Let’s Move
Michelle Obama’s “Let’s Move” program calls for a myriad initiatives that target what Mrs. Obama calls four key pillars: getting parents better informed about nutrition and exercise, improving the quality of food in schools, making healthy foods more affordable and accessible for families, and focusing more on physical education. In each domain, considerable efforts will emerge to provide tools and toolkits to families, schools and healthcare providers. For example, “the American Academy of Pediatrics, in collaboration with a broader medical community, will educate doctors and nurses across the country about obesity, ensure they regularly monitor your child’s Body Mass Index (BMI) provide counseling for healthy eating early on, and even write a prescription for parents laying out the simple things they can do to increase healthy eating and active play.” Let’s Move uses excellent principles of self-regulation by setting specific goals within each of its four pillars and enumerating strategies to reach those goals (e.g., to double the number of children that earn the President’s Active Lifestyle Award; to use the new “Healthy Food Financing Initiative” to bring more high quality fresh food to underserved communities).

Making a Good Thing Better: Three Ideas
Let’s Move is a dynamic initiative, equipped with a large government task force, and an emphasis on adding ideas as it grows. Wellspring’s experience and research suggests three ideas that could help:

• Emphasize Referral for Treatment as an Early Intervention: Previous studies support Let’s Move’s emphasis on more consistent diagnosis of obesity. Those studies indicate that when obese children are diagnosed as such based on their BMIs they become ten times more likely to receive dietary counseling compared to obese children whose doctors do not provide parents with their children’s BMI-based diagnosis(1). However, dietary counseling alone usually does not help. Such educational approaches rarely help overweight children and their families make the major changes in their attitudes and lifestyles required for successful weight change (2,3). Two expert groups have provided very useful sets of recommendations for treatment that healthcare providers can use to promote substantial change, and they can begin making such referrals when children reach the 85th% in BMI – the overweight level, rather than wait for those children reach the 95th% – the obese level (4,5). We favor the 7 Steps Model for the treatment of overweight young people because it strongly encourages pursuit of reductions in excess weight by adding greater intensities of interventions until success is achieved (5).
• Take a Stand Against Dietary Fat- Set a National Goal for Zero Fat grams per day: Goals for changes in eating are needed that clearly correspond to the overarching goal of reduction in overweight. The ideal goal might help overweight young people and their families focus on a key simple (easily remembered and readily understood) and measurable aspect of eating. This goal should, to maximize impact on weight, correlate with increased consumption of low caloric density high fiber foods (like fruits and vegetables), increase satiety, and help reduce consumption of total calories. A very-low fat goal satisfies those criteria (6). The vast majority of experts on obesity support at least a low fat goal, but in CBM and Wellspring we believe targeting as little consumption of all types of fat (not just saturated fats) produces the best outcomes. To support this position, tax incentives could be provided to restaurants that offer 5 or more entire meals that provide less than 10g of fat, tax levies could be added to high fat foods and so on. Encouraging everyone to set a goal for zero consumption of fat will help make the key point: Minimize consumption of fat every time you eat and you’ll find losing weight much easier (for those who are overweight). This goal will also help parents create a home environment conducive to preventing obesity in their children. This goal does not apply to babies, nor are we suggesting that people will succeed at eating zero fat per day. The goal will just help Americans get closer to the ideal – a very low fat diet.
• Provide Pedometers to All School Children: Using pedometers to measure steps promotes more activity and setting goals in addition to wearing pedometers encourages even more activity (7). As a society, we provide books to children in schools. Why not provide pedometers? In addition to the ideas on the Let’s Move website to get increased activities in the schools (and to and from school), how about acknowledging schools that offer principal’s walks before and after school – with pedometers, and targeting a mile walk around the school? Let’s make steps a focus in every family and every school.

Conclusions
CBM applauds Mrs. Obama’s incredibly important efforts to ameliorate the devastating problem of childhood obesity and looks forward to witnessing it mobilize our culture toward healthier lifestyles.

References
1. Kim C, Haemer M, Krebs NF. Parental and provider perceptions of children’s weight status: where and why the gaps. Obes Manage.2008;4:236-241.
2. Saelens BE, Sallis JF, Wilfley DE, Patrick K, Cella JA, Buchta R. Behavioral weight control for overweight adolescents initiated in primary care. Obes Res. 2002;10:22-32.
3. Stice E, Shaw H, Marti CN. A meta-analytic review of obesity revention programs for children and adolescents. Psych Bull 2006; 132:667-691.
4. Spear BA, Barlow S, Ervin C, Ludwig D, Saelens B, Schetzina KE, Taveras Em. Recommendations for treatment of child and adolescent overweight and obesity. Pediatrics. 2007;120(suppl 4):253-287.
5. Kirschenbaum DS, DeUgarte D, Frankel F, Germann JN, McKnight TL, Nieman P, Sandler RH Slusser MD. Seven steps to success: a handout for parents of overweight children and adolescents. Obes Manage. 2009;5:29-31.
6. Kirschenbaum DS. The Healthy Obsession Program: Smart Weight Loss Instead of Low-Carb Lunacy. Dallas, TX: BenBella Books; 2006.
7. Bravata DM et al. Using pedometers to increase physical activity and improve health. JAMA 2007;298:2296-2304.

Reuters
NEW YORK (Reuters Health) – When it comes to weight-loss surgery for very obese adolescents, having the surgery sooner rather than later may yield a better long-term outcome, new study findings hint.
Surgical treatment for extreme obesity may be appropriate for some adolescents, Dr. Thomas H. Inge, of Cincinnati Children’s Hospital Medical Center, Ohio, and colleagues note in the Journal of Pediatrics.
Based on their experience, Inge told Reuters Health, “the timing of surgery for adolescent obesity is an important consideration, as ‘late’ referral for (weight-loss) surgery at higher body mass index (BMI) values may preclude reversal of obesity or extreme obesity within the first post-operative year and may increase the risk of weight regain over the long term.”
But regardless of body weight going into the surgery, weight-loss surgery improves cardiovascular risk factors and brings body weight down significantly in all patients, the study team found.
BMI — calculated by dividing weight in kilograms by height in meters squared — is a standard way to determine how fat or thin a person is. Values between 20 and 25 are typically considered normal. Any value of 30 or greater is considered obese. Morbidly obese people have a body mass index (BMI) of 40 or greater — equal to being about 100 pounds or 50 kilograms overweight.
To determine the effect of pre-surgery BMI status on outcomes in their younger patients, Inge’s team followed 61 adolescents for a year after they underwent the most common and most effective form of weight-loss surgery for severe obesity called Roux-en-Y gastric bypass.
The procedure involves stapling off the upper portion of the stomach to create a small pouch that restricts the amount of food a person can eat at one time. The surgeon also makes a bypass from the pouch that skirts around the rest of the stomach and a portion of the small intestine, limiting the body’s absorption of nutrients.
Inge’s team stratified the adolescents in their study into three groups based on their pre-surgery BMI. Group 1 consisted of 23 patients with a BMI between 40.0 and 54.9. Group 2 consisted of 21 individuals with a BMI between 55.0 and 64.9, and Group 3 consisted of 17 individuals whose BMI fell between 65.0 and 95.0.
The average BMI in the overall cohort, which was 60.2 at the time of surgery, fell by roughly 37 percent at 1 year after surgery, with little variation in BMI reduction among the groups, the investigators report.
It is noteworthy, the investigators say, that subjects in Group 1 — who had the lowest BMI going into the surgery — had the lowest BMI a year after the surgery. Still, only 10 patients (17 percent) achieved a BMI of less than 30 at 1 year. Eight of these 10 were from Group 1.
“In this investigation, we found that most adolescents within the highest ranges of baseline BMI…remained extremely obese…despite BMI reductions averaging nearly 40 percent,” the investigators note.
Adolescents “who present at higher weights and BMI values lose more weight than those who present at lower weights but also plateau at a higher weight on average,” they add. “The biological and potentially behavioral reasons for this are unclear.”
Regardless of pre-surgery BMI, weight-loss surgery led to a healthy reduction in blood pressure, cholesterol levels and triglycerides (harmful blood fats).

Dr. Jeffrey Zigman is an assistant professor of internal medicine and psychiatry at UT Southwestern and co-senior author of a new study that appearing online and in a future edition of Biological Psychiatry. Dr. Zigman and colleagues investigated why we eat when we’re full. Humans and mice share the same type of brain-cell connections and hormones, as well as similar architectures in the so-called “pleasure centers” of the brain. First, Dr. Zigman and colleagues evaluated whether mice that were fully sated preferred a room where they had previously found high-fat food over one that had only offered regular bland chow. Next, the team observed how long mice would continue to poke their noses into a hole in order to receive a pellet of high-fat food. Listed below is what they found.

ScienceDaily (Dec. 28, 2009) — The premise that hunger makes food look more appealing is a widely held belief — just ask those who cruise grocery store aisles on an empty stomach, only to go home with a full basket and an empty wallet.
Prior research studies have suggested that the so-called hunger hormone ghrelin, which the body produces when it’s hungry, might act on the brain to trigger this behavior. New research in mice by UT Southwestern Medical Center scientists suggest that ghrelin might also work in the brain to make some people keep eating “pleasurable” foods when they’re already full.
“What we show is that there may be situations where we are driven to seek out and eat very rewarding foods, even if we’re full, for no other reason than our brain tells us to,” said Dr. Jeffrey Zigman, assistant professor of internal medicine and psychiatry at UT Southwestern and co-senior author of the study appearing online and in a future edition of Biological Psychiatry.
Scientists previously have linked increased levels of ghrelin to intensifying the rewarding or pleasurable feelings one gets from cocaine or alcohol. Dr. Zigman said his team speculated that ghrelin might also increase specific rewarding aspects of eating.
Rewards, he said, generally can be defined as things that make us feel better.
“They give us sensory pleasure, and they motivate us to work to obtain them,” he said. “They also help us reorganize our memory so that we remember how to get them.”
Dr. Mario Perello, postdoctoral researcher in internal medicine and lead author of the current study, said the idea was to determine “why someone who is stuffed from lunch still eats — and wants to eat — that high-calorie dessert.”
For this study, the researchers conducted two standard behavioral tests. In the first, they evaluated whether mice that were fully sated preferred a room where they had previously found high-fat food over one that had only offered regular bland chow. They found that when mice in this situation were administered ghrelin, they strongly preferred the room that had been paired with the high-fat diet. Mice without ghrelin showed no preference.
“We think the ghrelin prompted the mice to pursue the high-fat chow because they remembered how much they enjoyed it,” Dr. Perello said. “It didn’t matter that the room was now empty; they still associated it with something pleasurable.”
The researchers also found that blocking the action of ghrelin, which is normally secreted into the bloodstream upon fasting or caloric restriction, prevented the mice from spending as much time in the room they associated with the high-fat food.
For the second test, the team observed how long mice would continue to poke their noses into a hole in order to receive a pellet of high-fat food. “The animals that didn’t receive ghrelin gave up much sooner than the ones that did receive ghrelin,” Dr. Zigman said.
Humans and mice share the same type of brain-cell connections and hormones, as well as similar architectures in the so-called “pleasure centers” of the brain. In addition, the behavior of the mice in this study is consistent with pleasure- or reward-seeking behavior seen in other animal studies of addiction, Dr. Zigman said.
The next step, Dr. Perello said, is to determine which neural circuits in the brain regulate ghrelin’s actions.

Editor’s Choice Main Category: Eating Disorders Article Date: 07 Dec 2009 – 5:00 PST

Medical News Today

Binge eating disorder typically includes periods of excessive overeating. However, a person with a binge eating disorder does not subsequently induce purging (vomiting), as is the case with bulimia. 

Binge eating can occur on its own, or alongside other disorders or conditions, such as Prader-Willi disorder, or a lesion of the hypothalamus gland. 

Binge eating can encourage the development of hypertension (high blood pressure), obesity, diabetesand heart disease. Treatment options depend on what is causing the binge eating. 

A person with a binge eating disorder feels compelled to eat too much. Individuals will consume enormous quantities of food, even when they are not hungry. Binge eaters believe they have absolutely no control over their eating. 

After a bout of binge eating the person feels disgust and guilt. This feeling of failed self may form part of an underlying problem, such as anxiety or depression – both can either cause or exacerbate the disorder. 

Even the best of us occasionally overeats, helping ourselves to seconds, and even thirds; especially on holiday or festive celebrations. This is not a binge eating disorder. It becomes a disorder when the bingeing occurs regularly, and the binger is shrouded in shame and secrecy. The binger is deeply embarrassed about overeating and vows never to do it again. However, the compulsion is so strong that subsequent urges to gorge themselves cannot be resisted. 

In many parts of the world binge eating disorder is not considered a distinct condition. However, it is the most common of all eating disorders. Perhaps as more research is published and scientists learn more about it, this may change.

What are the risk factors for binge eating disorder?

A risk factor is something which increases the likelihood of developing a condition or disease. For example, obesity significantly raises the risk of developing diabetes type 2. Therefore, obesity is a risk factor for diabetes type 2. 

Experts are not sure how many people have binge eating disorder; partly because bingers tend to be secretive, and also the exact definition of the disorder tends to vary from person-to-person, expert-to-expert and health center to health center. According to the Mayo Clinic, USA, there are estimates which suggest that possibly up to 4% of the American population has a bingeing disorder. It appears to be marginally more common among females than males. 

The following risk factors have been suggested:

• Age – although people of any age may be affected, a higher percentage of adults in their 40s and 50s have the disorder.
• Other eating disorders – patients who have or had other eating disorders, such as anorexia or bulimia are at a higher risk of developing binge eating disorder.
• Dieting – experts know that dieting is a risk factor for bulimia and anorexia. Some people with eating disorder have never dieted, while others have a history of dieting. More studies are needed in this area.
• Psychological problems - people with binge eating disorder act impulsively and feel they lack control over their eating. A higher percentage of people with binge eating disorder have problems coping with stress, anxiety, anger, sadness, boredom and worry. It has been suggested that there may be a link with depression.
• Sexual abuse – some individuals with the disorder report that they were sexually abused when they were young.
• Society’s expectations – it has been suggested that the media’s obsession with body shape, appearance and weight may be a trigger for binge eating disorder.
• Biology – the development of binge eating disorder may be linked to a person’s biological vulnerability, involving genes as well as brain chemicals. Current research is looking at how the appetite regulation of the central nervous system may affect people’s eating habits. There may also be clues in how some people’s gut functions.
• Some jobs – there is some looming evidence that a higher percentage of sportsmen, sportswomen and models have binge eating disorder compared to other people. Although some people suggest that individuals who work in catering (making and serving food) may be susceptible, further studies are required.

What are the signs and symptoms of binge eating disorder?

A symptom is something the patient feels and reports, while a sign is something other people, such as the doctor detect. For example, pain may be a symptom while a rash may be a sign. 

When people have a binge eating disorder, also referred to as compulsive eating, they frequently eat huge amounts of food – they binge. In some cases 10,000 to 20,000 calories of food may be consumed in one bout of bingeing. The average person consumes between 1,500 to 3,000 calories per day. 

However, there are varying definitions for a binge; it may typically last a couple of hours. Some experts, however, say a binge may last up to a whole day. 

In many cases of binge eating disorder there are no clear signs or symptoms. The following signs and symptoms, as well as potential consequences, may include: 

Weight gain – the main sign. A significant proportion of people with the disorder are grossly overweight. Being obese or very overweight carries with it some serious health risks, including:

• Diabetes
• Heart disease
• Hypertension (high blood pressure)
• Some cancers
• High cholesterol
• Gallbladder disease

A person with binge eating disorder may also:

• Crave sugar
• Experience stomach pain
• Find high or low temperatures difficult to bear
• Have more frequent headaches

Psychological characteristics:

• Despair at being trapped in a binge -> guilt -> attempt at self-discipline -> binge -> guilt cycle
• Low self-esteem
• Self-blame (which further damages self-esteem)

The following psychological problems may already exist, or occur as a consequence:

• Depression
• Panic attacks
• Lack of focus
• Anxiety
• Despair (hopelessness)

A person with a binge eating disorder may typically (source: Mayo Clinic, USA):

• Have periods when huge amounts of food are consumed
• Eat even when full
• Eat rapidly during a bout of bingeing
• Feel that the eating behavior is uncontrollable
• Have depression
• Have anxiety
• Diet frequently without any success
• Often eat alone
• Hoard food
• Hide empty food containers
• Feel remorse, shame, guilt, disgust, despair about their eating

What are the treatment options for binge eating disorder?

Treatment is usually aimed at:

• Reducing eating binges
• Improving emotional well-being
• Losing weight (when necessary)

Binge eating is closely linked to guilt, shame, low self-esteem, self-disgust, as well as other negative emotions. These, as well as some other psychological problems need to be addressed. 

Anybody who suspects they may have binge eating disorder should get medical help as soon as possible. 

The National Health Service (NHS), UK, says that NICE (National Institute for Health and Clinical Excellence) recommends the following therapies for eating disorders:

• A self-help program; which should be under the supervision of health care professionals
• Psychological therapy
• An SSRI (selective serotonin reuptake inhibitor) antidepressant (sometimes)

Psychological treatment – the patient is encouraged to cease relying on the guilt-bingeing cycle as a way of coping with emotional problems. The following types of therapy have been shown to help people with binge eating disorder:

• CBT (cognitive behavioral therapy) – the therapist helps the patient seek out new ways of interpreting and dealing with situations, feelings and food.
• Joining and attending self-help and support groups
• Various psychotherapies - regularly meeting with a therapist who helps the patient understand what is making him/her anxious, and to accept his/her strengths, weaknesses, etc. Often this involves interpersonal therapy, which focuses on the patient’s current relationships with other people. If poor relationships and unhealthy communication skills have contributed to binge eating disorder, interpersonal therapy may help. 

Psychotherapy may also involve dialectical behavior therapy, which helps the individual learn behavioral skills to help tolerate stress, monitor and control emotions, as well as improving relationships with other people.

Weight control – for the patient to successfully reach an ideal body weight, existing underlying psychological problems need to be addressed first. An overweight individual should follow a weight-loss plan set up by a qualified health care professional.

Prevention of binge eating disorder

Avoiding Low blood sugar – low blood sugar levels can cause food craving, as well as having some other effects on the body. Some studies indicate that good control of blood sugar levels may help reduce the number of bingeing episodes. 

Keeping A food diary – by keeping a food diary, the person with binge eating disorder may be able to eventually identify which eating patterns, or types of food, tend to trigger a sudden and false sense of hunger. 

Consuming low sugar foods – these foods; those with a low glycemic index, will release sugar (energy, glucose) more slowly and more consistently throughout the day. 

Increase Eating frequency – in order to keep blood sugar levels constant, eat more meals per day, more smaller meals. Include complex carbohydrates. 

Avoid Sugary foods, alcohol and caffeine - cut out all foods and drinks which tend to cause severe fluctuations on your blood sugar levels. 

While experts continue to disagree on the precise definition of binge eating disorder, there also various different recommendations for prevention. Although there is no definite way to prevent the disorder, most agree that some steps (including those mentioned above) may help. 

Pediatricians are often able to identify the early signs of an eating disorder that begins in childhood, and take steps to prevent its development. Psychologist and pediatricians agree that parents should cultivate and reinforce a healthy body image in their offspring, regardless of their body size or shape. 

Written by Christian Nordqvist 
Copyright: Medical News Today

A group within the US Department of Health and Human Services called the US Preventive Services Task Force (USPSTF – for those who enjoy acronyms) just published a set of recommendations that strongly endorse the value of treating childhood and adolescent obesity with intensive CBT treatments.  This note provides a description of this group, a summary of key conclusions, an historical perspective on this new set of recommendations relative to two other sets of recommendations, and a bottom line recommendation for you to consider.

Here is the scoop on USPSTF, check out this website for additional details and a list of the current members of this group: http://www.ahrq.gov/clinic/uspstfab.htm <http://www.ahrq.gov/clinic/uspstfab.htm>

About USPSTF: As you’ll see from the information below, this is a very medically oriented group.  At the time this report was finalized it consisted of 16 people– primarily academic primary care physicians and administrators– not primarily researchers, but practitioners and teachers at university medical centers.  Several of them do a fair amount of research, but I do not believe any of them specializes in research on obesity.

The U.S. Preventive Services Task Force (USPSTF), first convened by the U.S. Public Health Service in 1984, and since 1998 sponsored by the Agency for Healthcare Research and Quality (AHRQ), is the leading independent panel of private-sector experts in prevention and primary care. The USPSTF conducts rigorous, impartial assessments of the scientific evidence for the effectiveness of a broad range of clinical preventive services, including screening, counseling, and preventive medications. Its recommendations are considered the “gold standard” for clinical preventive services. The mission of the USPSTF is to evaluate the benefits of individual services based on age, gender, and risk factors for disease; make recommendations about which preventive services should be incorporated routinely into primary medical care and for which populations; and identify a research agenda for clinical preventive care. Background and Mission <http://www.ahrq.gov/clinic/uspstfab.htm#Background#Background>  / Process <http://www.ahrq.gov/clinic/uspstfab.htm#Process#Process>  / Members of the USPSTF <http://www.ahrq.gov/clinic/uspstfab.htm#Members#Members>  / Role of AHRQ Staff <http://www.ahrq.gov/clinic/uspstfab.htm#Role#Role>  / Role of Partners <http://www.ahrq.gov/clinic/uspstfab.htm#Partners#Partners>  / Impact of the USPSTF <http://www.ahrq.gov/clinic/uspstfab.htm#Impact#Impact>  / For More Information <http://www.ahrq.gov/clinic/uspstfab.htm#Information#Information>

Background and Mission: Public Law Section 915 mandates that AHRQ convene the USPSTF to conduct scientific evidence reviews of a broad array of clinical preventive services, develop recommendations for the health care community, and provide ongoing administrative, research, technical, and dissemination support. The Task Force’s pioneering efforts began with the 1989 Guide to Clinical Preventive Services. A second edition of the Guide was published in 1996. The current Guide to Clinical Preventive Services <http://www.ahrq.gov/clinic/pocketgd.htm> is available on the Web. Return to Contents <http://www.ahrq.gov/clinic/uspstfab.htm#contents#contents>

Process: The Task Force makes its recommendations on the basis of explicit criteria. Recommendations issued by the USPSTF are intended for use in the primary care setting. The USPSTF recommendation statements present health care providers with information about the evidence behind each recommendation, allowing clinicians to make informed decisions about implementation.* <http://www.ahrq.gov/clinic/uspstfab.htm#asterisk#asterisk>   The USPSTF is supported by an Evidence-based Practice Center <http://www.ahrq.gov/clinic/epc/>  (EPC). Under contract to AHRQ, the EPC conducts systematic reviews of the evidence on specific topics in clinical prevention that serve as the scientific basis for USPSTF recommendations. The USPSTF reviews the evidence, estimates the magnitude of benefits and harms for each preventive service, reaches consensus about the net benefit for each preventive service, and issues a recommendation. The Task Force grades the strength of the evidence from “A” (strongly recommends), “B” (recommends), “C” (no recommendation for or against), “D” (recommends against), or “I” (insufficient evidence to recommend for or against).

*From: Harris RP, Helfand M, Woolf SH, et al. Current methods of the U.S. Preventive Services Task Force: a review of the process. Am J Prev Med 2001;20(suppl 3):21-35.

The primary conclusions reached in their 2010 recommendations:

a. Screen children aged 6 yr and older for obesity (using BMI standards).  Offer or refer for intensive counseling and behavioral interventions. They defined “intensive” as moderate or high levels of contact with professionals (moderate = 26-75 hours; high = >75 hours).  “Behavioral interventions” means CBT.  Counseling in this case refers to teaching about nutritional and physical activities.
They gave this recommendation a grade of “B.”  That means that “there is a high certainty that the net benefit is moderate or there is moderate certainty that the net benefit is moderate to substantial.”  In other words, DO IT – IT HELPS A LOT OF PEOPLE MOST OF THE TIME!

b. Lower intensity interventions (e.g., educational counseling alone about diet and activity) did not demonstrate “a significant consistent benefit.” In other words, just working with a dietitian or a trainer for relatively limited periods of time (even as many as 24 sessions) does not work.

c. The risk of harm of these intensive interventions is small. They found “no evidence of adverse effects on growth, eating disorder pathology, or mental health” for these programs. Recall the recent debates in which Wellspring researchers were engaged about this in which we argued against others who stipulated that such treatments do increase risk of harm.

Perspective – other sets of recommendations: In 2005, this group (probably a similar group of academically oriented medical professionals put together by this branch of the Department of Health and Human Services) recommended that BMI screening was valid to assess obesity.  However, they viewed the evidence of the effectiveness of CBT interventions for the treatment of childhood obesity as inadequate.  Considering the number and quality of studies available at that time, I find that conclusion very surprising.  On the other hand, remember that this group included folks who did not specialize in the treatment of obesity.
Now, however, they view the evidence differently.  They apparently commissioned a group of researchers to review the evidence for them (see reference 15).  The current evidence overwhelmingly shows the benefits short term and long term of CBT interventions combined with nutrition and physical activity counseling.
Two other sets of recommendations are attached.  You may recall seeing the 2007 “Expert Panel” recommendations published in Pediatrics (as is the present set of recommendations).  That group was comprised of representatives from 15 healthcare agencies, including the AMA and CDC.  Note that the summary of that group’s recommendations focused on 4 stages of interventions, from educational ones to intensive treatments (including immersion treatment and surgery).  That paper was 33 pages long and included 284 references.  The present USPSTF recommendations is 6 pages long and includes 19 references.  The former set of recommendations provided a much more detailed perspective on some of the relevant literature, but also agreed with the present group in advising that intensive CBT interventions are effective.  Our 7 Steps summary paper (also attached) agreed more with the conclusions of the USPSTF recommendations by asserting that educational counseling alone is simply inadequate.

Bottom Line: All three of the attached sets of recommendations support the work that we do in Wellspring (Wellspring Camps, Wellspring Academies, see www.wellspringweightloss.com). We provide the most intensive and promising versions of counseling + CBT interventions available anywhere – with locations geographically convenient for most families in the USA, as well as for many in Canada and the UK.

This study used complex statistical analyses to examine contributors to change and some could argue with their classifications of techniques and with the inclusion criteria they used for their studies.  Nonetheless, the results support the primacy of self-monitoring and indirectly support the importance of techniques that nurture healthy obsessions.

Self-monitoring – powerful in meta regression Michie HP 2009

ScienceDaily (Dec. 19, 2009) — Time and time again, it has been documented that regular exercise has many health benefits including lowering risks associated with the comorbidities of obesity. With only 30% of Americans trying to lose weight meeting the National Institutes of Health exercise guidelines of 300 minutes/week, a study in the January/February 2010 issue of the Journal of Nutrition Education and Behavior explores the paradox that exists — an antidote for obesity and its comorbidities is exercise, but the majority of obese Americans do not exercise.
Investigators explore and compare the barriers associated with regular exercise in health clubs between overweight and normal weight individuals.
Researchers at The George Washington University Medical Center examined overweight individuals’ intent to exercise at health clubs by administering an online survey instrument based on Ajzen’s Theory of Planned Behavior. This theory is based on
1.     one’s attitude toward the behavior in question,
2.     the perceived social pressure (subjective norm) to perform the behavior, and
3.     the ease or difficulty with which one can actually perform the behavior (perceived control).
Of the 1,552 individuals surveyed, 989 were classified into the overweight category.
The researchers found overweight individuals believed exercise improved appearance and self image more than normal weight individuals. In addition, overweight individuals felt more embarrassed and intimidated about exercising, exercising around young people, exercising around fit people, and about health club salespeople than individuals of normal weight. Overweight and normal weight individuals felt the same about exercising with the opposite sex, complicated exercise equipment, exercise boredom, and intention to exercise. The study interestingly found that the demographics of older age and overweight Caucasians (versus overweight non-Caucasians) had more of an effect on exercise intent than did weight. Most notably, the heavier the subject’s weight, the lower his or her perception of health. In other words, for the overweight, sedentary person, the negative emotions associated with health club exercise may be stronger in controlling regular exercise than the intellectual facts.
Writing in the article, the authors state, “One of the most noteworthy findings of this study was that OW [overweight] and NW [normal weight] subjects did not differ in their overall attitude toward exercising at a health club. This similarity in overall attitude of the OW and NW to club exercise is somewhat surprising, in that it is often assumed that OW people do not exercise as much as NW people because the 2 groups have different attitudes about exercise.
The behavior theories that propose that attitude drives the intent to exercise describe attitude as an evaluation of positive versus negative. If this is the case, then, it is important to minimize the negative and maximize the positive in order to promote the desired behavior. Thus, it would be wise for exercise professionals and commercial health clubs to help OW people feel more comfortable around those who are different from themselves and to minimize the intimidating aspects of the exercise environment, while promoting the benefits of exercise to personal health and wellbeing.
Regardless of which subset of the OW population is the target for increasing health club exercise, the ultimate goal is to increase the number of positive beliefs the individual has concerning exercising in a health club…Accordingly, individual beliefs about health club exercise should be evaluated for each new client. If a plan to increase the positive beliefs and reverse the negative beliefs is constructed and followed, the likelihood of retention of that client will be augmented.”

In an attempt to promote better nutrition for children, General Mills has announced they will be reducing the amount of sugar in their cereals for children under twelve years old. The prevalence of overweight children has increased, leading to various health problems. Although this effort does not illustrate a perfect solution, it is a step in the direction of improving children’s lives.

Food maker responds to calls for more nutritious breakfast food

WEDNESDAY, Dec. 9 (HealthDay News) — Good news for health-conscious parents: General Mills plans to further cut the amount of sugar in the cereals it markets to children under 12.

The Minneapolis-based company, the maker of such cereals as Lucky Charms and Cocoa Puffs, announced Wednesday that it will reduce the sugar content in 10 of its products to less than 11 grams, following up on product modifications begun two years ago.
“Our first target was to reduce sugar in cereals advertised to children to 12 grams of sugar or less,” Jeff Harmening, president of General Mills’ Big G cereal division, said in a prepared statement.
“As a result, we have already reduced sugar in many cereals, some by as much as 20 percent, and by spring General Mills cereals advertised to children will all have 11 grams of sugar per serving or less,” he said.
The move is part of an industry-wide response to complaints from consumers, health groups and federal regulators about the nutritional content of foods aimed at U.S. children, who are becoming increasingly overweight and obese, putting them at risk for a variety of health problems, including diabetes. Health experts worry that added sugar contributes to weight gain without providing any nutritional benefit.
“The reduction … doesn’t represent perfection but it represents improvement,” Kelly Brownell, director of the Rudd Center for Food Policy and Obesity at Yale University, told the Associated Press. “Children deserve to be marketed products that are healthier to them than what is being marketed now,” Brownell added.
According to General Mills, the product changes are not a response to criticism, but rather an attempt to make its products healthier. Other steps include increasing whole grain and nutrients in its cereals. Every Big G cereal now provides 8 grams of whole grain per serving or more, the company said.
Post Foods and Kellogg Co. have also made changes in their cereal lines. Kellogg’s Froot Loops, Apple Jacks and Corn Pops, among others, were updated last year, with sugar reduced by 1 to 3 grams and fiber added to some of the products, the AP said.
Post, which increased the vitamin D in Pebbles and Honeycomb cereals this year, has announced sugar reductions of 20 percent in its Fruity Pebbles and Cocoa Pebbles brands.
Misleading food packaging has come under attack from the U.S. Food and Drug Administration, which is trying to keep companies from touting false health benefits. Already one industry group has discontinued its “Smart Choices” labeling program, because of criticism that sugary cereals qualified for the seal of approval, the AP said.
A recent study published by the Rudd Center, which listed the 10 least healthy cereals, found that General Mills made six of the cereals on the list. It also found that the cereal giant markets to children more than any other cereal maker, the news service reported.
The study also found that children eat twice as much of the highly sweetened cereals as low-sugar cereals.

Is it genetics? Is it neglect or abuse from the parents? Is it the media? Since we know that genetics plays a role, is biology destiny? What exactly is to blame for child obesity? Well, Dr. Sadaf Farooqi and colleagues, James O. Hill, director of the Center for Human Nutrition at the University of Colorado in Denver, Dr. Marc Jacobson, of the American Academy of Pediatrics’ obesity leadership work group, ethicist Erika Blacksher, a research fellow at the Hastings Center, a nonpartisan bioethics research institution in Garrison, N.Y, Melinda Sothern, a clinical exercise physiologist at Louisiana State University New Orleans, and Virginia Williamson, general counsel for the South Carolina Department of Social Services are experts who raise interesting points examining what is to blame for children suffering form obesity.

Social service and legal authorities are grappling with the issue of when to intervene.
Los Angeles Times
December 21, 2009

When Dr. Sadaf Farooqi and colleagues discovered a genetic abnormality that caused severe obesity in a handful of children, she had no cure. Yet the scientist transformed four families’ lives nonetheless.

The British parents had been living in fear of losing their children — the youngsters’ severe obesity had been seen as a possible sign of abuse or neglect, and they had been put on the list of the country’s social services department.

“They were being blamed for their children’s condition, receiving frequent visits from social services, frequent reviews, knowing people could have their children taken away,” Farooqi said.

Farooqi told authorities that this abnormality — a DNA deletion — wiped out a key gene involved in the body’s response to leptin, a hormone that controls appetite. The children were taken off the list.

Farooqi’s study, published Dec. 6 in Nature, affected only five of about 1,200 severely obese youngsters. But as more genes related to obesity are unearthed, and as rates of childhood obesity climb, courts, social services and parents will increasingly have to grapple with difficult social and legal questions:

Can extreme childhood obesity be considered abuse? How much of a child’s weight can be blamed on the parents, and how much is out of their control?

Rising rates

A three-decade rise in childhood obesity rates has meant that related abuse and neglect cases are more often making their way into the courts. According to a 2008 report by the Child Welfare League of America, “California, Indiana, New Mexico, New York, Pennsylvania, and Texas have had to determine whether morbidly obese children whose parents are unable or unwilling to control their children’s weight against medical orders are properly considered abused or neglected.”

In 2007, North Carolina mother Joyce Painter was told she would lose her 255-pound, 7-year-old son if he did not show progress in his weight loss within two months.

And in June, South Carolina mother Jerri Gray lost custody of her son Alexander Draper after being charged with criminal neglect. The 14-year-old weighed 555 pounds. Gray is facing 15 years on two felony counts, the first U.S. felony case involving childhood obesity, said her lawyer, Grant Varner.

Such cases will require authorities to consider not only genetics but the helplessness parents can face in trying to regulate a child’s behavior, especially that of a teen, in today’s calorie-dense environment.

So far, genetic tests have played a very limited role in cases of childhood obesity in which authorities have become involved (Alexander Draper has not been tested, Varner says). The tests are fairly new, expensive and assess only a few of the genes known so far to strongly influence obesity.

In any case, for all but a small number of people, genes tell only part of the obesity story.

“What genetics does is sort of set the range of weights for you,” said James O. Hill, director of the Center for Human Nutrition at the University of Colorado in Denver. “If you’re somebody who is genetically predisposed . . . you may never be lean, but there’s still a wide range of weights in there.”

But today’s environment is likely to push many kids to the higher end of their range, said Dr. Marc Jacobson, who sits on the American Academy of Pediatrics’ obesity leadership work group. In 1955, he said, McDonald’s fries were 210 calories but the large portions more often consumed today are 500. A Coke was 6.5 ounces, versus 20 ounces in today’s plastic bottles. No wonder, he said, that today U.S. kids have an obesity rate of 15%, and that another 15% are overweight.

Food is everywhere

“Food is available 24/7. Domino’s delivers. We’re not programmed for that kind of environment,” Jacobson said. “We’re programmed for an environment where food is scarce.”

Some of the factors are hard for parents to control, especially if they live in disadvantaged communities, said ethicist Erika Blacksher, a research fellow at the Hastings Center, a nonpartisan bioethics research institution in Garrison, N.Y.

“It’s unfair to hold parents accountable for factors such as whether their neighborhoods have safe places for their children to play . . . or when their neighborhoods don’t have grocery stores that sell healthy foods,” she said. “We don’t want quick, easy, negative, punitive responses and tools.”

Melinda Sothern, a clinical exercise physiologist at Louisiana State University New Orleans who works with obese children, says physicians and social workers can be quick to rush to judgment and assume a parent is neglectful in such cases.

She cites an 8-year-old she treated who, at 6, had a body mass index of 48. The boy was so obese that he had to have knee surgery and use a machine to counteract his sleep apnea.

Genetic tests for two known obesity genes came up negative. The endocrinologist and social worker then suggested he be taken out of the home.

But, Sothern said, her patient’s mother was a single working mom in post-Katrina Louisiana who was not quite poor enough to qualify for Medicaid. She was making her doctors’ visits and enrolling her son in karate class.

Similarly, Varner said, Jerri Gray could not be held entirely responsible for what her son ate and did outside the home.

“She’s a single mom. She’s at work, busting her butt to make sure there’s a roof over their heads, and this kid’s at school six, seven hours a day,” Varner said. “Trying to control a teenager — that’s trying to knock down a solid brick wall with your bare hands.”

Virginia Williamson, general counsel for the South Carolina Department of Social Services, would not comment on the particulars of Gray’s case.

But, she said, “I think everybody wanted to see the mom supported and able to take care of her child. Our intervention only comes when we get information that there’s been a breakdown, in the form of a parent who isn’t following up with what the child’s doctors or treatment team would be recommending. That failure to follow up is placing the child at risk of harm.”

In the December issue of Archives of Pediatrics & Adolescent Medicine, Andrea Danese, M.D., M.Sc., of King’s College London, England, and colleagues studied the effects of adverse conditions in one’s childhood.  It seems that experiences with psychological and social adversities in childhood increases the risk of developing obesity, high blood pressure and other diseases in adulthood. With obesity and other chronic diseases reaching epidemic proportions in the world, becoming aware and active in prevention is fundamental from a health and financial perspective.

ScienceDaily (Dec. 8, 2009)

Individuals who experience psychological or social adversity in childhood may have lasting emotional, immune and metabolic abnormalities that help explain why they develop more age-related diseases in adulthood, according to a report in the December issue ofArchives of Pediatrics & Adolescent Medicine, one of the JAMA/Archives journals.
As the population ages, age-related conditions such as heart disease, type 2 diabetes and dementia are becoming more prevalent, according to background information in the article. New ways of preventing these diseases and enhancing the quality of longer lives are needed. “Interventions targeting modifiable risk factors (e.g., smoking, inactivity and poor diet) in adult life have only limited efficacy in preventing age-related disease,” the authors write. “Because of the increasing recognition that preventable risk exposures in early life may contribute to pathophysiological processes leading to age-related disease, the science of aging has turned to a life-course perspective.”
Andrea Danese, M.D., M.Sc., of King’s College London, England, and colleagues studied 1,037 members of the Dunedin Multidisciplinary Health and Development Study, a long-term investigation of individuals born in New Zealand between April 1972 and March 1973. During the first 10 years of life, participants were assessed for exposure to three adverse experiences: socioeconomic disadvantage, maltreatment and social isolation. At age 32, they were evaluated for the presence of three risks for age-related diseases: depression, high inflammation levels (measured by the blood marker C-reactive protein) and the clustering of metabolic risk factors, including high blood pressure, abnormal cholesterol levels and being overweight.
Individuals who had experienced adverse events as children were at higher risk of developing depression, high inflammation levels and the clustering of metabolic risk factors at age 32. The researchers estimate that 31.6 percent of the cases of depression, 13 percent of the cases of elevated inflammation and 32.2 percent of cases with clustered metabolic risk factors could be attributed to adverse childhood experiences.
“The effects of adverse childhood experiences on age-related disease risks in adulthood were non-redundant, cumulative and independent of the influence of established developmental and concurrent risk factors,” such as family history, low birth weight or high childhood body mass index, the authors write.
“In conclusion, it has long been known that pathophysiological processes leading to age-related diseases may already be under way in childhood,” they continue. “The promotion of healthy psychosocial experiences for children is a necessary and potentially cost-effective target for the prevention of age-related disease.”