine Practice 2006;12(1):18-28.
  • Maahs DM, Gonzalez-Serna D, Ralston S, Kolotkin RL, Schade D. A randomized double blind placebo controlled trial of orlistat for weight loss in obese adolescents. Pediatric Research 2004;55(4):147A.
  • McCallum 2007 {published data only}
  • Gibbons K, McCallum Z, Wake M. A primary care intervention for childhood obesity: Six-month results from LEAP (Live, Eat And Play), a randomised controlled trial. International Journal of Obesity 2004;28:S194.
  • McCallum Z, Wake M. A primary care intervention for childhood overweight/obesity (leap): methodology of a randomised controlled trial. Journal of Paediatrics and Child Health 2003;39(6):A16.
  • McCallum Z, Wake M, Baur L. The Leap (live, eat and play) trial: Results of a randomized controlled trial of a primary care intervention for childhood overweight/mild obesity. Obesity Research 2004;12:A15-6.
  • McCallum Z, Wake M, Gerner B, Baur LA, Gibbons K, Gold L, et al.Outcome data from the LEAP (Live, Eat and Play) trial: a randomized controlled trial of a primary care intervention for childhood overweight/mild obesity. International Journal of Obesity 2007;31(4):630-6.
  • McCallum Z, Wake M, Gerner B, Harris C, Gibbons K, Gunn J, et al.Can Australian general practitioners tackle childhood overweight/obesity? Methods and processes from the LEAP (Live, Eat and Play) randomized controlled trial. Journal of Paediatrics and Child Health 2005;41(9-10):488-94.
  • McCallum Z, Wake M, Gerner B, Sheehan J, Gibbons K, Harris C, et al.Six month results from the LEAP (Live, Eat and Play) trial: A randomised controlled trial of a primary care intervention for childhood overweight/mild obesity. Pediatric Research 2004;55(4):220A-1A.
  • Mellin 1987 {published data only}
  • Mellin LM, Slinkard LA, Irwin CE. Adolescent obesity intervention: validation of the SHAPEDOWN program. Journal of the American Dietetic Association 1987;87(3):333-8.
  • Munsch 2008 {published data only}
  • Munsch S, Roth B, Michael T, Meyer AH, Biedert E, Roth S, et al.Randomized controlled comparison of two cognitive behavioral therapies for obese children: Mother versus mother-child cognitive behavioral therapy. Psychotherapy and Psychosomatics 2008;77(4):235-46.
  • Nemet 2005 {published data only}
  • Nemet D, Barkan S, Epstein Y, Friedland O, Kowen G, Eliakim A. Short- and long-term beneficial effects of a combined dietary-behavioral-physical activity intervention for the treatment of childhood obesity. Pediatrics 2005;115(4):e443-9. [DOI: 10.1542/peds.2004-2172]
  • Nova 2001 {published data only}
  • Nova A, Russo A, Sala E. Long-term management of obesity in paediatric office practice: experimental evaluation of two different types of intervention. Ambulatory Child Health 2001;7(3/4):239-48.
  • Ozkan 2004 {published data only (unpublished sought but not used)}
  • Ozkan B, Bereket A, Turan S, Keskin S. Addition of orlistat to conventional treatment in adolescents with severe obesity. European Journal of Pediatrics 2004;163(12):738-41. [DOI: 10.1007/s00431-004-1534-6]
  • Rodearmel 2007 {published data only}
  • * Rodearmel SJ, Wyatt HR, Stroebele N, Smith SM, Ogden LG, Hill JO. Small changes in dietary sugar and physical activity as an approach to preventing excessive weight gain: the America on the Move family study. Pediatrics 2007;120(4):e869-79. [DOI: 10.1542/peds.2006-2927]
  • Rolland-Cachera 2004 {published data only}
  • Rolland-Cachera MF, Thibault H, Souberbielle JC, Souli‚ D, Carbonel P, Deheeger M, et al.Massive obesity in adolescents: dietary interventions and behaviours associated with weight regain at 2 y follow-up. International Journal of Obesity and Related Metabolic Disorders 2004;28(4):514-9.
  • Rooney 2005 {published data only}
  • Rooney BL, Gritt LR, Havens SJ, Mathiason MA, Clough EA. Growing healthy families: family use of pedometers to increase physical activity and slow the rate of obesity. WMJ : Official Publication of the State Medical Society of Wisconsin 2005;104(5):54-60.
  • Saelens 2002 {published data only}
  • Saelens BE, Sallis JF, Wilfley DE, Patrick K, Cella JA, Buchta R. Behavioral weight control for overweight adolescents initiated in primary care. Obesity Research 2002;10(1):22-32.
  • Satoh 2007 {published data only}
  • Satoh A, Menzawa K, Lee S, Hatakeyama A, Sasaki H. Dietary guidance for obese children and their families using a model nutritional balance chart. Japan Journal of Nursing Science 2007;4(2):95-102. [DOI: 10.1111/j.1742-7924.2007.00077.x]
  • Savoye 2007 {published data only}
  • Savoye M, Shaw M, Dziura J, Tamborlane WV, Rose P, Guandalini C, et al.Effects of a weight management program on body composition and metabolic parameters in overweight children: a randomized controlled trial. JAMA : the Journal of the American Medical Association 2007;297(24):2697-704.
  • Schwingshandl 1999 {published data only}
  • Schwingshandl J, Sudi K, Eibl B, Wallner S, Brokenstein M. Effect of an individualised training programme during weight reduction on body composition: a randomised trial. Archives of Diseases in Childhood 1999;81:426-8.
  • Senediak 1985 {published data only}
  • Senediak C, Spence SH. Rapid versus gradual scheduling of therapeutic contact in a family based behavioural weight control programme for children. Behavioural Psychotherapy 1985;13:265-87.
  • Srinivasan 2006 {published data only}
  • Srinivasan S, Ambler GR, Baur LA, Garnett SP, Tepsa M, Yap F, et al.Randomized, controlled trial of metformin for obesity and insulin resistance in children and adolescents: improvement in body composition and fasting insulin. Journal of Clinical Endocrinology and Metabolism 2006;91(6):2074-80.
  • Van Mil 2007 {published data only}
  • Van Mil EG, Westerterp KR, Kester AD, Delemarre-Van De Waal HA, Gerver WJ, Saris WH. The effect of sibutramine on energy expenditure and body composition in obese adolescents. Journal of Clinical Endocrinology & Metabolism 2007;92(4):1409-14. [DOI: 10.1210/jc.2006-0264]
  • Wadden 1990 {published data only}
  • Wadden TA, Stunkard AJ, Rich L, Rubin CJ, Sweidel G, McKinney S. Obesity in black adolescent girls: a controlled clinical trial of treatment by diet, behaviour modification and parental support. Pediatrics 1990;85(3):345-52.
  • Warschburger 2001 {published data only (unpublished sought but not used)}
  • * Warschburger P, Fromme C, Petermann F, Wojtalla N, Oepen J. Conceptualisation and evaluation of a cognitive-behavioural training programme for children and adolescents with obesity. International Journal of Obesity 2001;25(Suppl 1):S93-S95.
  • Weintraub 2008 {published data only}
  • * Weintraub DL, Tirumalai EC, Haydel KF, Fujimoto M, Fulton JE, Robinson TN. Team sports for overweight children: the Stanford Sports to Prevent Obesity Randomized Trial (SPORT). Archives of Pediatrics & Adolescent Medicine 2008;162(3):232-7.
  • Weyhreter 2003 {published data only}
  • Weyhreter H, Tannhauser S, Muche R, Debatin M, Heinze E, Strittmatter U, et al.Evaluation of an outpatient treatment program for obese children and adolescents [Ergebnisse einer ambulanten Behandlung von Kindern und Jugendlichen mit Adipositas]. Klinische Padiatrie 2003;215(2):57-64.
  • Williamson 2005 {published and unpublished data}
  • White MA. Mediators of weight loss in an internet-based intervention for African-American adolescent girls. Dissertation Abstracts International: Section B: The Sciences and Engineering 2004;7(7-B):3546.
  • White MA, Martin PD, Newton RL, Walden HM, York-Crowe EE, Gordon ST, et al.Mediators of weight loss in a family-based intervention presented over the internet. Obesity Research 2004;12(7):1050-9.
  • Williamson D, Martin P, White M, Newton R, Walden H. HIPTeens: Randomized controlled trial of the efficacy of an Internet-based weight management program for overweight African-American adolescent girls. Obesity Research 2003;11:A29.
  • * Williamson DA, Martin PD, White MA, Newton R, Walden H, York-Crowe E, et al.Efficacy of an internet-based behavioral weight loss program for overweight adolescent African-American girls. Eating and Weight Disorders : EWD 2005;10(3):193-203.
  • Williamson DA, Walden HM, White MA, York-Crowe E, Newton RL, Alfonso A, et al.Two-year internet-based randomized controlled trial for weight loss in African-American girls. Obesity (Silver Spring, Md.) 2006;14(7):1231-43.
  • Woo 2004 {published data only}
  • Woo KS, Chook P, Yu CW, Sung RY, Qiao M, Leung SS, et al.Effects of diet and exercise on obesity-related vascular dysfunction in children. Circulation 2004;109(16):1981-6. [DOI: 10.1161/01.CIR.0000126599.47470.BE]
  • References to studies excluded from this review
  • Abu-Abeid 2003 {published data only}
  • * Abu-Abeid S, Gavert N, Klausner JM, Szold A. Bariatric surgery in adolescence. Journal of Pediatric Surgery 2003;38(9):1379-82.
  • Adamson 2004 {published data only}
  • * Adamson AJ, Mathers JC. Effecting dietary change. Proceedings of the Nutrition Society 2004;63(4):537-47.
  • Al-Qahtani 2007 {published data only}
  • * Al-Qahtani AR. Laparoscopic adjustable gastric banding in adolescent: safety and efficacy. Journal of Pediatric Surgery 2007;42(5):894-7.
  • Alexy 2006 {published data only}
  • Alexy U, Reinehr T, Sichert-Hellert W, Wollenhaupt A, Kersting M, Andler W. Positive changes of dietary habits after an outpatient training program for overweight children. Nutrition Research 2006;26(5):202-8.
  • Allen 2005 {published data only}
  • Allen HF, Mazzoni C, Heptulla RA, Murray MA, Miller N, Koenigs L, et al.Randomized controlled trial evaluating response to metformin versus standard therapy in the treatment of adolescents with polycystic ovary syndrome. Journal of Pediatric Endocrinology & Metabolism : JPEM 2005;18(8):761-8.
  • Ames 2005 {published data only}
  • Ames GE, Perri MG, Fox LD, Fallon EA, De Braganza N, Murawski ME, et al.Changing weight-loss expectations: a randomized pilot study. Eating Behaviors 2005;6(3):259-69.
  • Anand 2007 {published data only}
  • Anand SS, Atkinson S, Davis AD, Blimkie C, Ahmed R, Brouwers M, et al.A family-based intervention to promote healthy lifestyles in an aboriginal community in Canada. Canadian Journal of Public Health-Revue Canadienne de Sante Publique 2007;95(6):447-52.
  • Anderson 1991 {published data only}
  • Anderson JW, Hamilton CC, Crown-Weber E, Riddlemoser M, Gustafson NJ. Safety and effectiveness of a multidisciplinary very-low-calorie diet program for selected obese individuals. Journal of the American Dietetic Association 1991;91(12):1582-4.
  • Angrisani 2005 {published data only}
  • Angrisani L, Favretti F, Furbetta F, Paganelli M, Basso N, Doldi SB, et al.Obese teenagers treated by Lap-Band System: The Italian experience. Surgery 2005;138(5):877-81.
  • Annesi 2007 {published data only}
  • Annesi JJ, Unruh JL, Smith AE. Relations of sex differences in initial Body Mass Index and physical activity with observed changes over 12 weeks among children in the youth fit for life after-school care intervention. Perceptual and Motor Skills 2007;105(3):1196-202.
  • Balagopal 2005 {published data only}
  • Altomare A, Graham TE, Kahn BB, George D, Funanage V, Balagopal P. Serum transthyretin (TTR) in obese children and relationship to serum retinol binding protein (RBP4) and inflammation after lifestyle changes that improve insulin sensitivity - A Randomized controlled intervention. Circulation 2007;116(16):519.
  • Balagopal P, George D, Patton N, Bayne E, Vaughan D. Differential changes in fibrinogen and fibrinolytic systems - a randomized controlled lifestyle intervention study in obese adolescents. Obesity Research 2003;11:A105.
  • Balagopal P, George D, Patton N, Bayne E, Vaughan D. Differential changes in fibrinogen and fibrinolytic systems - a randomized controlled lifestyle intervention study in obese adolescents. Obesity Research 2003;11:A105.
  • Balagopal P, George D, Russell L, Sager B, Everline L, Patton N, et al.Effects of low-intensity physical activity and controlled diets on hemostatic and clinical parameters in relation to changes in whole body protein turnover in obese adolescents. Circulation 2001;104(17):803.
  • Balagopal P, George D, Yarandi H, Funanage V. Adiponectin-leptin ratio is reduced by lifestyle-only intervention in obese adolescents - A randomized controlled study. Circulation 2005;112(17):U909.
  • Castro R, Roberts WL, Bayne E, George D, Balagopal PA. Effect of low-intensity physical activity and controlled diet on C-reactive protein levels in obese children. Faseb Journal 2002;16(4):A241.
  • Ball 2000 {published data only}
  • Ball GDC, Marshall DJ, McCargar LJ. A comparison of two weight management programs for obese children (abstract No 0128). Obesity Research 2000;8(Suppl 1):45S.
  • Ball 2002 {published data only}
  • Ball SD, Keller KR, Moyer-Mileur LJ, Ding Y-W, Donaldson D, Jackson WD. Prolongation of satiety after low compared to moderate glycemic index meals in obese adolescents. Pediatric Research 2002;51(4):202A.
  • Barnett 2005 {published data only}
  • Barnett SJ, Stanley C, Hanlon M, Acton R, Saltzman DA, Ikramuddin S, et al.Long-term follow-up and the role of surgery in adolescents with morbid obesity. Surgery for Obesity and Related Diseases 2005;1(4):394-8.
  • Barnow 2003 {published data only}
  • Barnow S, Bernheim D, Schroder C, Lauffer H, Fusch C, Freyberger HJ. Obesity in childhood and adolescence--first results of a multimodal intervention study in Mecklenburg-Vorpommern [Adipositas im Kindes- und Jugendalter--Erste Ergebnisse einer multimodalen Interventionsstudie in Mecklenburg-Vorpommern]. Psychotherapie, Psychosomatik, Medizinische Psychologie 2003;53(1):7-14.
  • Bauer 2006 {published data only}
  • Bauer C, Fischer A, Keller U. Effect of sibutramine and of cognitive-behavioural weight loss therapy in obesity and subclinical binge eating disorder. Diabetes, Obesity & Metabolism 2006;8(3):289-95.
  • Becque 1988 {published data only}
  • Becque MD, Katch VL, Rocchini AP, Marks CR, Moorehead C. Coronary risk incidence of obese adolescents: reduction by exercise plus diet intervention. Pediatrics 1988;81(5):605-12.
  • Bialokoz-Kalinowska 2005 {published data only}
  • Bialokoz-Kalinowska I, Konstantynowicz J, Abramowicz P, Piotrowska-Jastrzebska J. The usefulness of the educational program "School of Healthy Nutrition" for the promotion of the correct nutritional habits in obese children and their parents. Pediatria Wspolczesna 2005;7(3):239-41.
  • Bonet 2007 {published data only}
  • Bonet Serra B, Quintanar Rioja A, Sentchordi Montane L, Lindo Gutarra D, Perez-Lescure Picarzo J, Martinez Org. Group therapy for the treatment of obesity in children and adolescents. Anales de Pediatria 2007;67(1):51-6.
  • Braet 1997 {published data only}
  • Braet C, Van Winkel M, Van Leeuwen K. Follow-up results of different treatment programs for obese children. Acta Paediatrica 1997;86(4):397-402.
  • Braet 2003 {published data only}
  • * Braet C, Tanghe A, De Bode P, Franckx H, Van Winckel M. Inpatient treatment of obese children: A multicomponent programme without stringent calorie restriction. European Journal of Pediatrics 2003;162(6):391-6.
  • Braet Caroline. Patient Characteristics as Predictors of Weight Loss after an Obesity Treatment for Children. Obesity Research 2006;14(1):148-55.
  • Brown 2007 {published data only}
  • Brown III HS, Perez A, Li Y-P, Hoelscher DM, Kelder SH, Rivera R. The cost-effectiveness of a school-based overweight program. International Journal of Behavioral Nutrition and Physical Activity 2007;4:7.
  • Brownell 1983 {published data only}
  • Brownell KD, Kelman JH, Stunkard AJ. Treatment of obese children with and without their mothers: changes in weight and blood pressure. Pediatrics 1983;71:515-23.
  • Bustos 1997 {published data only}
  • Bustos LG, Moreno MF, Calderin M, Martinez JJ, Diaz EM, Arana CC. Comparative study of medical advice and cognitive behavioral group therapy in the treatment of child-adolescent obesity [Estudio comparativo entre el consejo medico y la terapia grupal cognitivo conductual en el tratamiento de la obesidad infantojuvenil]. Anales Espanoles de Patriatia 1997;47(2):135-43.
  • Cairella 1991 {published data only}
  • Cairella M. Overweight and obesity: significance of diet therapy. Clinica Terapeutica 1991;136(3):211-6.
  • Capella 2003 {published data only}
  • Capella JF, Capella RF. Bariatric surgery in adolescence. Is this the best age to operate?. Obesity Surgery 2003;13(6):826-32.
  • Carrasco 2007 {published data only}
  • Carrasco N, F. Non-nutritional treatment of infant-juvenile obesity. Revista Chilena de Pediatria 2007;78(3):315-20.
  • Carrel 2007 {published data only}
  • Carrel AL, Clark RR, Peterson S, Eickhoff J, Allen DB. School-based fitness changes are lost during the summer vacation. Archives of Pediatrics & Adolescent Medicine 2007;161(6):561-4.
  • Casado-Martinez 1993 {published data only}
  • Casado-Martinez JJ, Mora MF, Gonzalez Tapia MC, Vera PP, Munoz Barata MJ. A clinical trial on the efficicacy of an alternative diet in obese patients [Ensayo clínico sobre la eficacia de una dieta alternativa en pacientes obesos]. Atencia Primaria 1993;11(9):470-474.
  • Celio 2005 {published data only}
  • Celio AA. Early intervention of eating- and weight-related problems via the internet in overweight adolescents: A randomized controlled trial. Dissertation Abstracts International: Section B: The Sciences and Engineering 2005;4(4-B):2299.
  • Ceratti 1990 {published data only}
  • Ceratti F, Garavaglia M, Piatti L. Screening for obesity in a schoolchildren population of the 20th zone of Milan and a nutritional education intervention [Screening dell'obesita nella popolazione scolastica della zona 20 di Milano ed intervento di educazione alimentare]. Epidemiologia e Prevenzione 1990;12(45):1-6.
  • Chang 2008 {published data only}
  • Chang C, Liu W, Zhao X, Li S, Yu C. Effect of supervised exercise intervention on metabolic risk factors and physical fitness in Chinese obese children in early puberty. Obesity Reviews 2008;9:135-41.
  • Chen 2001 {published data only}
  • Chen M, Huang L, Wang EK, Cheng N, Hsu C, Hung L, et al.The effectiveness of health promotion counseling for overweight adolescent nursing students in Taiwan. Public Health Nursing. 2001;18(5):350-6.
  • Coates 1982 {published data only}
  • Coates TJ, Killen JD, Slinkard LE. Parent participation in a treatment program for overweight adolescents. International Journal of Eating Disorders 1982;1(3):37-48.
  • Collins 2007 {published data only}
  • Collins J, Mattar S, Qureshi F, Warman J, Ramanathan R, Schauer P, et al.Initial outcomes of laparoscopic Roux-en-Y gastric bypass in morbidly obese adolescents. Surgery for Obesity and Related Diseases 2007;3(2):147-52.
  • Danielzik 2007 {published data only}
  • Danielzik S, Pust S, Landsberg B, Muller MJ. First lessons from the Kiel Obesity Prevention Study (KOPS). International Journal of Obesity 2005;29(Suppl 2):S78-S83.
  • * Danielzik S, Pust S, Muller MJ. School-based interventions to prevent overweight and obesity in prepubertal children: Process and 4-years outcome evaluation of the Kiel Obesity Prevention Study (KOPS). Acta Paediatrica, International Journal of Paediatrics 2007;96(Suppl 454):19-25.
  • Davis 2006 {published data only}
  • Davis CL, Tkacz J, Gregoski M, Boyle CA, Lovrekovic G. Aerobic exercise and snoring in overweight children: a randomized controlled trial. Obesity (Silver Spring, Md.) 2006;14(11):1985-91.
  • Davis 2007 {published data only}
  • Davis CL, Tomporowski PD, Boyle CA, Waller JL, Miller PH, Naglieri JA, et al.Effects of aerobic exercise on overweight children's cognitive functioning: a randomized controlled trial. Research Quarterly for Exercise & Sport 2007;78(5):510-9.
  • Deforche 2001 {published data only}
  • Deforche B, De-Bourdeaudhuij I, Braet C, Hardyns L, Vermaut S, Bouckaert J. Evolution of overweight and fitness in obese children during residential treatment. [Evolutie van overgewicht en fitheid bij obese kinderen tijdens een residentiele behandeling]. Gedrag and Gezondheid: Tijdschrift voor Psychologie en Gezondheid 2001;2:98-108.
  • Deforche 2005 {published data only}
  • Deforche B, De Bourdeaudhuij I, Tanghe A, Debode P, Hills AP, Bouckaert J. Post-treatment phone contact: a weight maintenance strategy in obese youngsters. International journal of obesity 2005;29:543-6.
  • DeJongh 2006 {published data only}
  • DeJongh ED, Binkley TL, Specker BL. Fat mass gain is lower in calcium-supplemented than in unsupplemented preschool children with low dietary calcium intakes. American Journal of Clinical Nutrition 2006;84(5):1123-7.
  • DeWolfe 1984 {published data only}
  • Dewolfe JA, Jack E. Weight control in adolescent girls: a comparison of the effectiveness of three approaches to follow up. Journal of School Health 1984;54:347-9.
  • Dillard 2007 {published data only}
  • Dillard III BE, Gorodner V, Galvani C, Holterman M, Browne A, Gallo A, et al.Initial experience with the adjustable gastric band in morbidly obese US adolescents and recommendations for further investigation. Journal of Pediatric Gastroenterology and Nutrition 2007;45(2):240-6.
  • Dolan 2003 {published data only}
  • Dolan K, Creighton L, Hopkins G, Fielding G. Laparoscopic gastric banding in morbidly obese adolescents. Obesity Surgery 2003;13(1):101-4.
  • Dolan 2004 {published data only}
  • Dolan K, Fielding G. A comparison of laparoscopic adjustable gastric banding in adolescents and adults. Surgical Endoscopy 2004;18(1):45-7.
  • Dreimane 2007 {published data only}
  • Dreimane D, Safani D, MacKenzie M, Halvorson M, Braun S, Conrad B, et al.Feasibility of a hospital-based, family-centered intervention to reduce weight gain in overweight children and adolescents. Diabetes Research and Clinical Practice 2007;75(2):159-68.
  • Du 2002 {published data only}
  • Du ZM, Zhu C, Gao J, Li GC. The curative effect of fiber on simple children's obesity. Chinese Journal of Practical Pediatrics 2002;17(11):681-3.
  • Dupuis 2000 {published data only}
  • Dupuis JM, Vivant JF, Daudet G, Bouvet A, Clement M, Dazord A, et al.Self-training in the treatment of teenagers' obesity [Entrainement sporttif personnalise dans la prise en charge de garcons obese ages de 12 a 16 ans]. Archives of Pedatrics 2000;7:1185-93.
  • Dämon 2005 {published data only}
  • Damon S, Dietwch S, Widhalm K. PRESTO - Prevention Study of Obesity: A project to prevent obesity during childhood and adolescence. Acta Paediatrica Supplement 2005;94(448):47-8.
  • Ebbeling 2006 {published data only}
  • Ebbeling CB, Feldman HA, Osganian SK, Chomitz VR, Ellenbogen SJ, Ludwig DS. Effects of decreasing sugar-sweetened beverage consumption on body weight in adolescents: a randomized, controlled pilot study. Pediatrics 2006;117(3):673-80.
  • Eliakim 2002 {published data only}
  • Eliakim A, Kaven G, Berger I, Friedland O, Wolach B, Nemet D. The effect of a combined intervention on body mass index and fitness in obese children and adolescents - a clinical experience. European Journal of Pediatrics 2002;161(8):449-54.
  • Eliakim 2004 {published data only}
  • Eliakim A, Friedland O, Kowen G, Wolach B, Nemet D. Parental obesity and higher pre-intervention BMI reduce the likelihood of a multidisciplinary childhood obesity program to succeed--a clinical observation. Journal of Pediatric Endocrinology & Metabolism : JPEM 2004;17(8):1055-61.
  • Epstein 1984 {published data only}
  • Epstein LH, Wing RR, Koeske R. Effects of diet plus exercise on weight change in parents and children. Journal of Consulting Clinical Psychology 1984;52:429-37.
  • Epstein 1990a {published data only}
  • Epstein LH, McCurley J, Wing RR, Valoski A. Five-year follow-up of family-based behavioural treatments for childhood obesity. Journal of Consulting and Clinical Psychology 1990;58(5):661-4.
  • Epstein 1990b {published data only}
  • Epstein LH, Valoski A, Wing RR, McCuurley J. Ten-year follow-up of behavioural, family based treatment for obese children. JAMA 1990;264(19):2519-23.
  • Epstein 1994b {published data only}
  • Epstein LH, Valoski A, Wing RR, McCurley J. Ten year outcomes of behavioural family based treatment for childhood obesity. Health Psychology 1994;13:373-83.
  • Epstein 1996 {published data only}
  • Epstein LH, Coleman KJ, Myers MD. Exercise in treating obesity in children and adolescents. Medicine and Science in Sports and Exercise 1996;28(4):428-35.
  • Epstein 1997 {published data only}
  • Epstein LH, Saelens BE, Myers MD, Vito D. Effects of decreasing sedentary behaviours on activity choice in obese children. Health Psychology 1997;16(2):107-113.
  • Epstein 2001a {published data only}
  • Epstein LH, Paluch RA, Saelens BE, Ernst MM, Wilfley DE. Changes in eating disorder symptoms with pediatric obesity treatment. Journal of Pediatrics 2001;139(1):58-65.
  • Epstein 2001b {published data only}
  • Epstein LH, Roemmich JN, Raynor HA. Behavioral therapy in the treatment of pediatric obesity. Pediatric Clinics of North America 2001;48(4):981-93.
  • Epstein 2007 {published data only}
  • Epstein LH, Paluch RA, Roemmich JN, Beecher MD. Family-Based Obesity Treatment, Then and Now: Twenty-Five Years of Pediatric Obesity Treatment. Health Psychology 2007;26(4):381-91.
  • Epstein 2008b {published data only}
  • Epstein LH, Roemmich JN, Robinson JL, Paluch RA, Winiewicz DD, Fuerch JH, et al.A randomized trial of the effects of reducing television viewing and computer use on body mass index in young children. Archives of Pediatrics & Adolescent Medicine 2008;162(3):239-45.
  • Ezendam 2007 {published data only}
  • Ezendam NP, Oenema A, van de Looij-Jansen PM, Brug J. Design and evaluation protocol of "FATaintPHAT", a computer-tailored intervention to prevent excessive weight gain in adolescents. BMC Public Health 2007;7:324.
  • Faden 2004 {published data only}
  • Faden D, Tanofsky-Kraff M, McDuffie J, Fredricks A, Mercado AB, Yanovski JA. Loss of control eating & dieting in treatment-seeking overweight adolescents. International Journal of Eating Disorders 2004;35(4):422-3.
  • Faith 2001 {published data only}
  • Faith MS, Berman N, Heo M, Pietrobelli A, Gallagher D, Epstein LH, et al.Effects of contingent television on physical activity and television viewing in obese children. Pediatrics 2001;107(5):1043-8.
  • Fernandez-Paredes 1986 {published data only}
  • Fernandez-Paredes F, Sumano-Avendano E. Obesity in childhood and adolescence: evaluation after 1 year of intergrated treatment [Obesidad en la ninez y adolescencia: evaluacion a un ano de tratamiento integral]. Boletin Medico del Hospital Infantil de Mexico 1986;43(9):555-7.
  • Fielding 2005 {published data only}
  • Fielding GA, Duncombe JE. Laparoscopic adjustable gastric banding in severely obese adolescents. Surgery for Obesity and Related Diseases 2005;1(4):399-405.
  • Figueroa-Colon 1993 {published data only}
  • Figueroa-Colon R, von Almen TK, Franklin FA, Schuftan C, Suskind RM. Comparison of two hypocaloric diets in obese children. American Journal of Diseases of Children 1993;147(2):160-6.
  • Figueroa-Colon 1996 {published data only}
  • Figueroa-Colon R, Franklin FA, Lee JY, von Almen KT, Suskind RM. Feasibility of a Clinic-Based Hypocaloric Dietary Intervention Implemented in a School Setting for Obese Children. Obesity Research 1996;4(5):419-29.
  • Foger 1993 {published data only}
  • Foger M, Bart G, Rathner G, Jager B, Fischer, Zollner-Neussl D. Physical activity, nutritional counseling and psychological guidance in treatment of obese children. A controlled follow-up study over six months [Korperliche Aktivitat, Ernahrungsberatung und psychologische Fuhrung in der Behandlung adiposer Kinder. Eine kontrollierte Verlaufsstudie uber sechs Monate]. Monatsschrift Kinderheilkunde 1993;141(6):491-7.
  • Foreyt 1991 {published data only}
  • Foreyt JP, Ramirez AG, Cousins JH. A weight-reduction intervention for Mexican Americans. American Journal of Clinical Nutrition 1991;53(6 Suppl):1639S-41S.
  • Foster 1985 {published data only}
  • Foster GD, Wadden TA, Brownell KD. Peer-led program for the treatment and prevention of obesity in the schools. Journal of Consulting and Clinical Psychology 1985;53(4):538-40.
  • Freemark 2000 {published data only}
  • Freemark M, Bursey D. A therapeutic trial of metformin in obese adolescents predisposed to type 2 diabetes mellitus. Pediatric Research 2000;47(4):128A.
  • Frenn 2005 {published data only}
  • Frenn M, Malin S, Brown RL, Greer Y, Fox J, Greer J, et al.Changing the tide: an Internet/video exercise and low-fat diet intervention with middle-school students. Applied Nursing Research : ANR 2005;18(1):13-21.
  • Fu 2007 {published data only}
  • Fu J-F, Liang L, Zou C-C, Hong F, Wang C-L, Wang X-M, et al.Prevalence of the metabolic syndrome in Zhejiang Chinese obese children and adolescents and the effect of metformin combined with lifestyle intervention. International Journal of Obesity 2007;31(1):15-22.
  • Fullerton 2007 {published data only}
  • Fullerton Laura. Quality of life in Mexican American children following a weight management program. Dissertation Abstracts International: Section B: The Sciences and Engineering 2007;7(7-B):4103.
  • Gale 2004 {published data only}
  • Gale TJ, Daly M. "New diets' for weight loss in Type 2 diabetes. Diabetic Medicine 2004;21:13-5.
  • Gately 2007 {published data only}
  • Gately PJ, King NA, Greatwood HC, Humphrey LC, Radley D, Cooke CB, et al.Does a high-protein diet improve weight loss in overweight and obese children?. Obesity 2007;15(6):1527-34.
  • Germann 2006 {published data only}
  • Germann JN, Kirschenbaum DS, Rich BH, O'Koon JC. Long-term Evaluation of Multi-disciplinary Treatment of Morbid Obesity in Low-income Minority Adolescents: La Rabida Children's Hospital's FitMatters Program. Journal of Adolescent Health 2006;39(4):553-61.
  • Gidding 2006 {published data only}
  • Gidding SS, Barton BA, Dorgan JA, Kimm SYS, Kwiterovich PO, Lasser NL, et al.Higher self-reported physical activity is associated with lower systolic blood pressure: The Dietary Intervention Study in Childhood (DISC). Pediatrics 2006;118(6):2388-93.
  • Goldfield 2000 {published data only}
  • Goldfield GS, Kalakanis LE, Ernst MM, Epstein LH. Open-loop feedback to increase physical activity in obese children. International Journal of Obesity 2000;24:888-892.
  • Goldfield 2006 {published data only}
  • Goldfield GS, Paluch R, Keniray K, Hadjiyannakis S, Lumb AB, Adamo K. Effects of breastfeeding on weight changes in family-based pediatric obesity treatment. Journal of Developmental & Behavioral Pediatrics 2006;27(2):93-7.
  • Gottschalk 2007 {published data only}
  • Gottschalk M, Danne T, Vlajnic A, Cara JF. Glimepiride versus metformin as monotherapy in pediatric patients with type 2 diabetes: a randomized, single-blind comparative study. Diabetes Care 2007;30(4):790-4.
  • Graf 2005b {published data only}
  • Graf C, Kupfer A, Kurth A, Stutzer H, Koch B, Jaeschke S, et al.Effects of an interdisciplinary intervention on the BMI-SDS and the endurance performance capacity of adipose children - the CHILT III project. Deutsche Zeitschrift fur Sportmedizin 2005;56(10):353-7.
  • Gutin 1995 {published data only}
  • * Gutin B, Cucuzzo N, Islam S, Smith C, Moffat R, Pargman D. Physical-training improves body-composition of black obese 7-year-old to 11-year-old girls. Obesity Research 1995;3:305-312.
  • Gutin 1996 {published data only}
  • * Gutin B, Cucuzzo N, Islam S, Smith C, Stachura ME. Physical training, lifestyle education and coronary risk factors in obese girls. Medicine and Science in Sports Exercise 1996;28(1):19-23.
  • Gutin 1999 {published data only}
  • Barbeau P, Gutin B, Litaker M, Owens S, Riggs S, Okuyama T. Correlates of individual differences in body-composition changes resulting from physical training in obese children. American Journa of Clinical Nutrition 1999;69:705-711.
  • Ferguson MA, Gutin B, Le N-A, Karp W, Litaker M, Humphries M, Okuyama T, Owens S. Effects of exercise training and its cessation on components of the insulin resistance syndrome in obese children. International Journal of Obesity 1999;22:889-895.
  • Ferguson MA, Gutin B, Owens S, Barbeau P, Tracy RP, Litaker M. Effects of physical training and its cessation on the hemostatic system of obese children. American Journal of Clinical Nutrition 1999;69:1130-4.
  • * Gutin B, Owens S, Okuyama T, Riggs S, Ferguson M, Litaker M. Effect of physical training and its cessation on percent fat and bone density of children with obesity. Obesity Research 1999;7(2):208-214.
  • Gutin B, Owens S, Slavens G, Riggs S, Treiber F. Effect of physical training on heart-period variability in obese children. The Journal of Pediatrics 1997;130(6):938-943.
  • Gutin B, Ramsey L, Barbeau P, Cannady W, Ferguson M, Litaker M, Owens S. Plasma leptin concentrations in obese children: changes during 4-mo periods with and without physical training. American Journal of Clinical Nutrition 1999;69:388-394.
  • Gutin B, Riggs S, Fersuson M, Owens S. Description and process evaluation of a physical training program for obese children. Research Quarterly for Exercise and Sport 1999;70(1):65-69.
  • Owens S, Gutin B, Allison J, Riggs S, Ferguson M, Litaker M, Thompson W. Effect of physical training on total and visceral fat in obese children. Medicine and Science in Sports and Exercise 1999;31(1):143-8.
  • Hardin 1997 {published data only}
  • * Hardin DS, Hebert JD, Bayden T, Dehart M, Mazur L. Treatment of childhood syndrome X. Pediatrics 1997;100: E5:page 257.
  • Harrell 1998 {published data only}
  • * Harrell JS, Gansky SA, McMurray RG, Bangdiwala SI, Frauman AC, Bradley CB. School-based interventions improve heart health in children with multiple cardiovascular disease risk factors.. Pediatrics 1998;102:371-380.
  • Haymond 2007 {published data only}
  • Haymond M, Anderson B, Barrera P, Brosnan P, Bush C, Green T, et al.Treatment options for type 2 diabetes in adolescents and youth: A study of the comparative efficacy of metformin alone or in combination with rosiglitazone or lifestyle intervention in adolescents with type 2 diabetes. Pediatric Diabetes 2007;8(2):74-87.
  • Herrera 2004 {published data only}
  • Herrera EA, Johnston CA, Steele RG. A comparison of cognitive and behavioral treatments for pediatric obesity. Children's Health Care 2004;33(2):151-67.
  • Hoeger 2004 {published data only}
  • Hoeger KM, Kochman L, Guzick DS. Impact on androgen and cardiovascular risk parameters by treatment of overweight adolescents with polycystic ovary syndrome (PCOS): A randomized 24-week pilot study. Fertility & Sterility 2004;82 Suppl 2:S.
  • Holterman 2007 {published data only}
  • Holterman AX, Browne A, Dillard BE, Tussing L, Gorodner V, Stahl C, et al.Short-term outcome in the first 10 morbidly obese adolescent patients in the FDA-approved trial for laparoscopic adjustable gastric banding. Journal of pediatric gastroenterology and nutrition 2007;45(4):465-73.
  • Hope 2002 {published data only}
  • * Hope Tana Louise. Treatment outcome of childhood obesity: The effect of children's psychological distress and problematic behavior.. Dissertation Abstracts International: Section B: The Sciences and Engineering August 2002;B(2-B Aug 2002):1030.
  • Huang 2007 {published data only}
  • Huang JS, Norman GJ, Zabinski MF, Calfas K, Patrick K. Body image and self-esteem among adolescents undergoing an intervention targeting dietary and physical activity behaviors. The Journal of adolescent health : official publication of the Society for Adolescent Medicine 2007;40(3):245-51.
  • Ildik¢ 2007 {published data only}
  • Ildik¢ V, Zs¢fia M, J nos M, Andreas P, D¢ra NE, Andr s P, et al.Activity-related changes of body fat and motor performance in obese seven-year-old boys. Journal of physiological anthropology 2007;26(3):333-7.
  • Inge 2004 {published data only}
  • Inge TH, Garcia V, Daniels S, Langford L, Kirk S, Roehrig H, et al.A multidisciplinary approach to the adolescent bariatric surgical patient. Journal of Pediatric Surgery 2004;39(3):442-7.
  • Ippisch 2008 {published data only}
  • Ippisch HM, Inge TH, Daniels SR, Wang B, Khoury PR, Witt SA, et al.Reversibility of Cardiac Abnormalities in Morbidly Obese Adolescents. Journal of the American College of Cardiology 2008;51(14):1342-8.
  • Jiang 1997 {published data only}
  • * Jiang, Jingxiong. Comprehensive family based behaviour modification for obese children. The effects of quality daily physical education on movement competency in obese versus non obese children. Effects of decreasing sedentary behaviors on activity choice in obese children. Effects of an obesity prevention program on the eating behavior of African American mothers and daughters. Chinese Mental Health 1997;11:242-245.
  • Johnson 1997 {published data only}
  • * Johnson WG, Hinkle LK, Carr RE, Anderson DA, Lemmon CR, Engler LB, Bergeron KC. Dietary and exercise interventions for juvenile obesity: long-term effect of behavioral and public health models. Obesity Research 1997;5(3):257-611.
  • Johnston 2004 {published data only}
  • Johnston K, Jenkins, Roberts C, Stick S. Improved attitude to exercise in overweight children with lung conditions after an exercise intervention [Abstract]. Respirology 2004;9(2 Suppl):A60.
  • Jones 2002 {published data only}
  • Jones KL, Arslanian S, Peterokova VA, Park J-S, Tomlinson MJ. Effect of metformin in pediatric patients with type 2 diabetes: A randomized controlled trial. Diabetes Care 2002;25(1):89-94.
  • Kalarchian 2004 {published data only}
  • Kalarchian M, Marcus M, Arslanian S, Ewing L, Higginbotham M, Weissfeld L, et al.Family-based behavioral weight control in the management of severe pediatric overweight. Obesity Research 2004;12:A16.
  • Kay 2001 {published data only}
  • Kay JP, Alemzadeh R, Langley G, D'Angelo L, Smith P, Holshouser S. Beneficial effects of metformin in normoglycemic morbidly obese adolescents. Metabolism: clinical and experimental 2001;50(12):1457-61.
  • Lake 2007 {published data only}
  • Lake K. Family intervention and therapy for overweight and obese kids. Community Practitioner 2007;80(6):10-2.
  • Lavine 2006 {published data only}
  • Lavine JE, Schwimmer JB. Clinical Research Network launches TONIC trial for treatment of nonalcoholic fatty liver disease in children. Journal of Pediatric Gastroenterology & Nutrition 2006;42(2):129-30.
  • Lawson 2006 {published data only}
  • Lawson ML, Kirk S, Mitchell T, Chen MK, Loux TJ, Daniels SR, et al.One-year outcomes of Roux-en-Y gastric bypass for morbidly obese adolescents: a multicenter study from the Pediatric Bariatric Study Group. Journal of pediatric surgery 2006;41(1):137-43; discussion 137-43. [PUBMED: 16410123]
  • Lazaar 2007 {published data only}
  • Lazaar N, Aucouturier J, Ratel S, Rance M, Meyer M, Duche P. Effect of physical activity intervention on body composition in young children: influence of body mass index status and gender. Acta Paediatrica 2007;96(9):1315-20.
  • Le 2002 {published data only}
  • Le Q, Wang DX, Xia XH. [Clinical observation on effect of heze oral liquid in treating children simple obesity]. Zhongguo Zhong xi yi jie he za zhi Zhongguo Zhongxiyi jiehe zazhi = Chinese journal of integrated traditional and Western medicine / Zhongguo Zhong xi yi jie he xue hui, Zhongguo Zhong yi yan jiu yuan zhu ban 2002;22(5):384-5.
  • Libman 2006 {published data only}
  • Libman I, Marcus M, Kalarchian M, Levine M, Bartucci A, Arslanian S. Family-based behavioral weight control intervention (FBBWCI) in severely obese children: Does it improve cardiometabolic risk factors (CMT-RF)?. Diabetes 2006;55:A599.
  • Madan 2007 {published data only}
  • Madan AK, Dickson PV, Ternovits CA, Tichansky DS, Lobe TE. Results of teenaged bariatric patients performed in an adult program. Journal of Laparoendoscopic and Advanced Surgical Techniques 2007;17(4):473-7.
  • Maffeis 2007 {published data only}
  • Maffeis C, Castellani M. Physical activity: An effective way to control weight in children?. Nutrition Metabolism and Cardiovascular Diseases 2007;17(5):394-408.
  • Malecka-Tendera 1996 {published data only}
  • * Melecka-Tendera E, Koehler B, Muchacka M, Wazowski R, Trzciakowska A. Efficacy and safety of dexfenfluramine treatment in obese adolescents. Pediatria Polska 1996;71(5):431-466.
  • McDuffie 2004 {published data only}
  • McDuffie JR, Calis KA, Uwaifo GI, Sebring NG, Fallon EM, Frazer TE, et al.Efficacy of orlistat as an adjunct to behavioral treatment in overweight African American and Caucasian adolescents with obesity-related co-morbid conditions. Journal of Pediatric Endocrinology & Metabolism : JPEM 2004;17(3):307-19.
  • McGarvey 2004 {published data only}
  • McGarvey E, Keller A, Forrester M, Williams E, Seward D, Suttle DE. Feasibility and benefits of a parent-focused preschool child obesity intervention. American Journal of Public Health 2004;94(9):1490-5.
  • Mo-suwan 1993 {published data only}
  • Mo-suwan L, Junjana C, Puetpaiboon. Increasing obesity in a transitional society and the effect of the weight control program. Southeast Asian Journal of Tropical Medicine and Public Health 1993;24(3):590-4.
  • Mohn 2005 {published data only}
  • Mohn A, Catino M, Capanna R, Giannini C, Marcovecchio M, Chiarelli F. Increased oxidative stress in prepubertal severely obese children: Effect of a dietary restriction-weight loss program. Journal of Clinical Endocrinology and Metabolism 2005;90(5):2653-8.
  • Mulkens 2007 {published data only}
  • Mulkens S, Fleuren D, Nederkoorn C, Meijers J. RealFit: A multidisciplinary (CBT) group treatment for obese youngsters [RealFit: Een multidisciplinaire groepsbehandeling voor jongeren met overgewicht]. Gedragstherapie 2007;1:27-48.
  • Munguba 2008 {published data only}
  • Munguba MC, Valdes MT, da Silva CA. The application of an occupational therapy nutrition education programme for children who are obese. Occupational Therapy International 2008;15(1):56-70.
  • Nadler 2007 {published data only}
  • Nadler EP, Youn HA, Ginsburg HB, Ren CJ, Fielding GA. Short-term results in 53 US obese pediatric patients treated with laparoscopic adjustable gastric banding. Journal of Pediatric Surgery 2007;42(1):137-42.
  • Nadler EP, Youn HA, Ren CJ, Fielding GA. An update on 73 US obese pediatric patients treated with laparoscopic adjustable gastric banding: comorbidity resolution and compliance data. Journal of Pediatric Surgery 2008;43(1):141-6.
  • Nuutinen 1992 {published data only}
  • Nuutinen O, Knip M. Weight loss, body composition and risk factors for cardiovascular disease in obese children: long-term effects of two treatment strategies. Journal of the American College of Nutrition 1992;11(6):707-14.
  • Ong 2007 {published data only}
  • Ong K, de Zegher F, Valls C, Dunger DB, Ibanez L. Persisting benefits 12-18 months after discontinuation of pubertal metformin therapy in low birthweight girls. Clinical Endocrinology 2007;67(3):468-71.
  • Pangrazi 2003 {published data only}
  • Pangrazi RP, Beighle A, Vehige T, Vack C. Impact of Promoting Lifestyle Activity for Youth (PLAY) on children's physical activity. Journal of School Health 2003;73(8):317-21.
  • Papadia 2007 {published data only}
  • Papadia FS, Adami GF, Marinari GM, Camerini G, Scopinaro N. Bariatric surgery in adolescents: a long-term follow-up study. Surgery for Obesity and Related Diseases 2007;3(4):465-8.
  • Patrick 2006 {published data only}
  • Patrick K, Calfas KJ, Norman GJ, Zabinski MF, Sallis JF, Rupp J, et al.Randomized controlled trial of a primary care and home-based intervention for physical activity and nutrition behaviors - PACE+ for adolescents. Archives of Pediatrics & Adolescent Medicine 2006;160(2):128-36.
  • Peneau 2008 {published data only}
  • Peneau S, Thibault H, Meless D, Soulie D, Carbonel P, Roinsol D, et al.Anthropometric and behavioral patterns associated with weight maintenance after an obesity treatment in adolescents. Journal of Pediatrics 2008;152(5):678-84.
  • Rand 1994 {published data only}
  • Rand CS, Macgregor AM. Adolescents having obesity surgery: a 6-year follow-up. Southern Medical Journal 1994;87(12):1208-13.
  • Reinehr 2003 {published data only}
  • Reinehr T, Kersting M, Alexy U, Andler W. Long-term follow-up of overweight children: After training, after a single consultation session, and without treatment. Journal of Pediatric Gastroenterology and Nutrition 2003;37(1):72-4.
  • Reinehr 2006 {published data only}
  • Reinehr T, de Sousa G, Toschke AM, Andler W. Long-term follow-up of cardiovascular disease risk factors in children after an obesity intervention. American Journal of Clinical Nutrition 2006;84(3):490-6.
  • Reybrouck 1990 {published data only}
  • Reybrouck T, Vinckx J, Van Den Berghe G, Vanderschueren-Lodeweyckk M. Exercise therapy and hypocaloric diet in the treatment of obese children and adolescents. Acta Paediatrica Scandinavica 1990;79(1):84-9.
  • Roemmich 2004 {published data only}
  • Roemmich JN, Liu EY, Rogol AD, Epstein LH, Quattrin T. Diminished insulin resistance with weight loss in severely overweight youth. Metabolic Syndrome and Related Disorders 2004;2(3):160-8.
  • Rudolf 2006 {published data only}
  • Rudolf M, Christie D, McElhone S, Sahota P, Dixey R, Walker J, et al.WATCH IT: a community based programme for obese children and adolescents. Archives of Disease in Childhood. 2006;91(9):736-9.
  • Ryttig 1989 {published data only}
  • Ryttig KR, Tellnes G, Haegh L, Boe E, Fagerthun H. A dietary fibre supplement and weight maintenance after weight reduction: a randomised, double blind, placebo-controlled long-term trial. International Journal of Obesity 1989;13:165-71.
  • Savoye 2005 {published data only}
  • Savoye M, Berry D, Dziura J, Shaw M, Serrecchia JB, Barbetta G, et al.Anthropometric and psychosocial changes in obese adolescents enrolled in a weight management program. Journal of the American Dietetic Association. 2005;105(3):364-70.
  • Schwimmer 2005 {published data only}
  • Schwimmer JB, Middleton MS, Deutsch R, Lavine JE. A phase 2 clinical trial of metformin as a treatment for non-diabetic paediatric non-alcoholic steatohepatitis. Alimentary Pharmacology & Therapeutics 2005;21(7):871-9.
  • Silberhumer 2006 {published data only}
  • Silberhumer GR, Miller K, Kriwanek S, Widhalm K, Pump A, Prager G. Laparoscopic adjustable gastric banding in adolescents: The Austrian experience. Obesity Surgery 2006;16(8):1062-7.
  • Sothern 1993 {published data only}
  • Sothern MS, von Almen TK, Schumacher H, Zelman M, Farris P, Carlisle L, et al.An effective multidisciplinary approach to weight reduction in youth. Annals of the New York Academy of Sciences 1993;699:292-4.
  • Stanford 2003 {published data only}
  • Stanford A, Glascock JM, Eid GM, Kane T, Ford HR, Ikramuddin S, et al.Laparoscopic Roux-En-Y gastric bypass in morbidly obese adolescents. Journal of Pediatric Surgery 2003;38(3):430-3.
  • Stauber 2004 {published data only}
  • Stauber T, Petermann F, Korb U, Bauer A, Hampel R. Cognitive behavioral stress management for training obese children and adolescents. Monatsschrift Kinderheilkunde 2004;152(10):1084-93.
  • Stein 2006 {published data only}
  • Stein D, Koch S, Ingrisch S, Bauer CP, Ulm K, Schuster T. Child and adolescent obesity. Long term results at weight loss programs, child obesity, BMI, BMI-SDS, SDS-difference, weight %. Padiatrische Praxis 2006;68(2):293-302.
  • Sternberg 2006 {published data only}
  • Sternberg A, Muzumdar H, Dinkevich E, Quintos JB, ustin-Leon G, Owens T, et al.The Downstart Program: a hospital-based pediatric healthy lifestyle program for obese and morbidly obese minority youth. Pediatric Endocrinology Reviews 2006;3 Suppl 4:584-9.
  • Strauss 2001 {published data only}
  • Strauss RS, Bradley LJ, Brolin RE. Gastric bypass surgery in adolescents with morbid obesity. Journal of Pediatrics 2001;138(4):499-504.
  • Sugerman 2003 {published data only}
  • Sugerman HJ, Sugerman EL, DeMaria EJ, Kellum JM, Kennedy C, Mowery Y, et al.Bariatric surgery for severely obese adolescents. Journal of Gastrointestinal Surgery 2003;7(1):102-7. [PUBMED: 12559191]
  • Sung 2002 {published data only}
  • Sung RY, Yu CW, Chang SK, Mo SW, Woo KS, Lam CW. Effects of dietary intervention and strength training on blood lipid level in obese children. Archives of Disease in Childhood 2002;86(6):407-10.
  • Suttapreyasri 1990 {published data only}
  • Suttapreyasri D, Suthontan N, Kanpoem J, Krainam J, Boonsuya C. Weight-control training-models for obese pupils in Bankok. Journal of the Medical Association of Thailand 1990;73(7):394-400.
  • Taitano 1998 {published data only}
  • Taitano RT. Development and evaluation of an nutrition curriculum to prevent obesity in inner city teens. Doctoral Thesis, Colorado University. Published in UMI Microform 9835036 1998.
  • Tanas 2007 {published data only}
  • Tanas R, Marcolongo R, Pedretti S, Gilli G. A family-based education program for obesity: A three-year study. BMC Pediatrics 2007;7:33.
  • Till 2008 {published data only}
  • Till HK-H, Muensterer O, Keller A, Korner A, Blueher S, Merkle R, et al.Laparoscopic sleeve gastrectomy achieves substantial weight loss in an adolescent girl with morbid obesity. European Journal of Pediatric Surgery 2008;18(1):47-9.
  • Tsai 2007 {published data only}
  • Tsai WS, Inge TH, Burd RS. Bariatric surgery in adolescents: recent national trends in use and in-hospital outcome. Archives of pediatrics & Adolescent Medicine 2007;161(3):217-21. [PUBMED: 17339501]
  • Tsiros 2008 {published data only}
  • Tsiros MD, Sinn N, Brennan L, Coates AM, Walkley JW, Petkov J, et al.Cognitive behavioral therapy improves diet and body composition in overweight and obese adolescents. American Journal of Clinical Nutrition 2008;87(5):1134-40.
  • Turabian 1989 {published data only}
  • Turabian JL, de Juanes JR. Health Education in obesity: evaluation of the effectiveness of a program. Atencion Primaria 1989;6(9):640-5.
  • Umbehr 2008 {published data only}
  • Umbehr M. A one-year prevention program against childhood obesity in 3-year follow-up without long-term effect. Schweizerische Rundschau fur Medizin - Praxis 2008;97(3):153-4.
  • Van Dongen 1995 {published data only}
  • Vandongen R, Jenner DA, Thompson C, Taggart AC, Spickett EE, Burke V, et al.A controlled evaluation of a fitness and nutrition intervention program on cardiovascular health in 10- to 12-year-old children. Preventive Medicine 1995;24:9-22.
  • Van Egmond-Frohlich 2006 {published data only}
  • Van Egmond-Frohlich A, Brauer W, Goldschmidt H, Hoff-Emden H, Oepen J, Zimmermann E. Effects of a programme for structured outpatient follow-up care after inpatient rehabilitation of obese children and adolescents -- a multicentre, randomized study [Effekte eines strukturierten ambulanten Weiterbehandlungsprogrammes nach stationarer medizinischer Rehabilitation bei Kindern und Jugendlichen mit Adipositas - Multizentrische, randomisierte, kontrollierte Studie]. Die Rehabilitation (Stuttgart). 2006;45(1):40-51.
  • Vicente-Rodriguez 2007 {published data only}
  • Vicente-Rodriguez G, Libersa C, Mesana MI, Beghin L, Iliescu C, Moreno Aznar LA, et al.Healthy lifestyle by nutrition in adolescence (HELENA). A new EU funded project. Therapie 2007;62(3):259-70.
  • Vido 1993 {published data only}
  • Vido L, Facchin P, Antonell I, Gobber D, Rigon F. Childhood obesity treatment: double blinded trial on dietary fibres (glucomannan) versus placebo. Padiatrie und Padologie 1993;28(5):133-136.
  • Walker 2008 {published data only}
  • Walker K. Mechanisms of self-esteem change in overweight children participating in a family-based weight management program. Dissertation Abstracts International: Section B: The Sciences and Engineering 2008;9(9-B):6341.
  • Webb 2006 {published data only}
  • Webb E, Viner R. Should metformin be prescribed to overweight adolescents in whom dietary/behavioural modifications have not helped?. Archives of Disease in Childhood 2006;91(9):793-4.
  • Weigel 2005 {published data only}
  • Weigel C, Jung R, Kokocinski K, Lederer P, Rascher W, Knerr I. Comparison of two different treatment approaches for obese children and adolescents. Klinische Padiatrie 2005;217:98.
  • Widhalm 2004 {published data only}
  • Widhalm K, Dietrich S, Prager G. Adjustable gastric banding surgery in morbidly obese adolescents: Experiences with eight patients. International Journal of Obesity 2004;28(SUPPL. 3):S42-5.
  • Widhalm K, Dietrich S, Prager G, Silberhummer G, Orth D, Kispal ZF. Bariatric surgery in morbidly obese adolescents: A 4-year follow-up of ten patients. International Journal of Pediatric Obesity 2008;3(Suppl 1):78-82.
  • Wilfley 2007 {published data only}
  • Wilfley DE, Stein RI, Saelens BE, Mockus DS, Matt GE, Hayden-Wade HA, et al.Efficacy of maintenance treatment approaches for childhood overweight: a randomized controlled trial.[see comment]. JAMA 2007;298(14):1661-73.
  • Willi 2004 {published data only}
  • Willi SM, Martin K, Datko FM, Brant BP. Treatment of type 2 diabetes in childhood using a very-low-calorie diet. Diabetes Care 2004;27(2):348-53.
  • Williamson 2007 {published data only}
  • Williamson DA, Copeland AL, Anton SD, Champagne C, Han H, Lewis L, et al.Wise Mind project: a school-based environmental approach for preventing weight gain in children. Obesity (Silver Spring, Md.) 2007;15(4):906-17.
  • Wrotniak 2004 {published data only}
  • Wrotniak BH, Epstein LH, Paluch RA, Roemmich JN. Parent weight change as a predictor of child weight change in family-based behavioral obesity treatment. Archives of Pediatrics & Adolescent Medicine 2004;158(4):342-7.
  • Wunsch 2006 {published data only}
  • Wunsch R, de Sousa G, Toschke AM, Reinehr T. Intima-media thickness in obese children before and after weight loss. Pediatrics 2006;118(6):2334-40.
  • Yitzhak 2006 {published data only}
  • Yitzhak A, Mizrahi S, Avinoach E. Laparoscopic gastric banding in adolescents. Obesity Surgery 2006;16(10):1318-22.
  • Yoshinaga 2004 {published data only}
  • Yoshinaga M, Sameshima K, Miyata K, Hashiguchi J, Imamura M. Prevention of mildly overweight children from development of more overweight condition. Preventive Medicine 2004;38(2):172-4.
  • Young-Hyman 2002 {published data only}
  • Young-Hyman D, Schlundt DG, Herman L, Bozylinski K, Johnson-Baugh S. Adherence to lifestyle intervention improves weight status in obese African American children participating in the OBCT prevention trial. Diabetes 2002;51:A16.
  • Yu 2005 {published data only}
  • Yu CCW, Sung RYT, So RCH, Lui K, Lau W, Lam PKW, et al.Effects of strength training on body composition and bone mineral content in children who are obese. Journal of Strength and Conditioning Research. 2005;19(3):667-72.
  • References to ongoing studies
  • Brennan 2008 {published data only}
  • Brennan L, Walkley J, Fraser SF, Greenway K, Wilks R. Motivational interviewing and cognitive behaviour therapy in the treatment of adolescent overweight and obesity: Study design and methodology. Contemporary Clinical Trials 2008;29(3):359-75. [DOI: http://dx.doi.org/10.1016/j.cct.2007.09.001]
  • Janicke 2008 {published data only}
  • Janicke DM, Sallinen BJ, Perri MG, Lutes LD, Silverstein JH, Huerta MG, et al.Sensible Treatment of Obesity in Rural Youth (STORY): Design and methods. Contemporary Clinical Trials 2008;29(2):270-80.
  • Additional references
  • Avenell 2004
  • Avenell A, Broom J, Brown TJ, Poobalan A, Aucott L, Stearns SC, et al.Systematic review of the long-term effects and economic consequences of treatments for obesity and implications for health improvement. Health Technology Assessessme 2004;8(21).
  • Barlow 1998
  • Barlow SE, Dietz WB. Obesity evaluation and treatment: Expert Committee recommendations. The Maternal and Child Health Bureau, Health Resources and Services Administration and the Department of Health and Human Services.. Pediatrics 1998;102(3):e29.
  • Cole 2000
  • Cole TJ, Bellizzi MC, Flegal KM, Dietz WH. Establishing a standard definition for child overweight and obesity worldwide:international survey. BMJ 2000;320:1240-1253.
  • Collins 2006
  • Collins CE, Warren J, Neve M, McCoy P, Stokes BJ. Measuring effectiveness of dietetic interventions in child obesity: a systematic review of randomized trials. Archives of Pediatric & Adolescent Medicine 2006;160(9):906-22.
  • De Onis 2007a
  • de Onis M, Garza C, Onyango AW, Borghi E. Comparison of the WHO child growth standards and the CDC 2000 growth charts. Journal of Nutrition 2007;137(1):144-8.
  • De Onis 2007b
  • de Onis M, Onyango AW, Borghi E, Siyam A, Nishida C, Siekmann J. Development of a WHO growth reference for school-aged children and adolescents. Bulletin of the World Health Organization 2007;85(9):660-7.
  • Dietz 1998
  • Dietz, WH. Health consequences of obesity in youth: Childhood predictors of adult disease. Paediatrics 1998;101(3S):518-25.
  • Ebbeling 2002
  • Ebbeling CB, Pawlak DB, Ludwig DS. Childhood obesity: public-health crisis, common sense cure. Lancet 2002;360(9331):473-82.
  • Freedman 1999
  • Freedman DS, Dietz WH, Srinivasan SR, Berenson GS. The relation of overweight to cardiovascular risk factors among children and adolescents: the Bogalusa Heart Study. Pediatrics 1999;103(6 Pt 1):1175-82.
  • Glenny 1997
  • Glenny A, O'Meara S, Melville A, Sheldon TA, Wilson C. The treatment and prevention of obesity: a systematic review of the literature. International Journal of Obesity 1997;21(9):715-37. [MEDLINE: 98025490]
  • Higgins 2006
  • Higgins JPT, Green S, editors. Cochrane Handbook for Systematic Reviews of Interventions 4.2.6 [updated September 2006]. http://www.cochrane.org/resources/handbook/hbook.htm (accessed Jan 2008).
  • Higgins 2008
  • Higgins JPT, Green S (editors). Cochrane Handbook for Systematic Reviews of Interventions Version 5.0.0 [updated February 2008]. The Cochrane Collaboration 2008. Available from www.cochrane-handbook.org 2008. [: Available from www.cochrane-handbook.org.]
  • Hong 2007
  • Hong TK, Dibley MJ, Sibbritt D, Binh PN, Trang NH, Hanh TT. Overweight and obesity are rapidly emerging among adolescents in Ho Chi Minh City, Vietnam, 2002-2004. International Journal of Pediatric Obesisty 2007;2(4):194-201.
  • Killen 1994
  • Killen JD, Taylor CB, Hayward C, Wilson DM, Haydel KF, Hammer LD, et al.Pursuit of thinness and onset of eating disorder symptoms in a community sample of adolescent girls: a three-year prospective analysis. International Journal of Eating Disorders 1994;163:227-38.
  • Lobstein 2004
  • Lobstein T, Baur L, Uauy R. Obesity in children and young people: a crisis in public health. Obesity Review 2004;5(Suppl 1):4-104.
  • Moher 2001
  • Moher D, Schulz KF, Altman DG. The CONSORT statement: revised recommendations for improving the quality of reports of parallel-group randomised trials. Lancet 2001;357(9263):1191-4. [PUBMED: 11323066]
  • Must 1992
  • Must A, Jacques PF, Dallal GE, Bajema CJ, Dietz WH. Long-term morbidity and mortality of overweight adolescents: a follow-up of the Havard Growth Study of 1922 to 1935. New England Journal of Medicine 1992;327:1350-1355. [MEDLINE: 93024760]
  • Must 1999
  • Must A, Strauss RS. Risks and consequences of childhood and adolescent obesity. International Journal of Obesity 1999;23(Suppl2):S2-S11.
  • Parsons 1999
  • Parsons TJ, Power C, Logan S, Summerbell CD. Childhood predictors of adult obesity: a systematic review. International Journal of Obesity 1999;23(Suppl 8):S1-S107.
  • Patton 1990
  • Patton GC, Johnson-Sabine E, Wood K, Mann AH, Wakeling A. Abnormal eating attitudes in London schoolgirls-a prospective epidemiological study: outcome at twelve month follow-up. Psychological Medicine 1990;20(2):383-394.
  • Popkin 2004
  • Popkin BM, Gordon-Larsen P. The nutrition transition: worldwide obesity dynamics and their determinants. International Journal of Obesity and Related Metabolic Disorders 2004;28(Suppl 3):S2-9. [PUBMED: 15543214]
  • Power 1997
  • Power C, Lake JK, Cole TJ. Measurement and long term health risks of child and adolescent fatness. International Journal of Obesity 1997;21:507-526.
  • Puhl 2007
  • Puhl RM, Latner JD. Stigma, obesity, and the health of the nation's children. Psychology Bulletin 2007;133(4):557-80.
  • Reilly 2003
  • Reilly JJ, Methven E, McDowell ZC, Hacking B, Alexander D, Stewart L, et al.Health consequences of obesity. Archives of Diseases in Childhood 2003;88(9):748-52.
  • Schleimer 1983
  • Schleimer K. Dieting in teenage schoolgirls. A longitudinal prospective study. Acta Paediatrica Scandinavica Supplement 1983;312:1-54.
  • Shrewsbury 2008
  • Shrewsbury V, Wardle J. Socioeconomic status and adiposity in childhood: a systematic review of cross-sectional studies 1990-2005. Obesity.(Silver.Spring) 2008;16(2):275-84.
  • SIGN 2003
  • Guideline development group, Scottish Intercollegiate Guidelines Network. Management of obesity in children and young people. A national clinical guideline, No 69. http://www.sign.ac.uk/pdf/sign69.pdf . Accessed May 14th 2003 2003. [: ISBN 1 899893431]
  • Singh 2008
  • Singh AS, Mulder C, Twisk JW, van Mechelen W, Chinapaw MJ. Tracking of childhood overweight into adulthood: a systematic review of the literature. Obesity Reviews 2008;9(5):474-88.
  • Stephenson 1998
  • Stephenson J, Imrie J. Why do we need randomised controlled trials to assess behavioural interventions?. BMJ 1998;316:611-3. [MEDLINE: 98179423]
  • Strauss 2001
  • Strauss RS, Pollack HA. Epidemic increase in childhood overweight, 1986-1998. JAMA 2001;286:2845-8.
  • Tang-Peronard 2008
  • Tang-Peronard JL, Heitmann BL. Stigmatization of obese children and adolescents, the importance of gender. Obesity Review 2008;9:1467-789.
  • Wang 2002
  • Wang Y, Monteiro C, Popkin BM. Trends of obesity and underweight in older children and adolescents in the United States, Brazil, China, and Russia. American Journal of Clincal Nutrition 2002;75(6):971-7.
  • Wang 2006
  • Wang Y, Lobstein T. Worldwide trends in childhood overweight and obesity. Int.J.Pediatr.Obes. 2006;1(1747-7166 (Print), 1):11-25.
  • Weiss 2004
  • Weiss R, Dziura J, Burgert TS, Tamborlane WV, Taksali SE, Yeckel CW, et al.Obesity and the metabolic syndrome in children and adolescents. New England Journal of Medicine 2004;350(23):2362-74.
  • Whitaker 1997
  • Whitaker RC, Wright JA, Pepe MS, Seidel KD, Dietz WH. Predicting obesity in young adulthood from childhood and parental obesity. New England Journal of Medicine 1997;337(13):869-73. [MEDLINE: 97433004]
  • Whitlock 2008
  • Whitlock EP, O'Connor EA, Williams SB, Beil TL, Lutz KW. Effectiveness of Weight Management Programs in Children and Adolescents. Evidence Report/Technology Assessment No. 170 AHRQ Publication No. 08-E014. Rockville, MD: Agency for Healthcare Research and Quality, 2008. [: http://www.ahrq.gov/downloads/pub/evidence/pdf/childweight/chweight.pdf]
  • WHO 2000
  • World Health Organization. Obesity: preventing and managing the global epidemic. Report of a WHO consultation. World Health Organization Technical Report Series. Vol. 894, Geneva: WHO, 2000.
  • References to other published versions of this review
  • Summerbell 2003
  • Summerbell CD, Ashton V, Campbell KJ, Edmunds L, Kelly S, Waters E. Interventions for treating obesity in children. Cochrane Database of Systematic Reviews 2003, Issue 3. [DOI: 10.1002/14651858.CD001872]