Beyond Diet and Exercise
This is part two of an evidence-based review of nontraditional therapies for childhood and adolescent obesity.
By Sarah C. Armstrong, MD; Richard Chung, MD; Alexandra C. Russell, MD; Michelle Bailey, MD; Diana H. Dolinksy, MD; and Terrill Bravender MD, MPH

As the epidemic of childhood obesity continues to escalate, both traditional and non-traditional solutions have been attempted. Most widely described are the so-called "big two" namely, diet and exercise. Many other options exist for treatment of overweight children and their families, however. This review attempts to describe the existing evidence for nonlifestyle treatment; part one focused on pharmacotherapy, bariatric surgery, and literacy-based interventions. This portion of the review covers technology-based and mind-body approaches to obesity as well as the link between sleep duration and obesity. The first part of this review appeared in the March 2009 issue.

Technology-based Approaches (T Bravender)
The influence of high-tech electronics has increased dramatically over the past 20 to 30 years. Prior to the 1970s, radio and television comprised virtually the entirety of consumer electronic goods sold in the United States, but now these older technologies compete with home computers, DVDs, digital audio and other media, and video gaming systems.¹ Children today have more access to technology than ever before, and for the majority of children, most of their time not spent in school or sleeping is taken up by time spent in from of a screen.² Although these screens have deservedly been implicated in the rise in childhood obesity rates,³ recent work has investigated the use of such technologies to improve the health of children. Such investigations have included the use of television, online communities, multimedia educational programs, personal communication tools, and video games. Many studies have shown potential, however, the systematic evaluation of new technologies falls far behind the fast pace of development.^4,5

Television has long been implicated as a significant contributor to childhood obesity.⁶ Surprisingly, viewing appears to have only a minimal impact on physical activity,⁷ and the effects of television on children are complex. For example, children watching television have lower metabolic rates than those children who are simply resting in a quiet room,⁸ and children who watch more television tend to consume more calories than those children who watch less.⁹ One intervention program designed to decrease television viewing noted that decreased television viewing had no significant effect on physical activity, but did decrease energy intake.¹⁰ The advertising that children are exposed to while watching television may also impact food choices, and food products are the most commonly advertised items on television.¹¹ Regardless of the mechanism, it is clear that children who are able to limit television viewing and participate in physical activity are the most likely to avoid being obese.¹²

In addition to limiting television exposure, creating contingency systems in order for children to access television have been associated with favorable changes in body weight and composition. Children in one intervention had to accumulate a certain level of physical activity as measured by activity monitors. Participants could then cash in a certain amount of the monitored physical activity for an hour of television viewing.¹³ As might be expected, these children watched less television, had higher levels of physical activity, and lower body mass indexes (BMIs) than children in the control arm of the study. Another contingency system involved televisions and stationary exercise bicycles. For children to watch television, they had to pedal the bicycles; as soon as they stopped, the televisions turned off. As hypothesized, over the 12 weeks of the study these children watched less television and had higher activity levels than those children who did not have to ride the bicycles in order to turn on the televisions.¹⁴

Video games that promote physical activity have been termed exergames.¹⁵ Recently, these games have proven wildly popular, as exemplified by the interactive Wii System (Nintendo, Redmond, WA). In fact, in December 2008, the game Wii Sports surpassed the game Super Mario Brothers (Nintendo) as the best selling video game of all time, with over 40 million units sold worldwide.¹⁶ The Wii platform may either be controlled using push buttons or using a hand-held position sensor that may be used to mimic swinging a tennis racquet, throwing a ball, or other ways of interfacing with the screen. Children use more energy playing these active video games than they do while playing sedentary video games. Graves and colleagues noted that energy expenditure was 51% greater when children played Wii Sports than when they played the more traditional, sedentary game, Xbox 360 (Microsoft, Redmond, WA), which translates to an additional 60 kcal/hour expended.¹⁷ Active video games using other platforms have also been shown to result in greater energy expenditure than sedentary games.¹⁸ These other games included Nicktoon's Movin' (Viacom International, New York, NY) (in which a child is placed in the game on the screen using a small camera and has to jump and catch objects interactively), as well as Dance Dance Revolution (Konami Corporation, Osaka, Japan).

Despite the evidence for increased energy expenditure by children playing active video games, there is little evidence that these games have any effect on children's weight. The one small trial of Dance Dance Revolution we reviewed showed no association between use of the video game and BMI z-score.⁵ The authors also noted that, after 3 months of the study, only two out of 21 children used Dance Dance Revolution at least twice weekly, despite multiple telephone reminders to do so. The decline in use over time should not be surprising since as the novelty of the game wears off, children are likely to move on to the next high-tech entertainment. Another concern regarding the use of video games is that, in order for them to be helpful, they must take the place of sedentary activities, and not take the place of more traditional active pursuits.¹⁹

Although there have been examples of effective nutrition education interventions,²⁰ these programs have been difficult to replicate, and few have received vigorous evaluation, and among those that have, few have shown much benefit.²¹ Because many of these interventions have been implemented in schools using traditional teacher-student interactions, some investigators have pursued other educational strategies, including interactive multimedia education. These interactive multimedia programs integrate the educational content into games and characters with which children interact. These may be based on CD-ROM or online platforms. One example of such a game is Squire's Quest (Baylor College of Medicince).²² In this game, children play a knight who must ensure that the kingdom has sufficient fruit, vegetables, and fruit juice to prosper. Children who spend ten 25 minute session with the game over 5 weeks consumed 1 serving more of fruits, vegetable, or fruit juice as compared to children who did not play the game. Although consumption of juice has been associated with increased obesity in those children at risk,²³ the authors contend that the game shows promise in changing dietary behavior. While simple games like Squire's Quest may be effective for younger children, adolescents are more likely to be drawn to more complex games that online, interactive personas or avatars that they can use to interact with others.²⁴

The ability to update and disseminate Internet-based programs may give them an advantage of CD-ROM based programs. These Internet-based education programs may be useful to promote healthier lifestyles and weight loss, and it appears that the more interactive programs are more effective. Frequent e-mail reminders and tracking logs may increase the effectiveness of such programs.^25,26 A major impediment to the effectiveness of such programs is the frequency with which participants access the web sites. One study even found that paying teenage girls $5 weekly for logging-on to the study Web site did not increase rates of use. Most participants, whether being paid weekly or not, stopped accessing the web site after week 4 of the 8-week study.²⁷ This should not some as much of a surprise, as attrition from in-person weight-loss programs is likely the greatest barrier to effectiveness.²⁸ Although the effectiveness of these programs seems to be greater in adults than teens,²⁹ such programs, particularly with high levels of interactivity, may show promise for adolescents given the ease with which many of them communicate electronically.

One area that has not received much study involves the use of online communities, or social networking sites to promote healthy weight and nutrition. Much has been written about the potential deleterious effects of these sites, particularly with regard to so-called "pro-ana" or pro-eating disorder sites and discussion groups,³⁰ but there may be health benefits to developing large peer groups focused on health promotion. Interactive sites such as YouTube (YouTube, LLC, San Bruno, CA) and social networking sites such as Facebook (Facebook, Inc., Santa Clara, CA) and MySpace (MySpace, Inc., Beverly Hills, CA) (among others) have been exploited by advertisers, but public health research has lagged behind.³¹ There are currently over 500 Facebook groups focused on weight loss ranging from support groups to advice groups to weight-acceptance groups.

The interactivity of current Internet technologies such as cell phones, personal digital assistants, and smart phones is another potential target for intervention. Many teens carry these devices with them constantly, so they may be convenient and accessible tools for delivering positive health messages. Unfortunately, just as computer use is associated with higher BMIs in teens, there may also be a correlation between the length of time spent using cell phones and higher BMIs in teens,³² and the preliminary data using personal digital assistants for obese adults do not show much promise.³³ On the other hand, office-based personal digital assistants have been shown to be effective in health screening and in delivering health promotion messages to adolescents.³⁴ The next step should be to deliver these messages to adolescents out of the office in a personalized manner via the wireless communication device of the teens' choice.

Mind-Body Approaches (M Bailey)
The use of complementary and alternative therapies (CAM) in children is increasing.¹ More patients and families are turning to CAM to care for their children, particularly those with chronic illness. In fact, a recent study conducted by the US Centers for Disease Control and Prevention showed that more than one in nine children use some form of CAM.²

CAM is defined as a group of diverse medical and health care systems, practices and products that are not presently considered to be part of conventional medicine. The list of what is considered to be CAM changes continually as new approaches to care emerge that are determined to be safe and effective. The National Center for Complementary and Alternative Medicine (NCCAM) groups CAM practices into four domains: (1) biologically-based practices, (2) energy medicine, (3) manipulative and body-based therapies, and (4) mind-body medicine. Specific studies on mind-body interventions in children who have obesity are few in number,^3,4 however mind-body medicine is widely used in children for the management of stress, depression, anxiety, low self-esteem, and coping, all of which have been shown to occur in children who have obesity.^5,6 In 2002, mind-body techniques, including relaxation techniques, meditation, guided imagery, biofeedback and hypnosis were used by 17% of adults in the United States.⁷

Mindfulness meditation involves the cultivation of moment-to-moment awareness in which people learn to accurately label their inner experience while detaching from judging it.^8,9 Mindfulness interventions may regulate health behaviors such as eating and being active. Mindfulness meditation has been used to promote feelings of well-being and to improve overall quality of life. While meditation has been well studied in adult patients who have chronic illness,^10,11 no controlled studies examining its specific use in pediatric obesity have been published.

Mindfulness-based approaches to modify disordered eating patterns in adults are empirically supported,^12,13 and they are currently under study as treatments for losing weight (NIH Grant 5U01 AT002550) and maintaining weight loss (NIH Grants 5U01 AT004159 and 5 U01 AT004158). The Mindfulness-based Eating Awareness Training (MB-EAT),¹⁴ the first approach to combine cognitive behavioral therapy with mindfulness theory is consistent with affect regulation models,¹⁵ restraint theory (eg, chronic dieting model),¹⁶ the escape model,¹⁷ and mental control.¹⁸ The technique addresses weight, shape and eating-related self-regulatory processes; also the role of hunger and satiety cues. No published studies evaluate MB-EAT in overweight and obese children, however this technique may hold promise in helping to re-learn internal cues for eating and physical activity. .

Many obesity clinics and treatment centers currently teach individuals to increase their awareness of hunger and fullness sensations, a technique often referred to as mindful eating. Many use a hunger scale, on which 1 indicates an empty stomach and 10 indicates an overly full sensation. Individuals are encouraged to pay attention to how hungry they feel before eating a meal and to note any changes in how the stomach feels as they are eating. The goal is to stay between a 3 and a 7 on the scale. The principles of mindful eating as published by The Center for Mindful Eating (www.tcme.org) include: (1) purposefully paying attention, without judgment, to one's emotional reactivity to experiences involving food, eating or weight that may interfere with the ability to make wise choices around eating; (2) cultivating an openness to and acceptance of all experiences; an awareness of the whole eating experience, including emotions, thoughts, judgments, tastes, colors, aromas and textures leading to an increased receptivity to the multilayered experience of eating – identifying what foods may satisfy our individual hunger, guiding the time to stop eating by our own inner experience of satisfaction and satiety and truly experience the pleasures of eating; and (3) putting aside events from the past and thoughts and hopes for the future and instead focusing on the present moment; in this way, eating becomes a present moment activity with the mind fully engaged, letting go of the distractions that may negatively impact our eating behaviors and instead being led by the understanding of nutritional needs, hunger and satiety rather than hopes, fears and past experiences.

Many adults use food as a primary coping strategy (eg, a way to soothe stress and anxiety)¹⁹ and thus model such. It is not uncommon for individuals to use food to deal with boredom, stress, anger, loneliness, joy, and other emotions. According to Satter,²⁰ a child's innate ability to self-regulate may be diminished by a high degree of parental control over feeding practices. She recommends a division of responsibility in feeding children, where parents are responsible for providing safe and appropriate foods in a positive environment, and children are responsible for deciding what to eat and how much to eat from what is provided. The result when children are not given the opportunity to experience, interpret and trust their own satiety and hunger cues, is that they may lose their ability to self-regulate.²⁰

Several resources have been developed on the topic of mindful eating in children. Full Mouse/Empty Mouse—A Tale of Food and Feelings, is a storybook by psychologist Dina Zeckhausen that introduces young children to mindful eating. Dieticians are now incorporating mindful eating into their nutrition counseling.²¹ Mindfulness is also being explored as an adjunct to treatment in the bariatric surgery population.²² In this situation, mindfulness is used to bring the feeling of fullness into the patient's consciousness and to help combat the years of dysfunctional eating patterns.

Although mindfulness-based approaches to a variety of conditions are now being explored in clinical settings, research is needed to evaluate the safety and efficacy of these approaches in children. Mindful awareness practices have been investigated for use in preschool and school-age children to impact executive function and in older children for a variety of behavioral and psychological disorders and for chronic conditions such as pain. The Mindful Awareness Research Center (MARC) at UCLA was created to evaluate the efficacy of mindfulness practices across the lifespan. The STEALTH Mindful Eating Study is a pilot pediatric obesity study that is currently underway at the University of California, San Francisco, and is delivered to the child through the adult parent. The evaluation will be conducted by Drs. Mietus-Snyder, Jean Kristeller, and colleagues. InnerKids is investigating programs for children and families that are closely aligned with both time-tested mindfulness awareness practice and cutting-edge scientific research.

Previous research with mindfulness-based interventions has demonstrated efficacy with regulating mood state, including anxiety²⁴ and depression,^25,26 decreasing addictive behaviors,²⁷ and regulating physiological symptoms. Indeed, over the last several decades, a compelling body of research has suggested that the core deficits in disordered eating patterns stem from ineffective attempts to self-regulate.^28,29

Treatment options for overweight and obese children and adolescents have been frustratingly difficult, time-consuming, and expensive.³⁰ The resistance of adult obesity to long-term change suggests an increased effort needs to be directed to developing effective treatments for overweight and obese children.³¹ Novel approaches that explore the use of mindfulness-based skills training to modify behavior change, increasing the chance for sustained positive impact on weight are needed. While there are a few studies looking at using mind-body medicine (eg, yoga) to treat overweight in children,³² there are currently no published studies using mindfulness meditation for this condition in the pediatric population. Many mind-body therapies have the distinct advantage of being low-cost interventions that may be offered as a part of a school-based or community-based program, making these attractive, convenient options for families. Further research is needed to add to our knowledge of use of CAM treatment modalities in this vulnerable population.³³

Sleep Duration (D Dolinsky)
Another potential area of intervention relates to improving the quantity and quality of sleep, termed sleep hygiene. A large body of research has focused on assessing the relationship between sleep duration and obesity in children. The Sleep in America Poll found that 45% of 11- to 17-year-olds polled received fewer than 8 hours of sleep per night on school nights, while 31% received 8 to 9 hours of sleep.¹ Multiple cross-sectional studies have described the inverse relationship between sleep duration and obesity. One large study included 8,274 children aged 6 to 7 years and evaluated various durations of nightly sleep. Children who slept fewer than 10 hours per night were more likely to be obese (OR 1.49 for 9–10 hours, 1.89 for 8–9 hours, and 2.14 for <8 hours).² In addition, a recent meta-analysis demonstrated that a sleep duration of even 1 to 2 hours less than recommended is associated with a higher risk of being overweight or obese (OR 1.60), and greater than 2-hour deficit correlates even more strongly (OR 1.92).³ Some studies have found that the relationship may vary by gender. In a study of 8- to 11-year olds, mean sleep duration was significantly associated with the odds of being obese in boys but not in girls.⁴ Similar results are seen in adolescents.⁵

An association also exists between shorter sleep duration in young children and future risk of obesity. Shorter sleep duration of fewer than 10.5 hours per night at 30 months of age is associated with an increased risk of obesity at age 7 years.⁶ Hours of sleep reported in children between 3 and 5 years of age is inversely related to the risk of being overweight at 9.5 years of age.⁷ Shorter sleep time between ages 5 to 11 years correlates with higher adult BMI at 32 years of age after adjusting for adult sleep time, early childhood BMI, parental BMI, childhood socioeconomic status, child and adult TV viewing, and adult activity levels.⁸

The mechanism for this observation may potentially serve as a target for intervention. It has been suggested that a shorter sleep duration may lead to less physical activity but the evidence for this association has been inconsistent.^9,10 Others have proposed a relation between sleep duration and caloric intake by affecting food choices and the opportunity to eat but again the studies have not been consistent.^9-12 Sleep duration has also been found to have hormonal effects which may be the mechanism for an association with weight. Leptin, an adipocyte-derived hormone that suppresses appetite, was found to be lower in adults with short sleep duration but found to be higher in girls who sleep for shorter durations.^10,12 Ghrelin, a stomach-derived peptide that stimulates appetite, has been found to be higher in adults with shorter sleep duration.^12,13 Sleep duration has also been found to have effects on growth hormone and cortisol profiles.^14,15

More research is needed to further assess the usefulness of sleep modification to alter risk of obesity. No trials have been published evaluating sleep duration interventions and weight loss or maintenance either in children or adults. There is a current study recruiting adults looking at sleep duration modification and effects on weight (clinicaltrials.gov register number NCT00261898). Another study involves a multidisciplinary lifestyle intervention in children, including attempts to modify sleep duration, and its effects on BMI (clinicaltrials.gov register number NCT00674544). With the addition of further research evaluating sleep modification and weight, sleep counseling can become a more reliable component of the current approach to weight loss and maintenance in children.

Sarah C. Armstrong, MD, is the Medical Director of the Healthy Lifestyles Program, in the Division of Pediatric Primary Care at Duke University Medical Center. She may be reached at sarah.c.armstrong@duke.edu; phone: 919-620-5315; or fax: 919-471-6390. (Duke Children's).

Richard Chung, MD, is a resident in the Departments of Internal Medicine and Pediatrics, Duke University Medical Center. He may be reached at richardjchung@gmail.com; phone: 919-323-0809; or pager: 919-970-4740.

Alexandra C. Russell, MD, is in the Department of Internal Medicine and Pediatrics, Duke University Medical Center. She may be reached at russe060@mc.duke.edu.

Michelle Bailey MD, is Director of Education, Duke Integrative Medicine, Consultant, Healthy Lifestyles program and Medication Instructor in the Department of Pediatrics at Duke University Medical Center. She is also Director of Education, Dule Integrative Medicine. She may be reached at baile010@mc.duke.edu; phone: 919-660-6657; or fax: 919-681-0380 .

Diana H. Dolinksy, MD, is in the Department of Pediatrics, Education and Training, Duke University. She may be reached at dolin004@mc.duke.edu; or pager: 919-970-8415

Terrill Bravender MD, MPH, is Chief of the Section of Adolescent Health at Nationwide Children's Hospital, and Associate Professor, The Ohio State University College of Medicine. He may be reached at bravender.1@osu.edu; phone: 614-722-2458; or fax: 614-355-3583.