Published online November 30, 2007
PEDIATRICS Vol. 120 No. 6 December 2007, pp. e1450-e1457 (doi:10.1542/peds.2006-3321)
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ARTICLE

Weight Loss in Overweight Mexican American Children: A Randomized, Controlled Trial

Craig A. Johnston, PhDa, Chermaine Tyler, PhDa, Brian K. McFarlin, PhDb, Walker S.C. Poston, PhDc, C. Keith Haddock, PhDc, Rebecca Reeves, DrPHd and John P. Foreyt, PhDa,d

a Departments of Pediatrics-Nutrition, Children's Nutrition Research Center
d Medicine, Baylor College of Medicine, Houston, Texas
b Department of Health and Human Performance, University of Houston, Houston, Texas
c Department of Health Psychology and Medicine, University of Missouri, Kansas City, Missouri


   ABSTRACT
TOP
 ABSTRACT
PATIENTS AND METHODS
 RESULTS
 DISCUSSION
 CONCLUSIONS
 REFERENCES
 
OBJECTIVES. Childhood overweight has increased significantly in the past 20 years, with the highest rates noted among Mexican Americans. Although this minority group is in significant need of intervention, few programs have demonstrated actual decreases in weight. In this study we evaluated an intensive healthy lifestyle program designed to result in weight reduction for overweight Mexican American children. We hypothesized that children randomly assigned to an intensive intervention would significantly reduce their standardized BMI when compared with children randomly assigned to a self-help condition.

PATIENTS AND METHODS. A total of 60 children (33 boys; 55%) between the ages of 10 and 14 years at or above the 85th percentile for BMI were randomly assigned to a 6-month intensive-intervention or self-help condition.

RESULTS. Children in the intensive-intervention condition significantly reduced their standardized BMI when compared with the children in the self-help condition. The change in standardized BMI was significantly different at both 3 and 6 months, with intensive-intervention participants showing greater decreases in weight.

CONCLUSIONS. Overall, the results were promising, suggesting that an intensive, individualized intervention may be an effective means for promoting weight loss in overweight Mexican American children.

Key Words: children • adolescents • school-based program • weight management • outcomes research • prevention

Abbreviations: II—intensive intervention • SH—self-help • zBMI—standardized BMI • HDL—high-density lipoprotein • LDL—low-density lipoprotein • BP—blood pressure

Childhood overweight and obesity are epidemic in the United States, with ~34% of 2- to 19-year-olds classified as either at risk of overweight or overweight.1 The prevalence continues to increase,1 with overweight children getting heavier2 at even younger ages.3 Specific health consequences associated with overweight include hypertension, dyslipidemia, type 2 diabetes, sleep apnea, arthritis, gallstones, and some types of cancer.4–7 Although this problem affects individuals across racial categories, minorities are at increased risk for overweight.1 Specifically, Mexican American children have the highest rate of overweight compared with any other minority group. Despite the clear need for intervention, few effective interventions to decrease overweight in these children have been identified (eg, see ref 8).

The purpose of this study was to conduct a randomized, controlled trial to test an intensive intervention (II) for weight loss in overweight Mexican American middle school children. We compared the effectiveness of an intensive behavioral weight management program (II) and a self-help (SH) only condition for weight reduction in an at-risk group of middle school children. We hypothesized that children assigned to the II condition would show greater decreases in standardized BMI (zBMI) at 3 and 6 months compared with those in the SH group. Secondary outcomes were also examined (eg, cholesterol and insulin levels and blood pressure).


   PATIENTS AND METHODS
TOP
 ABSTRACT
 PATIENTS AND METHODS
RESULTS
 DISCUSSION
 CONCLUSIONS
 REFERENCES
 
Patients
A total of 181 children were approached for recruitment from a charter school that serves an urban student population that is 95% Mexican American in Houston, Texas. This 6th- through 12th-grade charter school uses a lottery system to enroll any student living in the larger Houston metropolitan area. There are no specific criteria for children being accepted for enrollment, and there is no fee for attendance.

Parents were informed that children would have an opportunity to participate in a class focused on healthy lifestyles. The class was described as an opportunity for learning healthy eating habits and participating in sports and other games requiring physical activity. Overall, the goal of the class was presented as preventing adult disease (eg, type 2 diabetes and cardiovascular disease). Consent forms for the program were given to all of the 6th- and 7th-grade students enrolled at the school in the fall of 2004 and the summer of 2005, and they were asked to return the forms with a parent signature indicating whether they wanted to participate. A separate, signed, parent consent was returned for participants to give blood, because this measurement was not required to participate in the study. Child assent was obtained after parental consent. All of the children, irrespective of weight, were eligible to participate. To prevent differentiating overweight from normal-weight children, both groups participated in the program, but we only report the results for the overweight participants.

A total of 60 overweight students were randomly assigned after baseline measurements were taken, with 40 in treatment and 20 in control. A statistical consultant generated the random allocation sequence using SPSS 13 statistical software (SPSS Inc, Chicago, IL). An unbalanced randomization (ie, a greater number of participants were assigned to the II condition) was used. This is an accepted strategy when the intervention is anticipated to have a positive benefit, thereby reducing the number of participants exposed to the control condition.10 Figure 1 provides a detailed schematic of the study design and participant flow.


Figure 1
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  		FIGURE 1 Consolidated Standards of Reporting Trials (CONSORT) diagram.

 
Children were between the ages of 10 and 14 years (mean: 12.4; SD: 0.7) and in the 6th or 7th grade. All of the children self-identified as Mexican American. All of the participants were at risk for overweight or overweight (ie, BMI ≥ 85th or ≥ 95th percentile for age and gender, respectively) according to Centers for Disease Control and Prevention guidelines.11 Participants included 33 boys (55%) and 27 girls. Baseline characteristics are presented in Table 1. This study was approved by the institutional review board for human subjects at Baylor College of Medicine.


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  		TABLE 1 Baseline Characteristics of Participants According to Treatment Assignment

 
Methods
The children were randomly assigned to 1 of 2 conditions in the spring and fall of 2005. Both conditions focused on increasing healthy eating and physical activity by using behavioral strategies to individualize the plans for the specific needs of the participants. Children in the SH condition used a 12-week parent-guided manual intended to promote child weight loss and long-term maintenance of changes.12 Those who were randomly assigned to the II condition participated in an instructor/trainer-led intervention for 12 weeks of daily (Monday through Friday) sessions followed by 12 weeks of biweekly sessions. Intervention classes for II were held during the last period of the school day while children not participating in the study and SH participants attended a study hall. All of the participants, regardless of condition, were assigned to a classroom during the school period when intervention was held, but SH and II participants were in separate rooms to reduce the likelihood of contamination. In addition, all of the children at the school received a snack during this period, although the II children received peanuts/peanut butter with a fruit or vegetable to enhance satiety and to provide an opportunity for fruit/vegetable consumption. During the first 12 weeks of II, participants attended 1 indoor nutrition lesson and 4 outdoor physical activity lessons weekly. Instructors were trained throughout the intervention to contract with, reinforce, and model for participants to encourage adherence to dietary and physical activity guidelines.

Specific Content of SH Sessions
Participants and their parents were provided Trim Kids, a book to be used for weight management in children and their families.12 The parent-led program consisted of 12 weekly sessions followed by maintenance activities for improving diet and level of physical fitness of children. Parents and children were instructed to contact interventionists to address any questions and report adverse effects.

Specific Content of II Sessions
During the 12-week intervention, participants received nutrition instruction (1 day/week) and physical activity training (4 days per week) during a standard school period lasting 35 to 40 minutes. In addition, their parents were invited to attend monthly meetings to teach them how to adapt family meals and activities to facilitate healthy changes. Children in this condition were instructed by undergraduate students trained in physical activity/nutrition. In terms of nutrition instruction, a bachelor-level instructor trained in nutrition led the sessions.

Nutrition instruction focused on teaching participants to make healthier food choices from the options available to them by reading labels and controlling the portion sizes of their foods. In addition, they learned to categorize commonly eaten foods into groups with varying degrees of health benefit. The food groups were labeled "safety," "caution," and "danger" zone foods, with rules for determining how to categorize them. Safety (ie, foods safe for your health) consisted of most fruits and nonstarchy vegetables. Caution (ie, use caution not to overeat) foods included low-fat meats, low-fat dairy, and starches. Danger (ie, foods that in excess can be dangerous to your health) consisted of foods with ≥5 g of fat or ≥15 g of sugar per serving. Creating a coding system to group foods has been demonstrated as an effective way to train children about nutrition (eg, see ref 13).

To ensure participants acquired nutrition information and were able to use information to make healthy choices, they took biweekly quizzes. The quizzes presented foods that participants reported eating and asked them to apply program rules to these foods (eg, distinguish between less and more healthy options, choose the healthiest portion size, and choose healthy snacks). Children with absences, low quiz grades, and/or continued weight gain for >2 weeks received further 1-on-1 education and treatment planning. This strategy promoted participants’ learning and being able to apply knowledge in their specific environments.

During weeks 1 to 6, the physical activity intervention was administered using a modified circuit-training approach to maintain heart rate within a target zone and to develop a basic level of physical fitness. 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 to 12, the stations were modified to focus on skill development for either school- or community-sponsored activities available for participants in their neighborhood or school. These included both team sports (eg, basketball, soccer, or softball) and leisure activities (eg, jumping rope, dance, or kickboxing). This 2-stage approach (ie, development of basic fitness followed by specific skills) successfully engaged the participants and allowed them to build skills in activities in which they could continue to participate beyond the end of the intervention. Over the course of the intervention, participants’ level of physical exertion was monitored by heart rate telemetry (Polar USA, Lake Success, NY). Participants exercised for 30 to 35 minutes at an intensity equivalent to 60% to 85% of the age-predicted maximal heart rate.

A token economy system was implemented for reinforcing each participant's changes. They received points for trying new fruits or vegetables, keeping their bodies moving during physical activity, and for meeting program and individual goals. These points were exchanged weekly for prizes. Participants also learned to self-monitor, set goals, and address self-identified barriers for improving health. In terms of monitoring, children were taught to monitor their physical activity, food intake, sedentary behavior, and weight. Behavior theory has been effective in modifying eating, exercise, and other factors that contribute to or maintain obesity (eg, see refs 13–15).

To individualize the program, several steps were taken. First, participants discussed food preferences and were then taught ways to modify these foods with healthier options. For instance, parents were taught to make traditional Mexican American foods less calorically dense. Likewise, the same approach was taken for physical activity, with research staff insuring that children remained moderately active while engaging in games that they chose. Second, all of the communication (eg, fliers and parent meetings) with parents was presented in both English and Spanish to promote participation. Finally, extended family members were included as a means of reaching all of the people who played a significant role in the children's health. Each of these strategies was intended to make the program culturally relevant to participants.16

Measures
Anthropometric
Participants’ heights and weights were collected at baseline, 3 months, and 6 months. Weights were obtained by using a digital scale with participants wearing light clothing and no footwear. Height was measured using a stadiometer, with no footwear. BMI was calculated by using measured height and weight and was standardized (zBMI) by using age- and gender-normative data from the Centers for Disease Control and Prevention.11

Percentage of body fat was obtained from a foot-to-foot bioelectrical impedance assessment by using a Tanita 300 series scale (Tanita, Arlington Heights, IL). This has been shown to be a reliable measure for use in a large adolescent population.17,18

Clinical Measures
Venous blood samples were collected in the morning (7:00 AM to 8:00 AM) after an overnight (>8-hour) fast by a trained research nurse or phlebotomist. EDTA-treated whole-blood samples were analyzed for total cholesterol, triglycerides, high-density lipoprotein (HDL) cholesterol, and calculated low-density lipoprotein (LDL) cholesterol using an automated analyzer (Hitachi, Tokyo, Japan). Plasma was separated by centrifugation and frozen (–80°C) until analysis for insulin and glucose. Plasma insulin concentration was determined using an enzyme-linked immunosorbent assay (Monobind Inc, Lake Forest, CA), whereas glucose concentration was determined using an automated analyzer (YSI 2300; Stat Plus, Yellow Springs, OH). Cholesterol analysis was completed in a clinical laboratory at Baylor College of Medicine, whereas insulin and glucose analyses were completed at the University of Houston.

Blood Pressure
Blood pressure (BP) was determined by using a Dinamap Monitor Pro 100 (GE Healthcare, Piscataway, NJ) after sitting for ≥5 minutes. BP was measured, and values were interpreted using the methods described by the National High Blood Pressure Education Program Working Group on Hypertension Control in Children and Adolescents.19

Statistical Analyses
Statistical analyses were performed by using SPSS 13.0.1 (SPSS Inc). t tests and {chi}2 tests were conducted to evaluate group differences on baseline characteristics (see Table 1) and differences between participants who remained in the study and those who dropped out before the end of the 6-month assessment. A 2-group (II versus SH) repeated-measures analysis of variance was used to evaluate group differences in zBMI for baseline, 3-month, and 6-month outcomes. Repeated-measures analysis of variance was also used to evaluate group differences for all of the secondary outcomes comparing baseline and 6-month outcomes on completers only. As recommended by the Consolidated Standards of Reporting Trials guidelines for randomized trials, models were developed for both completers and intention to treat using the last observation carried forward method.20


   RESULTS
TOP
 ABSTRACT
 PATIENTS AND METHODS
 RESULTS
DISCUSSION
 CONCLUSIONS
 REFERENCES
 
No differences were found between conditions with respect to baseline demographic or anthropometric variables. In addition, there were no significant differences between completers and noncompleters on baseline demographic variables. Of the 60 participants, 57 (95%) completed baseline, 3-month, and 6-month measurements.

Primary Outcome
Children in the II significantly reduced their zBMI when compared with children in the SH group (F = 11.72; P < .001) with significant differences in zBMI change at both 3 and 6 months (F = 16.50, P < .001 and F = 22.01, P < .001, respectively; see Fig 2 and Table 2). Using an intention-to-treat model produced similar results for zBMI change (overall: F = 12.74, P < .001; 3-month: F = 16.70, P < .001; 6-month: F = 24.18, P < .001).


Figure 2
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  		FIGURE 2 Change in zBMI at baseline and 3 and 6 months.

 

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  		TABLE 2 Change in Height, Weight, BMI, BMI Percentile, and Percentage of Body Fat According to Treatment Condition for Completers and ITTs

 
Secondary Outcomes
Children in the II significantly reduced their total cholesterol (F = 5.27; P = .027) and LDL cholesterol (F = 7.43; P = .01) compared with children in the SH condition at 6 months (see Table 3).


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  		TABLE 3 Change in Cardiovascular Parameters From Baseline to 6 Months for Completers and ITT

 

   DISCUSSION
TOP
 ABSTRACT
 PATIENTS AND METHODS
 RESULTS
 DISCUSSION
CONCLUSIONS
 REFERENCES
 
Ethnic minorities and low-income groups have the highest rates of overweight and associated health problems in the United States.21 Among minorities, Mexican American adults experience one of the highest prevalence rates of overweight and obesity (75.8%) when compared with other ethnic groups. Similarly, the prevalence of at-risk for overweight and overweight in Mexican American children and adolescents is higher (37%) than for other minorities.1 Given this increased prevalence, the need for effective interventions with this group is clear.

This behavioral intervention resulted in significant decreases in zBMI at 3 and 6 months in Mexican American children and adolescents when compared with their counterparts in the SH control group. Currently, few studies have demonstrated weight loss in this population.16 In our view, a primary difference of this program was the individualized nature of the interventions. For example, trained research staff worked with the children to adapt their specific lifestyle patterns using program principles. In addition, daily monitoring of children's individual dietary and exercise behaviors assisted them to gradually make changes tailored to their specific needs.

Providing consistent, frequent feedback strategies for gradually modifying diet and physical activity, as the current study did, may be needed initially to model and reward children in their efforts at achieving healthy weight status. Having professionals trained in nutrition, physical activity, and behavior modification may be necessary to initiate a program with sufficient intensity for weight change. Future research may evaluate additional strategies, including providing regular opportunities for practicing healthy living within naturalistic settings, such as schools. These approaches allow not only real-world training and modeling of healthy behaviors but also afford opportunities to build support from other individuals in the environment.

Our program was more intensive than most school-based interventions for weight management. With this level of intensity, issues such as cost-effectiveness arise. However, because there are limited data about the use of school-based programs for weight loss in Mexican American children,22 the need to identify efficacious programs is critical. This study was a first step in determining whether weight loss was achievable. Instead of beginning this process by identifying the minimal level of intensity needed, we approached this problem by providing the most II possible for our resources. Although this approach is costly, it provides evidence for the ability of school-based interventions to impact weight. Given the substantial cost of obesity, more intensive methods may be justified in addressing this epidemic.

The strategy of using community and neighborhood models for making changes has been successfully used to improve health in minority populations.23 Our program demonstrated that a school may be an optimal setting for promoting weight change in Mexican American children. Although a number of factors could potentially impact the outcomes for these children, the literature on this topic is limited. Additional research determining the most effective settings for initiating weight management in Mexican American children is clearly needed.

Addressing the specific needs of the populations being served will increase the likelihood of program success. For example, implementing strategies that address the dietary concerns of the population targeted for intervention may be effective in promoting weight change in minorities. Specific to this study, children often skipped school meals, only eating the low-nutrient, high-calorie afternoon snacks provided by the school. To address this issue, we provided peanuts or peanut butter with a fruit or vegetable as a healthy, nutrient-dense alternative.

In addition to our program reducing zBMI, children in the II also significantly lowered their total cholesterol and LDL when compared with the SH condition. Although differences were not found for BP, glucose, HDL, and insulin, this study was not designed to detect the small changes that occur in these cardiovascular parameters over time in growing children. In addition, these secondary measures were taken only on a subsample of participants, and most children demonstrated normal values at baseline. These factors further decreased the statistical power for detecting significant differences in blood levels over time. Future longitudinal studies using more participants or participants who have elevated cardiovascular parameters will facilitate the detection of changes associated with changes in child zBMI.

Given that the primary hypothesis focused on weight loss, additional components associated with weight management were not assessed. Although participants maintained diet and activity records as part of their participation in the program, these variables were viewed as independent (variables that caused change) versus dependent variables (variables that change as a result of treatment). Furthermore, the current study was not powered to detect differences in these factors. However, future research that focuses on program specific components (eg, diet, physical activity, and parental involvement) will be beneficial for determining their relative contributions to weight loss. In addition, long-term follow-up data are necessary to fully assess the impact of this type of program for sustained weight loss. Based on these results, additional research in these areas is warranted.


   CONCLUSIONS
TOP
 ABSTRACT
 PATIENTS AND METHODS
 RESULTS
 DISCUSSION
 CONCLUSIONS
REFERENCES
 
These results are promising and suggest that an individualized treatment of sufficient intensity is an effective means for promoting weight loss in overweight Mexican American children. Our participants’ weight loss was maintained from 3 to 6 months, but further efforts are needed to evaluate their long-term lifestyle changes. Our intensive program demonstrated that weight loss is possible in Mexican American children who are at risk for developing adult obesity. It is essential that future programs further establish specialized techniques that are effective for those populations most in need of weight management interventions.24 Ultimately, it is important that feasible weight management programs be disseminated and implemented to help manage the growing obesity epidemic in minority populations.


   ACKNOWLEDGMENTS
 
This work was supported by US Department of Agriculture grant ARS 2533759358. We thank the members of the Peanut Institute for their support of this study.


   FOOTNOTES
 
Accepted May 11, 2007.

Address correspondence to Craig A. Johnston, PhD, Baylor College of Medicine, 6655 Travis, Suite 320, Houston, TX 77030. E-mail: caj{at}bcm.edu

The authors have indicated they have no financial relationships relevant to this article to disclose.

This trial has been registered at www.clinicaltrials.gov (identifier NCT00454610).


   REFERENCES
TOP
 ABSTRACT
 PATIENTS AND METHODS
 RESULTS
 DISCUSSION
 CONCLUSIONS
 REFERENCES
 

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