IJE Advance Access originally published online on September 19, 2006
International Journal of Epidemiology 2006 35(6):1544-1552; doi:10.1093/ije/dyl208
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Article |
Lack of evidence on diets for obesity for children: a systematic review
1 Cancer Research UK Epidemiology and Genetics Group, Department of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK.
2 School of Health Sciences, Nutrition and Dietetics, Mailbox 38, University Newcastle, Callaghan NSW 2308, Australia.
* Corresponding author. Cancer Research UK Epidemiology and Genetics Group, Department of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine, Keppel Street, London WC1E 7HT, UK. E-mail: isabel.silva{at}lshtm.ac.uk
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Abstract |
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Background The prevalence of obesity has increased rapidly in most developed countries in the last decades, and this rise is now spreading to developing countries. Childhood obesity is also increasing. The UK government has set a target to halt the rise in childhood obesity by 2010. Dietary recommendations are a central component of any comprehensive weight-loss programme. A low-fat energy-restricted diet is the conventional therapy for obesity, but alternative dietary interventions have been proposed in recent years.
Methods We conducted a systematic review to assess dietary intervention studies designed to reduce weight in childhood and adolescence. The studies included overweight or obese children or adolescents in which there was a comparison group and change in body weight or BMI was reported.
Results We identified only nine such studies, seven of which were randomized. Six were conducted in the USA, two in Cuba, and one in France. Low-carbohydrate and low-glycaemic-index diets appeared to be at least as effective as energy-restricted low-fat diets for short-term weight loss, but most studies were too small to be informative, and none provided evidence on long-term weight control.
Conclusions There is a marked mismatch between the public health importance of childhood obesity and the number and quality of the studies conducted so far to assess dietary interventions for weight reduction in childhood and adolescence, and little evidence to support the current recommendation of a low-fat energy-restricted diet. There is an urgent need for well-designed intervention studies of the long-term effectiveness of alternative diets to provide a basis for evidence-based recommendations.
Keywords Obesity, overweight, childhood, adolescence, dietary interventions, weight-loss
Accepted 23 August 2006
Excess weight is associated with significant morbidity and premature mortality related to type 2 diabetes, dyslipidaemia, hypertension, and coronary heart disease, and may be the most important avoidable cause of cancer mortality among non-smokers.1 Overall mortality caused by being overweight or obese has probably not increased as rapidly as the prevalence of excess weight,2 but it is certainly a leading cause of premature death.
The prevalence of obesity has risen rapidly in most developed countries since the 1970s, particularly in the US, where almost one-third of adults are now obese.3,4 The prevalence of obesity in England increased steeply between 1993 and 2001,5 and by 2002 22% of men and 23% of women were obese.5 Obesity is also increasing in developing countries, especially in urban areas, as populations adopt more ‘westernized’ lifestyles, and the WHO has described obesity as a global pandemic.6
The American Diabetes Association, the North American Association for the Study of Obesity, and the American Society for Clinical Nutrition currently recommend energy-restricted low-fat diets (25–35% or less of total calories from fat) for the treatment of obesity.7 The British Heart Foundation and Diabetes UK make similar recommendations. Weight loss in adults on such diets is usually modest and transient,8 however, and the sharp increase in the prevalence of obesity in the USA has continued despite marked decreases in fat consumption as a percentage of total energy.9
Childhood obesity is also increasing. Among English children aged 2–10 years, the prevalence of obesity rose from 10% in 1995 to 14% in 2003.10,11 Excess weight is often persistent,12 and 
85% of obese adolescents remain obese at age 19–20 years.13 In childhood and adolescence, excess weight is associated with risk factors for cardiovascular diseases.14 The incidence of type 2 diabetes in children and adolescents has paralleled the rise in obesity,15 and adolescent cases are now being reported in the UK.16 The UK government has set a target to halt this increase in the prevalence of obesity in children by 2010.12 Dietary recommendations are a central component of any comprehensive weight-loss programme, and various alternative dietary interventions have been proposed in recent years,17–19 but no consensus on their effectiveness has yet emerged. We have, therefore, conducted a systematic review of published studies of dietary interventions in the treatment of overweight and obese children and adolescents.
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Methods |
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We searched English-language publications from January 1966 to September 2005 (inclusive) for randomized or non-randomized studies that compared changes in body weight or BMI in overweight or obese children or adolescents given different adequately described diets. PubMed and EMBASE were searched using the keywords: children/adolescent*/youth*/girl*/boy*/diet/weight-loss/trial/obesity/overweight. Searches using the MESH terms ‘obesity’, ‘weight loss’, ‘child’, ‘adolescent’ were also carried out. The Cochrane Central Register of Controlled Trials was also searched. Reference lists within relevant articles and reviews were searched to identify publications not captured by the computerized searches. Studies were included if: (i) they investigated dietary interventions in overweight or obese children or adolescents; (ii) there was a concurrent comparison group (either a control group not given any dietary intervention or a comparison group given another dietary intervention); (iii) a brief description of the diets was provided; (iv) change in body fatness, as measured by changes in weight and/or BMI, was an outcome. We included dietary interventions given in combination with other recommendations on physical activity or behavioural therapies but only if the regimens differed only in the recommended diets. We did not include dietary interventions that were assessed in combination with other treatments or interventions based on changes in levels of physical activity or on behavioural therapies as these have been reviewed elsewhere.20–22 Papers reporting dietary interventions to prevent rather than treat excess weight were also excluded.
Data extraction
Each publication was independently reviewed by two of the authors using a standardized data extraction sheet. Data extracted from each publication included details on the study population, sample size, types of diet being compared, duration of the intervention and post-intervention follow-up as well as data for weight and BMI at baseline and at successive follow-up times (Table 1). If necessary, these data were read from the published graphs.23–25 Changes in weight and BMI at the end of the intervention and subsequent follow-up periods relative to the values at the time of entry into the trial were given by some studies26–28; for others we calculated these from the values given at successive follow-up times.29 Ninety-five per cent confidence intervals (95% CIs) for the change in weight and BMI were extracted from the papers or calculated from the corresponding SDs/SEMs (Table 1). We did not perform a meta-analysis, because the studies included different comparisons and outcomes.
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A brief description of the composition of the diets as stated in the published papers is given in Table 1. Diets with the same composition may be called differently by different authors, and for ease of comparison, we categorized them into four groups: (i) LC = low carbohydrate (
20 g or 10% of total calories); (ii) MC = medium carbohydrate (45–50% of calories); (iii) LGI = low glycaemic index [medium carbohydrate (45–50% of calories) with a low glycaemic index]; and (iv) ER = energy restricted, low calorie. The ER diets included in this review were also low fat (25–31% of calories) except in the study by Amador et al.,30 in which the diet was energy restricted, but no information was given on its composition. In addition, we classified studies in (i)–(iii) according to whether they involved calorie restriction (R) or ad libitum consumption (A). |
Results |
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Identification and description of the included studies
Our search, including cross-references, yielded 824 references after exclusion of review papers. Screening of abstracts reduced this number to 58. Review of the complete text showed that only nine23–31 met our inclusion criteria. The main reasons for exclusion of the remaining 49 studies were: (i) inappropriate intervention (e.g. behavioural interventions; very short-term dietary intervention32,33), n = 23; (ii) ineligible study population (e.g. only adults; mixture of obese and non-obese children34,35), n = 9; (iii) inappropriate study design (e.g. observational study, lack of comparison group13,36), n = 16; (iv) change in weight or BMI not an endpoint,37 n = 1.
Owing to the small number of eligible studies, we included all of them (Table 1). The first was published in 1979.23 Six studies were conducted in the US,24–29 two in Cuba,23,30 and one in France.31 The criteria for subject eligibility included weight above the 75th percentile29 or BMI above the 95th24,26,28 or 97th percentile.30,31 Five studies involved only adolescents24,26,29–31 and four included children and adolescents.23,25,27,28 All studies recruited both sexes. The ethnic mix of the participants was reported for only two studies.24,28
In most studies, participants had been referred by their parents or physicians to clinics specialized in the treatment of weight disorders, or had been recruited through advertisements in the media. In some studies family participation was an essential component of the protocol,25,26 whereas others reported no direct family involvement.23,24,29,31 In one study,27 children and parents received information about lifestyle changes and daily activity; in addition, there were individual family sessions if the urine checks showed no ketosis. Spieth et al.28 used problem-focused behavioural therapy, with family participation being considered essential for success of the programme. There were dietary and lifestyle counselling sessions with at least one parent or guardian being required to participate in all sessions (both parents and siblings were encouraged to attend). In the study by Amador et al.,30 both children and parents participated in an educational programme on nutrition and physical activity. In the study by Epstein et al.,25 recruitment was by family with at least one parent also following the diet, while in the study by Sondike et al.,26 parents were asked to help with the completion of the child's diet diary. There was no direct parental involvement in the study by Rolland-Cachera et al.31 as the participants were all resident at a specialized centre.
The sample size ranged from 1624 to 121,31 with over half the studies24–27,29 having <20 subjects in each arm. Only one study presented a power calculation.29 Seven of the nine studies were randomized,23–26,29–31 in one allocation was by period of enrolment (incorrectly described as randomized),27 and in one subjects were allocated by availability of the nutritional teams.28 None of the randomized studies gave details of the random allocation procedure.
The duration of the intervention phase ranged from 8 weeks23,25 to 9 months,31 with five24,28,30,31 of the nine studies having an intervention phase that lasted for at least 3 months (Table 1). In five studies,24,25,27,30,31 subjects continued to be followed-up beyond the intervention phase. Not all studies provided information on attrition rates, but those that did showed relatively few drop-outs during the intervention period24,27–31 (Table 2). As expected, these increased the longer the post-intervention follow-up period. In most studies, attrition rate did not vary by study arm. None of the studies reported withdrawals due to side effects.
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All studies except two28,30 reported monitoring compliance (Table 2). This was mainly done through regular completion of food diaries by the children (sometimes with parental help). Of the five studies that include an arm with an LC or an LGI diet, three23,26,27 monitored compliance by measuring ketonuria (Table 2). Only two studies25,26 reported levels of compliance. The possibility of contamination between study arms was considered in only two studies. Becque et al.29 administered a post-intervention questionnaire to the controls to verify lack of behavioural change in this group. Sondike et al.26 reported that all the subjects in the intervention group had ketonuria on most days while none of those in the comparison group had ketonuria throughout the duration of the study.
All included studies, except one,23 described the methods used to perform the anthropometric measurements, but none addressed potential sources of measurement error such as within-observer and between-observer variability. In none of the nine studies, however, was the ascertainment of the outcomes performed in a blinded fashion.
Main findings
Energy-restricted diets
In a study30 comparing an energy-restricted diet and a less-restrictive diet designed for pubescent obese children (the exact composition of these diets is not provided in the original paper), weight loss at 12 months was significantly greater in the energy-restricted group (Figure 1; Table 1). Two studies25,29 that compared an energy-restricted low-fat diet vs no treatment are not shown in Figure 1, as neither gave standard errors for changes in weight (Table 1). One25 reported a significantly greater decline on the energy-restricted diet in the percentage of overweight children at 6 months (P < 0.01). The other29 also reported greater absolute declines in both weight and body fat in the energy-restricted group, but neither was statistically significant.
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Reduced carbohydrate diets
Three studies23,26,27 compared low-carbohydrate diets (
20 g/d or 10% of total daily calories) vs energy-restricted low-fat diets, with two allowing ad libitum consumption23,26 (Figure 1; Table 1). All three reported a significant (P < 0.05) reduction in weight or BMI in the low-carbohydrate group in the short-term (<3 months). Only one27 assessed the long-term effect of a low-carbohydrate diet; the BMI decrease was significantly greater than for the energy-restricted diet at both 10 weeks and 5.5 months. No BMI differences were observed at 14.5 months, but from 5.5 months the two groups were placed on the same energy-restricted regimen. A 9 month residential intervention study,31 which compared two similar energy-restricted medium-carbohydrate/high-protein diets (energy intake 54% protein/15% CHO vs 50% protein/19% CHO), showed no significant difference between the two groups, although very large weight (30 kg) and BMI (3.8 kg/m2) reductions occurred in each arm.31
Low-glycaemic-index diets
The two studies24,28 comparing an ad libitum low-glycaemic-index diet with an energy-restricted low-fat diet showed statistically significant weight or BMI loss at 4.3 and 12 months, respectively, in the intervention arm but no change in the energy-restricted group (Figure 1; Table 1).
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Discussion |
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Perhaps the most remarkable finding of this review is the mismatch between the public health significance of childhood obesity and the lack of evidence on the effects of dietary advice. We identified only seven randomized studies23–26,29–31 that assessed specific dietary interventions in the treatment of overweight and obesity in childhood and adolescence. Only two24,27(one with 78 participants and one with 14) reported results at 12 months, and none reported longer follow-up.
All dietary interventions included in our review reduced body weight, but the effect tended to decline with longer follow-up. Overall, low-carbohydrate diets, whether low-glycaemic-index or not, appeared to be as effective in the short-term as conventional energy-restricted low-fat regimens, but their long-term effects are unknown. Low-carbohydrate diets allowing ad libitum consumption23,26 did not appear to be less effective than those that were energy restricted,27,31 but the available data are too limited to allow any valid conclusions.
A energy-restricted low-fat diet is the conventional therapy for obesity.7 However, a recent Cochrane review8 of studies in adults concluded that such diets are no better than other calorie-restricted diets in achieving and maintaining weight loss. This lack of effectiveness, and the continuing increase in obesity, has led to a resurgence of interest in low-carbohydrate and low-glycaemic-index diets. Calorie-restricted diets are difficult to follow, because they do not curb appetite and, therefore, require a sustained commitment that many people, particularly children, find difficult to maintain. Ad libitum diets that increase satiety and, hence, reduce calorie consumption may, therefore, be more effective in treating obesity in children than conventional calorie-restricted diets. Protein is the most satiating of the macronutrients, and low-carbohydrate/high-protein diets may induce a stronger satiating effect than high-carbohydrate/low-protein diets.38 Satiety after a meal appears to be inversely related to the glycaemic and insulinaemic response, and diets designed to lower the insulin response to ingested carbohydrate33,36,39 may also decrease hunger and, hence, promote weight loss because calorie intake is decreased.
The US Department of Agriculture's Food Pyramid, introduced in 1992, recommended a diet low in fat (<30% of total calories) but rich in carbohydrate foods such as breads, cereal, rice, and pasta. These recommendations have been criticized by nutritional epidemiologists, as monounsaturated and polyunsaturated fats are probably healthier than refined carbohydrates such as white bread and white rice.19 Refined carbohydrates may be the most unnatural major component of modern Western diets. Carbohydrates eaten in the evolutionary past were mainly complex and of low glycaemic index. There is some evidence that high-protein/low-carbohydrate diets may be associated with an improvement in cardiovascular risk factors, particularly in the blood lipid profile.40
Strengths and weaknesses
We followed standard guidelines41 to identify all relevant papers published in the English literature. Checklists to assess potential for bias and, hence, eligibility for pooled analysis41 were not considered. The major limitation is not bias but the lack of a long-term follow-up in any of the studies. Most studies analysed the data by ‘intention to treat’, but subjects who were lost to follow-up had to be excluded as the analysis required at least one post-intervention measurement of weight. Studies that provided information on attrition rates reported relatively few drop-outs during the intervention period,24,27–31 but the number increased with longer follow-up. All studies except two28,30 monitored compliance, mainly through completion of food diaries, and three23,26,27 used urine analysis, although only two25,26 reported the levels. The possibility of contamination between study arms was considered in only two studies.26,29
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Conclusions |
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Tackling the current obesity epidemic is a major public health priority in the UK and in many other Western countries, but there is remarkably little evidence to support current dietary recommendations for weight reduction in childhood and adolescence. There is an urgent need for well-designed randomized trials to evaluate the long-term effectiveness of alternative dietary interventions. Ad libitum diets are of particular interest in view of the ineffectiveness of energy-restricted diets.
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Acknowledgments |
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This work was funded by Cancer Research UK (Programme grant number C150/A5660)
Details of contributors: All authors contributed to the design of the study: L.J.G. conducted the literature search; L.J.G. and I.S.S. extracted independently the data from the published papers and wrote the first draft of the paper; all authors reviewed and contributed to the final version of the manuscript.
Competing interests: All authors declare that they have no competing interests.
Ethics approval: Not required.
Details of funding: Cancer Research UK (Programme grant number C150/A5660). The funding source had no role in study design, data collection, data interpretation, or in the preparation of the manuscript. The corresponding author had final responsibility for the decision to submit the publication.
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