Tcmgmdtmvm

1

from the associationOF PROFESSIONAL INTEREST

Dietetic Management of Pediatric Overweight:Development and Description of a Practical and

Evidence-Based Behavioral ApproachLaura Stewart, SRD; Jan Houghton, SRD; Adrienne R. Hughes, PhD; Dympna Pearson, SRD;

John J. Reilly, PhD

ailitcmefotlK1silnrTwgdoc

cttabscqtwdcseTuht

cmplRaahwesatqcr

epttocOdnhs

iissmdinmlhc

BR

here is great uncertainty over howto treat childhood overweight. Re-cent systematic reviews provide a

onsensus on the most promising ele-ents of treatment, but no successful,

eneralizable, evidence-based treat-ent model is currently available. We

escribe a novel approach to treatmenthat is evidence-based, putting recom-endations of recent systematic re-

iews into practice. The novel treat-ent uses a client-centered approach

L. Stewart is a research dieti-tian, Division of DevelopmentalMedicine, University of Glasgowand Yorkhill Hospitals, Glasgow,Scotland and the Department ofNutrition and Dietetics, RoyalHospital for Sick Children, Edin-burgh, Scotland. J. Houghton isa research dietitian, Division ofDevelopmental Medicine, Univer-sity of Glasgow, and Departmentof Dietetics, Yorkhill Hospitals,Glasgow, Scotland. A. R. Hughesis a research fellow, Division ofDevelopmental Medicine, Univer-sity of Glasgow and Yorkhill Hos-pitals, Glasgow, Scotland. D.Pearson is a freelance dietitian,Leics, UK. J. J. Reilly is areader, Division of DevelopmentalMedicine, University of Glasgow,Yorkhill Hospitals, Glasgow, Scot-land.

Address correspondence to:John J. Reilly, PhD, Division ofDevelopmental Medicine, Univer-sity of Glasgow, Yorkhill Hospi-tals, 1st Floor Tower Block QMH,Glasgow, G3 8SJ Scotland.E-mail: jjr2y@clinmed.gla.ac.uk0002-8223/05/10511-0012$30.00/0

doi: 10.1016/j.jada.2005.08.006

810 Journal of the AMERICAN DIETETIC ASSOCIATI

nd behavioral change techniques toncrease and maintain motivation forifestyle change. It focuses on increas-ng physical activity, reducing seden-ary behavior, and changing diet inhildren who are overweight (bodyass index �98th percentile) and of

lementary school age. Treatment lastsor 6 months and requires 5 to 6 hoursf a dietetics professional’s time per pa-ient (in contrast to more traditional,ess intensive approaches in the Unitedingdom, which invest approximately.5 hours per patient). Preliminary as-essment of the program suggests thatt is practical, and patient dropout isow. Formal evaluation of efficacy willot be available until completion of aandomized, controlled trial in 2006.his description of our novel treatmentill enhance generalizability of the pro-ram if it is successful, and a detailedescription will assist in developmentf other treatments even if it is unsuc-essful.

Childhood overweight is now veryommon and is still increasing acrosshe world (1). There is clear evidencehat overweight in childhood is associ-ted with adverse health outcomes inoth childhood and adulthood (2,3). De-pite the combination of high and in-reasing prevalence, adverse conse-uences, and increasing public concern,reatment programs for childhood over-eight are not widely available. In ad-ition, systematic reviews have con-luded that there are currently nouccessful treatment models that arevidence-based and generalizable (2,4).reatment offered by many centers isnsuccessful and is characterized byigh patient dropout and continued pa-ient weight gain (5).

Recent systematic reviews have con- h

ON © 2005

luded that the most promising treat-ents are the intensive behavioral

rograms offered by Epstein and col-eagues in the United States (2,4,6,7).obinson concluded that a behavioralpproach to treatment was “state of thert” (7). However, Epstein’s treatmentsave not been described in detail oridely distributed, so they cannot beasily replicated. In addition, the Ep-tein program is not readily generaliz-ble to settings in which resources forreatment are limited, because it re-uires access to large numbers of spe-ialist health professionals for long pe-iods of time (2,4,6,8).

This report describes a simpler butvidence-based behavioral treatmentrogram for overweight in elemen-ary school-aged children. Becausehe treatment is being evaluated rig-rously in an ongoing randomized,ontrolled trial (Scottish Childhoodbesity Treatment Trial), a detailedescription of the program will beecessary if it is successful, or mayelp to provide an explanation of rea-ons for failure if unsuccessful.The novel treatment uses behav-

oral change techniques, and describ-ng the development of our approachhould be helpful for dietetics profes-ionals who are considering how toake their consultations in chronic

isease management more behavioraln nature. There is increasing aware-ess that a more behavioral approachay be beneficial in bringing about

ifestyle changes and encouraging ad-erence to prescribed treatments, in-luding dietary change (9).

ACKGROUND: THE EVIDENCE BASEecent systematic reviews of child-

ood obesity and expert committee

by the American Dietetic Association

rcm

1

2

3

4

5

mppcmaid

TTDTt

tEieldil“atf(ttl

CSCba(ptdacehudpua

ajfaemdwto

DPTiivwmcfe(pto6

BAtanc

Fi

OF PROFESSIONAL INTEREST

ecommendations (2,4,6,8,10,11) haveonsistently recommended that treat-ent:

. be directed at motivated families(in which the child and/or parentsperceive obesity as a problem andappear willing to make lifestylechanges);

. be directed at the entire familyrather than just the obese child;

. aim for weight maintenance (ratherthan weight loss);

. be more intensive than has beenthe norm (more frequent andlonger appointments); and

. should combine changes in dietplus changes in physical activityand/or reduction in sedentary be-havior (eg, television viewing).

We have incorporated these recom-endations in our novel treatment

rogram. However, the precise ap-roach taken to achieve these lifestylehanges has not been clearly recom-ended in any reviews or guidelines

nd so practical guidance as to dieteticmplementation of these recommen-ations is lacking.

HE SCOTTISH CHILDHOOD OBESITYREATMENT TRIAL NOVEL TREATMENTietary Changeshe dietary advice given in our novel

Red foodsa

● Fried foods● Potato chips● Pies, pastries● Take-out meals● Fries and burgers● Sugar● Sweets● Chocolate● Chocolate biscuits● Fancy biscuits● Cakes● Sugar-sweetened drinks● Desserts● Sugar- or honey-coated breakfast cereals

aLong-term aim to be restricted to one per day.bRecommended to be restricted to meal times.cTo be taken freely and substituted for red foods.

igure 1. Summary of the modified traffic lighn Scotland.

reatment is a simplified version of i

he “traffic light” diet concept used bypstein and colleagues (12). Our mod-

fied traffic light diet is intended to beasier for children and parents to fol-ow by reducing complexity and aban-oning the need to “calorie count,” asn the Epstein regimen. The trafficight method categorizes food intogood” and “bad” (green and red) foodsnd the child is actively encouragedo count and reduce the number of redoods he or she eats. The long-term6-month) aim of our program is forhe child to restrict his or her intakeo one red food per day. Figure 1 out-ines the traffic light food categories.

hanges in Physical Activity andedentary Behavioronsistent with recent evidence-ased guidelines, systematic reviews,nd Epstein’s pioneering work2,4,12-14), our program takes a two-ronged approach, with advice giveno both increase physical activity andecrease sedentary behavior. Thesere now widely regarded as separateonstructs (15), but in UK dietetics,mphasis on modifying sedentary be-avior as part of dietetic treatment isncommon. In our program, the chil-ren are encouraged to increase theirhysical activity initially to 30 min-tes of moderate to vigorous activityt least five times per week, increas-

Amber foodsb

● Lamb, pork, beef● Sausages and burgers● Chicken and turkey● Fish● Eggs and cheese● Vegetarian meals● Bread/chapatti● Potatoes● Rice● Pasta● Plain breakfast cereals

Low-fat alternatives of● Milk● Butter/margarine● Yogurts

iet used in a behavioral treatment program fo

ng to a long-term goal of 60 minutes l

November 2005 ● Journal

t least five times per week (in con-unction with UK recommendationsor all children) (2). The children arelso encouraged to restrict their sed-ntary time, as is widely recom-ended, to no more than 2 hours per

ay or the equivalent of 14 hours pereek. Written materials describing

hese lifestyle changes are handedut at the first appointment.

ESCRIPTION OF THE TREATMENTROGRAMhe treatment program is a structured

ntervention with the outline of eachnterview defined in advance. It in-olves eight appointments over 26eeks. The Table outlines the appoint-ent structure with a brief summary of

ontent. The need for parental andamily support is fundamental and ismphasized throughout the program2,7,10). Because the emphasis of therogram is on behavior change ratherhan weight change, the children arenly weighed three times during the-month intervention.

ehavioral Change Techniques Employedkey element of the intervention is

hat the approach is client-centerednd employs behavioral change tech-iques: the client (in this case thehild) takes control of his or her own

Green foodsc

● Fresh/dried fruit● Tinned fruit in fruit juice● Vegetables/salad● Homemade/tinned vegetable soup● Sugar-free gelatin● Plain breakfast cereals and low-fat milk● Plain popcorn, breadsticks● Sugar-free lollies● Diet or sugar-free drinks

erweight in elementary school–aged children

t d r ov

ifestyle changes. Various behavioral

of the AMERICAN DIETETIC ASSOCIATION 1811

cstmrfoc

bmdaabitre

EMTi

ftdcaoattp

ctastcuriaai

mhamptucochcsg

GObiaUas

)

OF PROFESSIONAL INTEREST

1

hange techniques (see Figure 2) de-igned to enhance the child’s motiva-ion are employed: goal setting, self-onitoring, use of contracts and

ewards. These techniques originaterom behavioral change programs inther settings, notably in smokingessation and alcohol reduction (16).

There is a reasonably good evidencease for more behavioral approaches toanagement of other chronic childhood

iseases that require nutritional ther-py, such as cystic fibrosis (9,17). Therere a number of important differencesetween traditional and more behav-oral approaches; however, describinghese would be beyond the scope of thiseport and they are described in detaillsewhere (7,9).

xploring and Reinforcing Readiness toake Lifestyle Changeshe first appointment in our program

Table. Summary of the novel treatment pro

AppointmentApproximateduration (min)

1 60

2 30

3 30

4 Parent(s) only 30

5 Home visit 60 Plus travel time

6 30

7 30

8 30

s the longest and the most important s

812 November 2005 Volume 105 Number 11

or setting the style and approach ofhe intervention as well as starting toevelop a shared agenda of lifestylehanges between the child, parent,nd dietetics professional. Educationn energy balance and why the threespects of lifestyle (diet, physical ac-ivity, and sedentary behavior) areargeted are explained using a simpleictorial Energy Balance sheet.Motivation and readiness to make

hanges are explored in depth inhis initial appointment. The childnd parent are asked separately tocore their perceived importancehat the child make the lifestylehanges necessary to “slim down”sing an Importance tool. The scoreanges from 0 to 10, with 0 indicat-ng no importance. The child is thensked to complete a decisional bal-nce chart (pros and cons of change)n which he or she is asked to con-

: Timing and duration of appointments, and

Materials used (behavioral strategies use

Energy balanceImportance (assessing readiness to changeMaking your mind up (exploring importance

exploring barriers to change)Typical dayHealthy eating planBe active!Don’t just sit there!My lifestyle diary (self-monitoring)

Goals sheet (goal setting)My lifestyle diary (self-monitoring)

Goals sheet (goal setting)My lifestyle diary (self-monitoring)

Exploring parents’ concernsDiscussing parenting skills

Goals sheet (goal setting)My lifestyle diary (self-monitoring)

Importance (assessing readiness)Coping with tricky situations (relapse preveGoals sheet (goal setting)Frequency recording sheets (self-monitoring

Goals sheet (goal setting)Frequency recording sheets (self-monitoring

Long-term goals sheet (goal setting)Frequency recording sheets (self-monitoring

ider aspects that are “good” about p

aking the changes that will lead toim or her being slimmer, as well asspects that are “not so good” aboutaking these changes. During this

art of the consultation it is essen-ial for the dietetics professional tose open questions and to allow thehild time and space to consider hisr her answers. In our program,hildren as young as 5 years oldave been able to complete thishart. Typical answers for bothides of the decisional balance areiven in Figure 3.

oal Setting and Behavioral Contractingne of the fundamental differencesetween the client-centered approachn novel treatment and typical pedi-tric weight management in thenited Kingdom is that it is the childnd not the dietetics professional whoets the lifestyle change goals. The

avioral strategies and materials used

Timetable(weeks)

change, problem solving,

0

2-3

4-5

7-8

11-12

n)15-16

20-22

24-26

gram beh

d)

)of

ntio

)

)

rogram is intended to empower the

chhccaeoiacodchitptmtbac

tsattvs

gwtgpcfgrimg“fa

taNehbnaa

SSeesotptmmaoeaaotsitassiau6i

PIiwiietssmdg

EPPOv

F roa

Ft

OF PROFESSIONAL INTEREST

hild to identify the lifestyle changese or she can make and to considerow to make them. For example, ahild who eats five packets of potatohips and two chocolate bars per daynd does almost no physical activityach day may wish to decrease choc-late consumption to one bar per day,ncrease physical activity modestly,nd continue eating five packets ofhips. It is essential to the principlesf a client-centered approach that theietetics professional accepts thehild’s choice of goals, as ownership ofis or her own goals is believed to be

mportant for the child’s adherence tohe program. However, the dieteticsrofessional in our program ensureshat the goals are “SMART” (ie, small,easurable, achievable, recorded,

imed). There needs to be acceptancey the dietitian of some resistancend ambivalence to change from the

Qualities of interviewer (dietitian)● Acceptance● Genuineness● Empathy

Skills required by interviewer● Appropriate use of questions (open questi● Active listening (mirroring, paraphrasing,

reflecting back)● Affirmation● Summarizing

igure 2. Summary of the client-centered app

Pros of lifestyle change● Will not be bullied● Will not be called names● Will be able to run faster● Will be happy● Will be able to fit into nice/fashionable clo

igure 3. Typical patient (child) answers toypically reported by the patient.

hild. When necessary throughout

he program, the dietetics profes-ional deals with this resistance andmbivalence by using reflective lis-ening skills and by referring back tohe decisional balance chart and re-iewing the importance of changecore.In our program, the child first sets

oals during the second appointment,hen he or she is asked to consider

wo to four possible lifestyle-changeoals to be kept until the next ap-ointment. Once the goals are set, thehild and parent agree on a rewardor the child achieving 100% of theoals for the next appointment. Theseewards should be small, relativelynexpensive, and nonfood, such as

usic CDs, books, or an outing. Bothoals and rewards are recorded on aMy Goal” sheet, which is signed as aorm of contract by the child, parent,nd dietetics professional.

)

Principles of approach● Client responsibility● Social influence● Collaboration● Expressing empathy● Rolling with resistance● Supporting self-efficacy● Deploying discrepancy

Strategies employed● Exploring readiness to change● Importance of change● Exploring ambivalence to

change● Understanding current

behaviours● Exchanging information● Exploring options● Problem solving● Goal setting● Self-monitoring● Preventing relapse● Use of contracts● Receiving of rewards

ch.

s

Cons of lifestyle change● Will miss sweets● Will miss potato chips● Will miss watching TV● Will miss playing computer games

isional charts: Pros and cons of change as

Parents are also encouraged to give e

November 2005 ● Journal

he child positive reinforcement forll lifestyle changes that are made.ew goals and rewards are set at

ach appointment. However, if a childas failed to meet his or her goals, thearriers to change are explored andew or modified goals that are morechievable are set and a new rewardgreed upon.

elf-Monitoringelf-monitoring of lifestyle is a keylement of behavioral change, as itnhances motivation by increasingelf-awareness (18). At the start ofur program, self-monitoring is usedo identify lifestyle changes that couldossibly be made by the child. Then,hroughout the program, it is used toonitor progress as changes areade (ie, whether goals have been

chieved) (16). For the first 4 monthsf the intervention, the child and par-nts are asked to keep a lifestyle di-ry in which diet, physical activity,nd sedentary behaviors are recordedn a single sheet each day. The die-etics professional reviews the life-tyle diary at the beginning of eachnterview, which helps to reinforcehe importance of keeping the diarynd informs discussions about goaletting. At 4 months, a simpler tickheet with 1 week to each page isntroduced and families are encour-ged to continue with self-monitoringsing this simple tick sheet after the-month treatment program has fin-shed.

reventing Relapsen an attempt to avoid a lapse becom-ng a relapse, planning for situationshere it may be difficult to meet goals

s an important aspect of the behav-oral change approach. A worksheetntitled “Dealing with Tricky Situa-ions” is used to help the child to con-ider and plan for potential difficultituations, such as birthdays, Christ-as, or rainy days, when it may be

ifficult to achieve his or her lifestyleoals.

VALUATION OF NOVEL TREATMENTROGRAMractical Utilityur novel treatment program was de-eloped to be delivered by a single

ons

the

dec

xperienced pediatric dietetics profes-

of the AMERICAN DIETETIC ASSOCIATION 1813

smtighrptltcdtcmt

swtcvcctgfOlte

COOcottCPmt(

PaTtatcnr

EFtt

iOctlc(phcoammpwm

DOlpCtmUbotabmtcoi

wigedgvmitUftb

npordStpw

dmugmnavaatshsipacw

ToOwutCPpui

R

OF PROFESSIONAL INTEREST

1

ional in an outpatient setting, thusaking the manpower burden and

reatment costs generalizable. Dietet-cs professionals delivering the pro-ram had 14 hours of training in be-avioral change techniques, selectedeading (16), and practice during ailot phase. The consultations under-aken when the intervention was pi-oted, and the initial consultations inhe main program, were tape-re-orded and analyzed by two indepen-ent experts in behavioral change in-erviewing to ensure that behavioralhange techniques were being imple-ented in the program according to

he training.Our novel treatment program con-

ists of eight appointments over 26eeks with a total patient contact

ime of approximately 5 hours, asompared with two to four outpatientisits and approximately 1.5 hoursontact time in standard care forhildhood overweight in Scotland. At-endance at the novel treatment pro-ram was good: 64% (44 of 69) of theamilies in the Scottish Childhoodbesity Treatment Trial randomly al-

ocated to the novel approach at-ended at least six out of the possibleight appointments.

haracteristics of the Scottish Childhoodbesity Treatment Trial Study Participantsne-hundred thirty-four primary school

hildren (5 to 11 years of age) who werebese (body mass index �98th percen-ile) and whose parents were willing toake part were recruited to the Scottishhildhood Obesity Treatment Trial.articipants were 75 girls and 59 boys,ean age 8.8 years (standard devia-

ion�1.8), body mass index z score�3.2standard deviation�0.6).

articipants’ Views of Novel Treatmentnd Typical Carewo qualitative studies will explorehe parents’ and children’s thoughtsnd feelings about both the novelreatment program and standardare. Results from these studies willot be available until 2006 and will beeported elsewhere.

fficacyull rigorous evaluation of the novelreatment program compared with

ypical dietetic care will be available m

814 November 2005 Volume 105 Number 11

n 2006 when the Scottish Childhoodbesity Treatment Trial has been

ompleted. This is a randomized, con-rolled trial following Consort guide-ines. Outcome measurements arehange in body mass index z scoreprimary outcome), growth velocity,hysical activity and sedentary be-avior (measured objectively with ac-elerometry), and quality of life (sec-ndary outcomes). Outcome measuresre made at baseline and 6 and 12onths after the beginning of treat-ent. Costs of both our novel ap-

roach and standard care in Scotlandill be estimated by a health econo-ist.

ISCUSSIONur novel treatment program was pi-

oted prior to use and all new writtenatient materials were peer reviewed.linical audit has put the benefits of

ypical or traditional pediatric weightanagement in doubt, at least in thenited Kingdom (5), and so our teamelieves it is important for us to shareur alternative, novel program. Thereatment program uses a behavioralpproach and techniques that mighte useful not only for the manage-ent of childhood overweight, but po-

entially for other chronic diseases ofhildhood for which lifestyle changer improving adherence to treatments important (9,17).

In contrast to the Epstein program,here many health professionals are

nvolved in the treatment, our pro-ram has been developed to be deliv-red by a single health professional (aietetics professional) who has under-one training in behavioral inter-iewing techniques. This shouldake our program very generalizable

f successful. The program is more in-ensive than typical care in thenited Kingdom, but focuses only on

amilies who appear to be motivatedo change and is not so intensive as toe unrealistic in routine practice.In conclusion, we have described a

ovel, evidence-based, behavioral ap-roach for the treatment of pediatricverweight. Two experienced pediat-ic dietetics professionals have beenelivering this program for 2 years incotland and have found it to be prac-ical and easy to implement in an out-atient situation. The novel programe have developed and described here

ay or may not be successful, but the

etailed description of it should per-it replication (if successful) and, if

nsuccessful, will provide a usefuluide for development of future treat-ents for pediatric overweight. Alter-

ative treatment programs are avail-ble for pediatric overweight, butery few have been described in such

way that other dietitians coulddopt them, with a few notable excep-ions (19,20). It is unlikely that anyingle approach will be practical in allealth care settings and in all circum-tances, so wider dissemination of ex-sting programs should be helpful inroviding dietetics professionals withvariety of means to tackle the in-

reasing problem of pediatric over-eight.

he treatment program was devel-ped as part of the Scottish Childhoodbesity Treatment Trial project,hich is funded by the Scottish Exec-tive Health Department. We wish tohank Professor Bryan Lask, MB,hB, MD; Professor Lori Stark; androfessor Jane Wardle for discussingossible behavioral approaches withs at the design stage of the

ntervention.

eferences1. World Health Organisation. Diet,

Nutrition and the Prevention ofChronic Diseases. WHO TRS 916.Geneva: WHO/FAO; 2003.

2. Scottish Intercollegiate GuidelineNetwork (SIGN). Management ofobesity in children and youngpeople. SIGN 69. 2003. Edin-burgh, SIGN. Available at: http://www.sign.ac.uk. Accessed March31, 2005.

3. Reilly JJ, Methven E, McDowellZC, Hacking B, Alexander D,Stewart L, Kelnar CJ. Healthconsequences of obesity. Arch DisChild. 2003;88:748-752.

4. Summerbell CD, Ashton V,Campbell KJ, Edmonds L, KellyS, Waters E. Interventions fortreating obesity in children. Co-chrane Database Syst Rev. 2003;(3):CD001872. Review.

5. Stewart L, Deane M, Wilson DC.Failure of routine managementof obese children: An audit ofdietetic intervention. Arch DisChild. 2004;89(suppl 1):A13-A16.

6. Reilly JJ, Wilson ML, Summer-

bell CD, Wilson DC. Obesity diag-

1

1

1

1

1

1

1

1

1

1

2

OF PROFESSIONAL INTEREST

nosis, prevention, and treatment:Evidence based answers to com-mon questions. Arch Dis Child.2002;86:392-395.

7. Robinson TN. Behavioral treat-ment of childhood and adolescentobesity. Int J Obes. 1999;23(suppl2):S52-S57.

8. Mulvihill C, Quigley R. The Man-agement of Obesity and Over-weight: An Analysis of Reviews ofDiet, Physical Activity and Be-havioural Approaches. EvidenceBriefing. 1st ed. London: NHSHealth Development Agency; 2003.

9. Lask B. Motivating children andadolescents to improve adherenceto treatment. J Pediatr. 2003;143:430-433.

0. Barlow SE, Dietz WH. Obesityevaluation and treatment: Expertcommittee recommendations. Pe-diatrics. 1998;102:1-11.

1. Gibson P, Edmonds L, Haslam

DW, Poskitt E. An approach to

weight management in childrenand adolescents (2-18 years) inprimary care (RCPCH). J FamHealth Care. 2002;12:108-109.

2. Epstein LH, Wing RR, ValoskiAM. Childhood obesity. PediatrClin North Am. 1985;32:363-379.

3. Epstein LH, Valoski AM, VaraLS, McCurley J, Wisniewski L,Kalarchian MA. Effects of de-creasing sedentary behavior andincreasing activity on weightchange in obese children. HealthPsychol. 1995;14:109-115.

4. Epstein LH, Paluch RA, GordyCC, Dorn J. Decreasing seden-tary behaviors in treating pediat-ric obesity. Arch Pediatr AdolescMed. 2000;154:220-226.

5. Dietz WH. The role of lifestyle inhealth: Epidemiology and conse-quences of inactivity. Proc NutrSoc. 1996;55:829-840.

6. Rollnick S, Mason P, Butler C.

Health Behavior Change. A Guide

November 2005 ● Journal

for Practitioners. 1st ed. London,UK: Churchill Livingstone; 1999.

7. Stark LJ. Can nutrition counsel-ling be more behavioural?: Les-sons learned from dietary man-agement of cystic fibrosis. ProcNutr Soc. 2003;62:793-799.

8. Foreyt JP, Paschali AA. Behav-iour therapy. In: Kopleman P, ed.The Management of Obesity andRelated Disorders. London, UK:Martin Dunitz; 2001:165-178.

9. Hipsky J, Kirk S. Healthworks:Weight management program forchildren and adolescents. J AmDiet Assoc. 2002;102(suppl 3):S64-S68.

0. Sothern M, Schumacher H, vonAlmen TK, Carlisle LK, Udall JN.Committed to kids: An inte-grated, 4-level team approach toweight management in adoles-cents. J Am Diet Assoc. 2002;

102(suppl 3):S81-S85.

of the AMERICAN DIETETIC ASSOCIATION 1815