24 Management of childhood obesity

Ms. Shumayla and Meenal Dhall

Contents:

1.       Introduction

2.      Goals of Childhood Obesity Treatment

3.      Management of Childhood Obesity

3.1     Comprehensive Programmes

3.2    Physical Activity

3.3    Nutrition

3.4    Parental Involvement

3.5    Psychosocial factors

3.5.1  Children’s social background

3.5.2 Stereotyping

3.5.3 Children’s perception of Obesity

3.5.4 Self-perception and self-esteem

3.5.5 Peer behavior

3.6    Other lifestyle and behavioral factor

4.      Psychodynamic Therapy

5.      Drug Therapy

6.      Surgical Treatment

7.      Prevention strategies for childhood Obesity

Summary

Learning Objective:

• To study various childhood management programs and other factors to control and manage childhood obesity.

    1.  Introduction

Obesity is not just a simple concern about size and appearance. The obesity epidemic contributes to 2.6 million deaths worldwide annually. These deaths are accredited to the comorbidities related with obesity like cardiovascular disease (CVD), diabetes mellitus and hypertension etc. These life threatening effects explain that why growing obesity has quite suddenly become a subject for medical and governmental concern. Paediatric age group is the fastest growing sub-population of obese individuals. Among young obese individuals, many of the chronic diseases may surge in childhood rather than adulthood affecting mental and physical health.

Childhood obesity is not only affluent in western and developed countries as a noticeable concern but for many of the less developed countries. It is disturbing that how some of the lesser developed countries in which undernutrition in childhood was the major concern has moved to one where the problem of overnutrition has now become a major concern (Popkin and Gordon-Larsen, 2004).

The inter-relationship between genetic and environment is central to regulation of the energy balance and hence the body weight. Therefore, the risk factors for this endemic can be stratified on the basis of environmental and genetic sources.

The past 20 years have seen an explosion of research into the relation of events in fetal and early postnatal life to disease processes in later childhood and adult life, the so-called ‘programming’ of chronic non-communicable diseases. Within the pediatric population, obesity frequently develops as early as in preschool or primary school age. Thus, interventions have to start early in life. Intervention program should target improvement of physical activity, healthy nutrition, reduction of TV-watching and other “quiet activities”. These multidisciplinary treatment approaches have been shown to be the most feasible, practical and effective. In addition, parental involvement has been found to be an important determinant for success (Sharma, 2007).

2. Goals of Childhood Obesity Treatment

Primary goal of children obesity treatment is to establish healthy eating and physical activity habits. Childhood obesity programs should not solely emphasis on achieving a healthy body weight rather it should be based on the acquisition and maintenance of skills, by the family as well as by the child. These skills may include awareness about the current eating habits, identifying problem behaviors such as overconsumption of particular high-calorie foods, gradual modification of eating and activity habits. Along with this, medical goals may also be established with regard to the improvement or resolution of secondary conditions such as high blood pressure or abnormal lipid profile. The initial weight goal should be maintenance of current weight, which will automatically result in a reduction of BMI as the child grows taller.

3. Management of Childhood Obesity

With an increase in the prevalence of paediatric obesity over the past several decades and the mandate to physicians to manage this important health issue, clinical obesity programs have been developed that coordinate the services of physicians and other specialists from the relevant disciplines to manage and distribute care to young, overweight individuals. Following are some instances for the management of obesity among children:

3.1 Comprehensive Programmes

Because childhood overweight/obesity is a complicated phenomenon, deciding which child require therapeutic intervention and which one not, requires expert evaluation, possibly by a team of specialists, and devising an effective treatment plan may also require input from a team of specialists. Expert panel guidelines outlined by Barlow and Dietz (1998) describe a two-level screening process for children who are overweight or at risk. The first level involves calculating the child’s BMI; those who are overweight (95th percentile or above) are referred for an in-depth medical assessment, while those at risk for overweight (85th-95th percentile) are referred to a second level of screening. This screening, focuses on five elements:

(1)   Family history of cardio vascular disease or diabetes, and parental hypercholesterolemia or obesity;

(2)   High blood pressure;

(3)   Elevated cholesterol;

(4)   Large recent increase in BMl and

(5)   Psychological or emotional problems related to weight, or child concerns about weight. Children with any of these criteria are referred for an in-depth medical examination.

Most successful childhood obesity treatment programs focus on a lifestyle approach and require cooperation and participation from the child’s parents or entire family. As with adults, losing weight and keeping it off, requires changes in fundamental aspects of daily life (e.g., food consumption, leisure activities); and in the case of a child, this inevitably requires changes from other members of the family as well. For these reasons, comprehensive, family-based behavioral treatment programs have produced the best results over both the short and long term. This is not surprising because most children learn their attitudes and beliefs about food, as well as their habitual behaviors regarding eating at home.

The essential issues that must be addressed in childhood obesity programs include nutrition, physical activity, and social support. While these components can be delivered from a single source, individual interaction with the specialists, family reliance and community resources should be encouraged for long-term weight maintenance and to reduce weight gain.

3.2 Physical Activity

There is strong evidence of the health benefits of physical activity including improvement in longevity, cardiovascular diseases, diabetes, obesity, osteoporosis, immune functioning, certain types of cancer and mental health. When trying to reduce sedentary behavior in overweight/obese children and adolescents, an easy way to increase physical activity is to encourage children to walk or to take bicycle to school whenever possible. The Centre for Disease Control and Prevention has recommended that children should avoid extended periods, i.e. > 2 hours, of inactivity (Maffeis and Castellani, 2007). Regular physical exercise has many positive effects on obesity, apart from weight loss or weight maintenance. It reduces cardiovascular risk and increases cardiorespiratory fitness and influences metabolic, cardiovascular, and orthopaedic comorbidities. Both, aerobic and resistance exercises have been proven to reduce the degree of obesity and the incidence of metabolic consequences, such as type 2 diabetes in predisposed individuals (Sigal et al., 2004).

The positive effect of aerobic exercise in overweight/obese children and adolescents is to increase cardiorespiratory capacity and to utilize fat metabolites during muscle work which is facilitated by increased enzymatic activity of skeletal muscles. In addition, an individual adapted to a higher level of dynamic, aerobic motor activity during growth may develop greater activity of specific enzymes which metabolize and utilize fatty acids (Raben et al., 1997). In a longitudinal study in obese girls, 12 weeks of aerobic exercises significantly improved insulin- sensitivity (Nassis et al., 2005).

As the reduction of body fat is best achieved by dynamic, aerobic exercise, the exercise programs should be started with swimming, brisk walking, or bicycling whenever possible. When some weight reduction and adaptation to increased physical activity has been achieved, exercise from lying down or sitting positions as well as the use of cycle-ergometers are useful approaches as well (Raben et al., 1997). However, exercise programs should be adjusted to individual cardiorespiratory fitness and body shape/ composition as well as age.

3.3 Nutrition

Poor dietary behaviors are known to be a risk factor for the development of obesity. Prior to initiating a nutritional intervention, the child’s nutritional status should be evaluated, and several factors such as the age of child, associated comorbidities and the degree of obesity should be considered. Caloric or energy restriction is an essentially required element for weight loss. However, simple dietary restriction has not been associated with successful weight control and may even result in a nutritionally inadequate diet. In general, with overweight and light obesity in children and adolescents, a balanced low-calorie diet (BLCD) is suggested, aiming at weight maintenance as the primary goal.

With moderate obesity, a diet in which energy intake is reduced by about 30% is advisable. The diet should contain approximately 20% of energy derived from protein, 30-35% from fat and 45-50% from carbohydrates, respectively (Caroli et al., 1992). With severe obesity, i.e. BMI far above the 97th centile and existing comorbidities, a very-low-caloric diet VLCD; =<800 kcal/d) should be considered rather than BLCD. In VLCD, the calories provided per day should be partially balanced, i.e. protein 25%, fat 30%, and carbohydrates 45% of energy intake. The protein-sparing modified fast (PSMF) or unbalanced very low caloric diet is supposed to spare lean body mass while producing rapid weight loss (protein 66%, fat 24%, carbohydrates 10% of energy intake).

Children and adolescents with severe obesity are most widely treated with PSMF (Caroli et al., 2002). A main factor influencing energy homeostasis and total energy intake are beverages. Higher consumption of sugar-sweetened beverages, seen in a Western dietary pattern, are clearly associated with a greater magnitude of weight gain and an increased risk for development of impaired glucose tolerance and type 2 diabetes (Schulze et al., 2004, Schulze et al., 2006). Thus, dietary interventions should in addition to the basic diet regime – aim to reduce the intake of soft drinks in favour of diluted fruit juices, tea or water (Berkey et al., 2004).

Dietary programs that have been applied to youth populations with reported success have included the stoplight diet developed by Leonard Epstein and colleagues, and committed to kids, developed at the Pennington Biomedical Research Centre. In the Stoplight Diet, foods are assigned colours that reflect calorie and fat content and are associated with eating recommendation.

(1)   Red foods are high-fat, high-calorie foods and youth are discouraged from eating these foods;

(2)  Yellow foods are moderate-fat, moderate calorie foods, and youth are instructed to eat these foods in moderation;

(3)   Green foods are low-fat, low calorie foods and youth are allowed to eat these foods freely.

3.4 Parental Involvement

Programs focused on the management of obesity must not only improve the dietary and physical activity behaviors of the children, they must also promote family and social environments that will foster adoption of healthy habits. In children obesity management programs, parental engagement and involvement in the weight-loss and weight-management program often essential for the success of the program.

Parental engagement can be affected by personal characteristics, parenting style and family dynamics. Parents have a strong influence on children’s dietary intake and level of physical activity, both through modelling and reinforcement of eating and exercise behaviors, and through active determination of food options and opportunities for activity.

3.5. Psychosocial factors

3.5.1 Children’s social background

Relationship between obesity and socio-economic status (SES) is not clearly understood till now, but SES plays a considerable role in the development of obesity. Socially disadvantaged families have low nutritional knowledge and interest, poor nutrition overall, and fewer opportunities for physical exercise and activity. In other words, the arguments for low SES causing obesity in children (as well as adults) are compelling.

3.5.2 Stereotyping

Research into stereotypes is important because stereotypes represent a way in which people integrate information about others (Zebrowitz, 1990). The stereotypes of fatness and thinness are commonly held as logical opposites and value laden in that ‘thin is good’ and ‘fat is bad.’ It has been seen that preadolescent children have accepted the above prevalent notion associated with thinness which in addition to personal and social edification includes the positive attributes of well-being, healthy eating and physical fitness. It is a notion that the heaviest children judged all the figures (fat and thin) to be more fit than did the lighter children. In addition, the heavy girls judged all figures to be more liked by their parents than did the lighter girls, the reverse being true for the boys. Overall, however, the heaviest children shared the extremely negative perception of the fat figures.

3.5.3 Children’s perception of Obesity

Research into children’s perception and attitudes to overweight and obesity has its origins in studies of the stereotyping of disability and of the personality attributes associated with particular body shapes. Richardson et al. (1961) used a picture-rating task. Six line drawings showed a child as physically normal and with each of have physical disabilities, one of which was obvious overweight. These drawings were presented to the respondent who was asked to choose the one he or she liked best. The selected picture was put to one side and the question repeated to give a rank order of preference.

The 10 and 11year-olds in Richardson et al.’s study consistently preferred the child with no physical handicap. The second most preferred drawing was the child with crutches and leg brace, followed by the child sitting in a wheelchair, the child missing his/her left hand, and the child with a facial disfigurement. The overweight child was ranked bottom. This negative picture is compounded by the general failure of studies to document the ‘fat but happy’ trait, which is believed to be the single, consistently positive feature of the overweight stereotype.

3.5.4 Self-perception and self-esteem

Body shape discontent is clearly evident. Amidst the tendency for preadolescent and adolescent girls to express a preference for a slimmer figure, there is a marked effect of actual weight. In one study, none of the overweight preadolescents placed their preferred body figure as broader than their current shape (Hill et al., 1994). The observation that overweight preadolescent and teenage girls (and some boys) express low physical-appearance self-esteem is of note. Research shows that self-evaluations of physical appearance are inextricably linked to global self-esteem, albeit from teenage years onwards, and remain so across the life span (Harter, 1993).

3.5.5 Peer behavior

Early adolescence sees a change in the balance of children’s social support from parents to peers. From the age of 12 years onwards parents become less important as support providers, although they rarely become unimportant (Berndt & Hestenes, 1996). Simultaneously, the nature of peer relationships changes from a platform of companionship to include loyalty and intimacy. With this change children are increasingly vulnerable to the vagaries of peer behavior, and while social support generally acts as a buffer against the negative effects of life stress, teasing and bullying by peers can be very hurtful.

The frequency of past teasing about weight/size was significantly associated with current body dissatisfaction and self-esteem. Wilfley et al. (1998) examined obese children attending a fitness and weight-loss camp. Eighty-one per cent had been either teased or criticized about their weight, a majority saying that they were at least moderately upset by it.

3.6 Other lifestyle and behavioral factors

Rise in the obesity amongst youngsters is a majorly attributable to individual lifestyle changes and habits, associated to general features in industrialized countries (sedentary lifestyle). Favourite leisure-time activities among children nowadays include television watching as well as video and computer games rather than physical exercise or outdoor-activities. TV viewing has become the most common recreational activity in majority of the developed in many of the developing countries and there is a significant association between TV viewing and the prevalence as well as the degree of obesity in several paediatric age groups (Kaur et al., 2003; Gupta & Kapoor 2010). A recent study from Australia reported that the increase of childhood obesity during the past 20 years is associated with a reduction of the number of children who walk or cycle to school (Salmon et al., 2005).

In most of the cities, “Junk food” has been made available and affordable more easily than a healthy diet to a growing number of individuals. Intakes of sugar-added beverages like soda, have increased dramatically. Higher intake of soft drinks are associated with lower milk and fruit juice intakes and with higher total energy intakes.

The lifestyle of parents also affects that of their children. Treatment of obesity as well as cognitive awareness for a healthy lifestyle should start early in childhood, as certain lifestyle changes and patterns are more easily incorporated into adulthood if learned early in life.

4. Psychodynamic Therapy

Psychodynamic therapy is used less for the management of obesity than for eating disorders. The obese child was described as living in a dysfunctional family, with disturbed communication between parents and child. The child had difficulties discriminating between emotions and other bodily sensations, such as hunger. Eating was then used as a substitute for emotional needs. This abnormal response developed early in the mother–child interaction if the child’s needs for love, warmth, food and so on were not adequately met.

Behavioral therapy is one of the important psychotherapy for obesity is centred on the concept of bad eating habits in which insufficient control of external stimuli to eat, or rewarding behaviors, result in increased food intakes. Bad eating habits can be broken down into small sequences: the frequency of chewing; the frequency of meals and so on. Parents may be seen as reinforcing children’s eating habits. Behavioral therapy is based on the belief that obesity is a ‘learned disease’, amenable to cure by ‘relearning’. The different treatments induced different ways of controlling weight. In some programs behavioral therapy is combined with cognitive or nutrition education.

5. Drug Therapy

The first drug for the management of obesity, thyroid hormone, was introduced in 1893. It was believed to be therapeutic because overweight patients were thought to have a reduced metabolic rate. Dinitrophenol, a drug that was noted to increase metabolic rate due to the uncoupling of oxidative phosphorylation and to produce weight loss, was soon abandoned because of severe side effects. But in childhood there is only very limited experience with anti-obesity drugs. Clinicians do not recommend drug therapy in the management of childhood obesity.

6. Surgical Treatment

Medical treatment for obesity and the prevention of obesity are, in most cases, discouraging and frustrating for subjects, doctors and dieticians. The surgical treatment of obesity ‘bariatric surgery’ was proposed 40 years ago. Morbid obesity in children and adolescents, arbitrarily defined as greater than 100% excess weight or BMI over 40 kg/m2 is associated with major health complications (Drenick, 1981). Even though the minimum recommended age for bariatric surgery has been placed at 18 years, a few cases have been reported where the severity of obesity and/or related complications were such that bariatric surgery was undertaken in younger subjects.

Surveys of patients who underwent bariatric surgery reported few cases of children under 18 years (Desaive, 1995; Scopinaro et al., 1996). Bariatric surgery has been advocated during the past years as an intervention for adolescents with extreme obesity who failed to respond to conservative treatment options. Current evidence suggests that after bariatric surgery, adolescents not only significantly decrease their BMI but also improve the status of related comorbidities and psychosocial well-being.

Surgical treatment of obesity in childhood and adolescence is undesirable and, in general, should only be considered when all else has failed, when children have achieved adult height and when severe, potentially life-threatening complications of obesity are present. Certainly, bariatric surgery cannot, and never will, solve the problems of management for the vast majority of obese and morbidly obese children and adolescents.

7. Prevention strategies for childhood Obesity

Obesity is the most common chronic disorder in the developed as well as in developing world. It might be expected that the rising prevalence of obesity at all ages would make preventive programmes a high priority in obesity research. The thermodynamic basis for obesity is positive energy balance. If energy consumed in the diet exceeds energy expended through exercise, then surplus energy is stored as fat. So the way to prevent obesity is (in theory) very simple – ensure negative energy balance. This encourages the conversion of stored fat into energy, with resulting loss in weight. Consequently, obesity should be preventable through:

• Increasing energy output (physical activity);
• Reducing energy intake (diet).

   The financial and societal consequences of the emerging epidemic of obesity and related disorders are substantial and demand a prompt public health response. Approximately 60-85% of obese pre-school children will remain obese during adulthood, and comorbidities represent a major health burden (Ebbeling et al., 2002). Emphasis must be placed upon preventive strategies rather than treating strategies. Commonly suggested modifiable public health strategies to diminish childhood obesity are promoting breast feeding, limiting television viewing, encouraging and improving physical activity, increasing fruit and vegetable intake, controlling portion size, and limiting soft drink consumption.

Prevention of obesity has to start very early in life, i.e. in early childhood, and weight stability in years of growth is the emphasized approach. Childhood is considered a priority population for prevention programs because

a)  It is easier to maintain weight in early childhood over a defined period of time than to lose weight in adolescence or adulthood and

b)  It is easier to implement prevention programs in school settings (Sharma, 2007).

Since dietary and physical activity behaviors, i.e. obesity prevention behaviors, are getting formed at these ages, primary school settings are the most ideal settings for school based interventions. At this age group, the establishment of healthy behaviors have a potential long-term impact. The majority of these interventions were able to demonstrate a positive change towards development of healthy behaviors, whereas results have been controversial in terms of adiposity indices such as BMI (Sharma, 2007).

In terms of specialties implemented in the intervention programs the most feasible and practical approach seems to be a multidisciplinary team, including- primary health physicians/ paediatricians, nutrition specialists/ dietitians, physical activity specialist, nurses, school teachers, and psychologists/social workers. In addition to the formation of multidisciplinary teams of health professionals, parental involvement has been found to be an important determinant for success in all interventions (Sharma, 2007).

In preventive measures, initial programmes as small, manageable enterprises may be the most effective. Too often, the vision of a programme is seen in terms of preventing all childhood obesity. Yet, even a small reduction in the fatness of children across a community could have dramatic effects on health and on the prevalence of adult obesity, particularly if the preventive methods could be carried forward into adult life. The prevention of obesity should be recognized for what it is: a positive message to develop a healthy enjoyable lifestyle which provides greater physical and social well-being. In other words: ‘Get a better life!’

Source: Mello et al., 2004

   There is a belief that the prevention of childhood obesity will only be achieved through wide-ranging community schemes which impact both on families and on the national consciousness. The first goal in this respect must be raising awareness, understanding, and public concern for the issue of childhood obesity.

Summary

Prevalence of obesity and overweight has increased considerably over the past years. Due to rapid prevalence increase and associated health consequences of obesity, it is considered as one of the most solemn health challenges of early 21st century. Raised body mass index is a major risk factors for certain noncommunicable diseases like cardiovascular diseases, many type of cancers (kidney cancer, colorectal cancer etc.), type 2 diabetes etc. Childhood obesity is considered as a serious medical condition which affects the children and adolescents. Obese children are above normal weight for their age and height. It is important to recognize that childhood obesity is a complex systems problem that has resulted from environmental changes and biological dispositions. Obesity should be addressed through a comprehensive approach across multiple settings and sectors that can change individual nutrition and physical activity behavior and the environments and policies that affect these behaviors. Society has now changed from times of food scarcity to the easy provision of calorie–dense food and elimination/reduction of daily activities that could consume calories. Prevention of obesity has to start very early in life, i.e. in early childhood, and weight stability in years of growth is the emphasized approach. There are many strategies to prevent childhood obesity including change in dietary pattern of child and including physical activity in the routine of the child, but one of the best strategies is to improve the eating and exercise habits of the entire family. As children learn what they see. We need to create and encourage interventions that integrate multiple levels of influence, and note the intervention effects on social and environmental change as well as behavioral and clinical changes at the individual and family level. Biology and culture have not adapted as rapidly as humans are still programmed to gain weight for survival and large children are a sign of successful parenting in many cultures. Hence early treatment and prevention for childhood obesity helps protect the child’s health now and in the future

References

• Berkey, C. S., Rockett, H. R., Field, A. E., Gillman, M. W., & Colditz, G. A. (2004). Sugar‐added beverages and adolescent weight change. Obesity research, 12(5), 778-788.
• Berndt, T. J., & Hestenes, S. L. (1996). The developmental course of social support: Family and peers. The developmental psychopathology of eating disorders: Implications for research, prevention, and treatment, 77-106.
• Caroli, M., Chiarappa, S., Borrelli, R. & Martinelli, R. (1992). Effciency and safety of using protein sparing modified fast in pediatric and adolescent obesity treatment. Nutrition Research,12, 1325–34.
• Desaive, C. (1995). A critical review of a personal series of 1000 gastroplasties. International Journal of Obesity, 19 (Suppl. 3), S55–60.
• Drenick, E.J. (1981). Risk of obesity and surgical indications. International Journal of Obesity, 5, 387–98.
• Ebbeling, C. B., Pawlak, D. B., & Ludwig, D. S. (2002). Childhood obesity: public-health crisis, common sense cure. The lancet, 360(9331), 473-482.
• Harter, S. (1993). Causes and consequences of low self-esteem in children and adolescents. In Self-esteem (pp. 87-116). Springer US.
• Hill, J. O., & Wyatt, H. R. (2005). Role of physical activity in preventing and treating obesity. Journal of Applied Physiology, 99(2), 765-770.
• Kaur, H., Choi, W. S., Mayo, M. S., & Harris, K. J. (2003). Duration of television watching is associated with increased body mass index. The Journal of pediatrics, 143(4), 506-511.
• Maffeis, C., & Castellani, M. (2007). Physical activity: an effective way to control weight in children?. Nutrition, metabolism and cardiovascular diseases, 17(5), 394-408.
• Mello, E. D. D., Luft, V. C., & Meyer, F. (2004). Childhood obesity: towards effectiveness. Jornal de pediatria, 80(3), 173-182.
• Nassis, G. P., Papantakou, K., Skenderi, K., Triandafillopoulou, M., Kavouras, S. A., Yannakoulia, M., … & Sidossis, L. S. (2005). Aerobic exercise training improves insulin sensitivity without changes in body weight, body fat, adiponectin, and inflammatory markers in overweight and obese girls. Metabolism, 54(11), 1472-1479.
• Popkin, B. M., & Gordon-Larsen, P. (2004). The nutrition transition: worldwide obesity dynamics and their determinants. International journal of obesity, 28, S2-S9.
• Raben, A., Macdonald, I., & Astrup, A. (1997). Replacement of dietary fat by sucrose or starch: effects on 14 d ad libitum energy intake, energy expenditure and body weight in formerly obese and never-obese subjects. International journal of obesity, 21(10), 846-859.
• Richardson, S. A., Goodman, N., Hastorf, A. H., & Dornbusch, S. M. (1961). Cultural uniformity in reaction to physical disabilities. American Sociological Review, 241-247.
• Salmon, J. O., Ball, K., Crawford, D., Booth, M., Telford, A., Hume, C., … & Worsley, A. (2005). Reducing sedentary behaviour and increasing physical activity among 10-year-old children: overview and process evaluation of the ‘Switch-Play’intervention. Health promotion international, 20(1), 7-17.
• Schulze, M. B., Fung, T. T., Manson, J. E., Willett, W. C., & Hu, F. B. (2006). Dietary patterns and changes in body weight in women. Obesity, 14(8), 1444-1453.
• Schulze, M. B., Manson, J. E., Ludwig, D. S., Colditz, G. A., Stampfer, M. J., Willett, W. C., & Hu, F. B. (2004). Sugar-sweetened beverages, weight gain, and incidence of type 2 diabetes in young and middle-aged women. Jama, 292(8), 927-934.
• Scopinaro, N., Gianetta, E., Adami, G.F., Friedman, D., Traverso, E., Marinari, G.M., Cuneo, S.,
• Sharma, M. (2007). International school‐based interventions for preventing obesity in children. Obesity Reviews, 8(2), 155-167.
• Sigal, R. J., Kenny, G. P., Wasserman, D. H., & Castaneda-Sceppa, C. (2004). Physical activity/exercise and type 2 diabetes. Diabetes care, 27(10), 2518-2539.
• Vitale, B., Ballari, F., Colombini, M., Baschieri, G. & Bachi V. (1996). Biliopancreatic diversion for obesity at eighteen years. Surgery, 119, 261–8.
• Wilfley, D., Frank, M., Welch, R., Spurrell, E., & Rounsaville, B. (1998). Adapting interpersonal psychotherapy to a group format (IPT-G) for binge eating disorder: Toward a model for adapting empirically supported treatments. Psychotherapy Research, 8(4), 379-391.
• Zebrowitz, L. A. (1990). Social perception. Thomson Brooks/Cole Publishing Co.

    Suggested Readings

• Kraak, V. A., Liverman, C. T., & Koplan, J. P. (Eds.). (2005). Preventing childhood obesity: health in the balance. National Academies Press.
• Thompson, J. K., & Smolak, L. (Eds.). (2001). Body image, eating disorders, and obesity in youth: Assessment, prevention, and treatment. Taylor & Francis.
• Burniat, W., Cole, T. J., Lissau, I., & Poskitt, E. M. (Eds.). (2006). Child and adolescent obesity: Causes and consequences, prevention and management. Cambridge University Press.
• Cooper, J. O., Heron, T. E., & Heward, W. L. (2007). Applied behavior analysis.