The objective of this technical report is to provide clinicians with evidence-based, actionable information upon which to make assessment and treatment decisions for children and adolescents with obesity. In addition, this report will provide an evidence base to inform clinical practice guidelines for the management and treatment of overweight and obesity in children and adolescents.

To this end, the goal of this report was to identify all relevant studies to answer 2 overarching key questions: (KQ1) “What are clinically based, effective treatments for obesity?” and (KQ2) “What is the risk of comorbidities among children with obesity?” See Appendix 1 for the conceptual framework and a priori key questions.

Obesity is a common concern in pediatric practice. In caring for patients with obesity or patients who may be at risk for developing obesity, clinicians have many unanswered questions. Examples of these questions include: What is the best way to identify excess adiposity, and does the identification of obesity provide opportunities for treatment? If so, what evidence-based interventions for obesity treatment, delivered at least in part by clinicians in office-based settings, are most effective? Among children and adolescents identified as having obesity, does screening for comorbidities result in improved health outcomes?

Many previous studies, most notably the systematic review conducted for the US Preventive Services Task Force (USPSTF), have synthesized research regarding the efficacy of treatment of obesity, particularly in the context of prevention of future comorbidities.1  However, some important gaps remain. First, the USPSTF recommended that obesity treatment should include at least ≥26 hours of face-to-face contact over 2 to 12 months. However, subsequent studies have failed to demonstrate a consistent hours-based dose-response. In addition, feasibility studies have clearly shown how unrealistic it is for primary care or tertiary care providers to deliver this many hours of treatment in real-world, clinical settings.2  Additional information is needed about resources or partnerships that help reach that contact hour goal, the essential components delivered during these contact hours, the period of time over which this is delivered, and information about lower-intensity strategies with some effectiveness.

Second, most treatment decisions are made in the context of choosing between alternative treatments, not effectiveness compared with no treatment, like many current randomized controlled trials (RCTs). The USPSTF had a primary goal of determining which interventions were efficacious, compared with no or minimal treatment. Our goal was to provide greater contextual evidence of the types of interventions that are effective, effectiveness compared with alternative interventions, and promising interventions that do not yet have randomized trials underlying them.

Finally, primary care pediatricians have a great need to understand how to approach recommendations for screening comorbidities in their patients with obesity. Although previous recommendations have supported screening for common comorbidities, such as dyslipidemia and diabetes, there has been conflicting evidence regarding timing and effectiveness of screening. We now have additional data that provide clinicians and researchers with information about comorbidity prevalence and severity by obesity class. The intent is to help the clinician screen for comorbidities when there is a high likelihood of detecting an abnormality and when detection of that abnormality leads to treatment options that can improve child health. Obesity classifications, including a more granular categorization of obesity as classes I through III, might assist us in determining for whom screening would be most useful, rather than viewing screening as a homogeneous approach for anyone whose BMI is ≥95th percentile.

This technical report was designed to answer 2 overarching key questions: (KQ1) “What are effective clinic-based treatments for pediatric obesity?” and (KQ2) “What is the risk of comorbidities among children with obesity?” We developed this focus based on the needs of clinicians and the evidence required to inform the future development of clinical practice guidelines. This report will not attempt to quantify the magnitude of the effect of obesity on child or adult outcomes. It will also not attempt to address treatment strategies for comorbidities (eg, hypertension), as other guidelines and reviews are available to guide such treatment.36 

In this paper, we report the results for KQ1, intervention studies. Results for KQ2, comorbidity studies, are reported separately.7  The 2 components of the review were conducted concurrently, so we present methods for both below.

Rationale for KQ1 (Intervention Studies)

Clinicians are a trusted source of health information for parents, including issues related to nutrition and physical activity, which are key components of obesity prevention and treatment. Clinicians need to know what strategies have high-quality evidence for effectiveness in preventing and treating obesity. Additionally, clinicians need guidance on which treatments are effective for their patient population and how to leverage available resources for treatment efforts.

Rationale for KQ2 (Comorbidity Studies)

Previous recommendations have included assessments of comorbidities, including hypertension, dyslipidemia, glucose, fatty liver disease, and others. It is not clear whether these assessments lead to improved treatment strategies or outcomes. Additionally, it is not clear whether conducting these assessments would result in an adverse patient outcome. We will examine specific conditions that were previously recommended or that would reasonably require screening: dyslipidemia, hypertension, diabetes, fatty liver disease, depression, sleep apnea, and asthma.

We searched Pubmed and CENTRAL (for trials), completing the final search on April 6, 2018. An additional search was conducted to update the review, covering the time period April 7, 2018, through February 15, 2020. We combined the searches for both key questions because of significant overlap and to more efficiently review studies. Because our focus was on interventions that are relevant to primary care, we did not search other discipline-specific databases, such as ERIC or PsycInfo.

The complete search strategies are included in Appendix 2. Briefly, we searched for studies of children or adolescents; with a focus on overweight, obesity, or weight status; involving clinicians, health care, or other treatment or screening (KQ1); and examining common comorbidities (KQ2). For both questions, we limited only using key words, not filters, to ensure we included the newest studies that were not yet fully indexed. No date limits were placed on searches. In practice, this meant we reviewed studies from 1950 to 2020, although <2% were published before 1980.

The complete inclusion criteria are included in Appendix 3.

Inclusion Criteria Common to All Studies

All studies were required to include children ages 2 to 18 years, although studies could also include young adults up to age 25 years if stratified from older adult participants, as long as children younger than 18 years were also included. Children could have other conditions (eg, asthma), as long as they were not known to cause obesity, such as Prader-Willi syndrome, obesogenic medication (eg, antipsychotics), or known genetic mutations associated with obesity (eg, MC4R). All studies had to originate from Organization for Economic Cooperation and Development (OECD) member countries and had to be available in English.

Inclusion Criteria for KQ1 (Intervention Studies)

The primary aim of the intervention studies had to be examination of an obesity prevention (targeting children of any weight status) or treatment intervention (targeting children with overweight or obesity). The primary intended outcome had to be obesity, broadly defined, and not an obesity comorbidity. Studies of obesity interventions that reported only other outcomes were not included. Interventions could be comprised of any approach, including screening, lifestyle counseling, medically managed weight loss, pharmaceutical treatment, or surgery. Regardless of the components, there had to be some level of outpatient clinical involvement in the treatment (ie, not just referral to an outside program), such as screening or a clinic follow-up appointment. Interventions completely outside the scope of health care were excluded. We did not limit based on study design but did report experimental and nonexperimental studies separately. Although we included nonexperimental designs, all studies had to have a relevant comparison group.

See the other technical report on comorbidities7  for a detailed description of KQ2 inclusion criteria.

We used Covidence to manage the review process. Covidence is a program for online collaboration and management of systematic reviews. All abstracts were reviewed by 2 independent reviewers for inclusion in full-text review. Articles were reviewed by 2 reviewers, with conflicts discussed and resolved. Articles excluded at this stage were assigned an exclusion reason, with a hierarchy as shown in Appendix 4.

All articles deemed relevant for full text inclusion were categorized into different data extraction strategies. Those given a quality assessment were reviewed using the Cochrane Risk of Bias tool. We chose not to limit studies based on quality, as many did not reach “high quality” using any tools. These studies did not meet “high quality” criteria largely because they were primarily behavioral interventions without the possibility of blinding. All studies, regardless of group, were fully extracted by 2 reviewers, and conflicts were reviewed.

Group 1 Extraction

Group 1 articles included randomized trials of diet or lifestyle interventions. “Diet” includes specific meal plans or substitutes, whereas “lifestyle” refers to nonpharmaceutical, nonsurgical intervention and may incorporate nutrition, activity, and other components. Extraction of these articles included sponsorship or funder, design, population information, provider type, detailed intervention strategies and intensity, and BMI-based outcomes. We also identified outcomes other than BMI, including lipids, glucose metabolism, blood pressure, other laboratory values, other obesity measures, psychosocial outcomes, mental health, behaviors, and other outcomes (primarily parent BMI and child cardiovascular fitness). We categorized the intensity of interventions in a manner consistent with the USPSTF, to allow for comparisons with its findings, into <5 hours, 5 to 25 hours, 26 to 51 hours, and 52 or more hours, all over ≤12 months. Quality assessment was conducted for group 1 articles.

Group 2 Extraction

Group 2 articles included randomized controlled trials of pharmaceutical treatments. We extracted similar information as above, using a brief description of the intervention and no categorization of intensity. These articles also received a quality assessment.

Groups 3 to 5 Extraction

Group 3 articles included nonrandomized comparative studies of diet and lifestyle interventions. Group 4 articles included nonrandomized comparative studies of pharmaceutical treatment, and Group 5 articles included any surgical studies. Because of small numbers, we combined randomized and nonrandomized surgical studies. Brief intervention descriptions and BMI-related outcome data were extracted from these, but the Cochrane Risk of Bias tool was not used because these were observational designs.

See other report for detailed description of KQ2 extraction procedures.

Our primary method of data synthesis is narrative. To allow broad inclusion, we did not limit to specific designs or measures that would facilitate meta-analysis. We report on studies in each group, based on their type and design, and we report findings for outcomes other than BMI.

A total of 15 988 studies were screened in the title and abstract stage. Of these, 1642 were given a full-text review. Excluded studies (n = 1260) were most commonly not original research, did not compare comorbidities by obesity (KQ2), or were not health-care system based (KQ1). See Fig 1 for the complete PRISMA diagram. Of the 382 studies included, 215 were intervention studies and 167 were comorbidity studies. This report focuses on the 215 intervention studies; the 167 comorbidity studies are reported separately.7 

FIGURE 1

PRISMA diagram.

Of the 215 studies included for KQ1, the majority (n = 126) were randomized trials of lifestyle or diet interventions (group 1), 27 were randomized trials of pharmaceutical treatments (group 2), 43 were observational studies of lifestyle or diet interventions (group 3), 8 were observational studies of pharmaceutical treatment (group 4), and 11 were studies of surgical interventions (group 5). Complete data extraction for all KQ1 studies is available in Appendix 5.

Group 1 studies included 54 with minimal-intervention controls861  and 72 comparative effectiveness studies62133  (Table 1). Overall, 35% of the studies demonstrated any difference in BMI SD score (SDS) or BMI attributable to the intervention. There was significant variation in the number of hours of contact among the studies, with an overall increase in the likelihood of any successful weight change as contact hours increased. Detailed summaries of each of these studies are available in Tables 2 and 3.

TABLE 1

Overall Summary of Lifestyle and Diet RCTs

NumberTotal With Any Success at Time 1Percent With Any Success at Time 2Total With Time 2 MeasuresTotal With Any Success at Time 2Percent With Any Success at Time 2
Studies with minimal control       
 Comparison is less than 5 h 20 25 
 Comparison is 5–25 h 26 35 11 27 
 Comparison is 26–51 h 71 60 
 Comparison is 52+ hours 100 100 
Comparative effectiveness studies       
 Most intense comparator is less than 5 h 22 50 
 Most intense comparator is 5–25 h versus lower intensity 10 30 20 
 Most intense comparator is 5–25 h versus same intensity 28 10 36 10 30 
 Most intense comparator is 26–51 h versus lower intensity 75 100 
 Most intense comparator is 26–51 h versus same intensity 40 
 Most intense comparator is 52+ hours versus lower intensity 11 45 38 
 Most intense comparator is 52+ hours versus same intensity 20 
Total 126 44 35 57 19 33 
NumberTotal With Any Success at Time 1Percent With Any Success at Time 2Total With Time 2 MeasuresTotal With Any Success at Time 2Percent With Any Success at Time 2
Studies with minimal control       
 Comparison is less than 5 h 20 25 
 Comparison is 5–25 h 26 35 11 27 
 Comparison is 26–51 h 71 60 
 Comparison is 52+ hours 100 100 
Comparative effectiveness studies       
 Most intense comparator is less than 5 h 22 50 
 Most intense comparator is 5–25 h versus lower intensity 10 30 20 
 Most intense comparator is 5–25 h versus same intensity 28 10 36 10 30 
 Most intense comparator is 26–51 h versus lower intensity 75 100 
 Most intense comparator is 26–51 h versus same intensity 40 
 Most intense comparator is 52+ hours versus lower intensity 11 45 38 
 Most intense comparator is 52+ hours versus same intensity 20 
Total 126 44 35 57 19 33 
TABLE 2

Description of Lifestyle and Diet Trials With Minimal-Intervention Controls

Provider TypesComponents
AuthorsCountryIntensityDifference T1Difference T2NAgesWeightLength (months)Outcome (months)PCPSubspecialistNutritionMental HealthPsychosocialExerciseResearchOtherUC OnlyNutrition CounselingActivity CounselingNutrition TrainingActivity TrainingMIPsychosocialMental healthParentingCommunity Rec CenterTexting and TechnologyTelemedicineSpecific dietIncentivesSleepOther
Comparison is less than 5 h 
Broccoli, S Italy <5 UC 372 4–7 OW 12 12/24                       
  <5 MI                              
Davis, A USA <5 Telemedicine  17 10 OW+ 12                   
  <5 In person                             
Davoli, A Italy <5 MI  372 4–7 OW 12 12                       
  <5 UC                              
Grieken, A The Netherlands <5 UC  637 OW 24 24                       
  <5 Intervention                            
Kong, A USA <5 ACTION  51 14–17 OW+                     
  <5 UC                              
Love-Osborne, K USA <5 Control  165 Mean 16 OW+                       
  <5 Intervention                           
McCallum, Z Australia <5 UC 163 Mean 7 OW 9/15                       
  <5 Solution-focused                            
Novotny, R USA <5 Attention control 85 5–8 HW/OW 6/15                      
  <5 PacDASH                           
Parra-Medina, D USA <5 Standard  118 5–14 OB+ 4.5 4.5                      
  <5 Intervention                            
Resnicow, K USA <5 UC  645 2–8 OW/OB 24 24                       
  <5 PCP                            
  <5 PCP + RD                           
Rifas-Shiman, S USA <5 UC  445 2–5 OW+ 12 24                       
  <5 High Five                            
Sherwood, N USA <5 Busy bodies  60 Mean 3 OW+                   
  <5 Healthy tots                             
Small, L USA <5 Treatment 60 4–8 OW+ 3/6                    
  <5 Attention control                             
Stovitz, S USA <5 Attention control  71 4–9 OW+                      
  <5 Prevention plus                           
Taveras, E USA <5 UC  445 2–6 OW+ 12 12                       
  <5 Intervention                           
Taveras, E USA <5 UC  549 6–12 OW+ 12 12                       
  <5 CDS                            
  <5 CDS + Coach                          
Taylor, R New Zealand <5 UC  206 4–8 OW+ 24 24                     
  <5 Tailored                       
Wake, M Australia <5 UC 258 5–10 OW 6/12                       
  <5 Solution-focused                             
Crespo N 2018 USA 5–25 Luces  291 5–10 OW+ 12 12                    
  <5 UC       Varied                       
Moschonis G 2019 Greece <5 Decision support  65 6–12 OW+ 1(?)                    
  <5 Control      1(?)                        
Comparison is 5–25 h 
Arauz Boudreau, A USA <5 WLC  26 9–12 OW+                       
  5–25 Power Up                       
Boutelle, K USA <5 WLC  50 8–12 OW+                        
  5–25 Self-help                            
Crabtree, V USA <5 UC  19 8–12 OB+                    
  5–25 Case mgmt                              
Croker, H UK <5 WLC  72 8–12 OW+                       
  5–25 FBT                         
Davis, A USA <5 In person  58 Mean 9 OW+                      
  5–25 Telemedicine                           
DeBar, L USA <5 UC  208 12–17 OB+ 12                       
  5–25 Intervention                      
Deforche, B Belgium <5 UC  20 11–18 OB+                       
  5–25 Maintenance                            
Fleischman, A USA <5 PCP 40 10–17 OB+ 3/6                      
  5–25 PCP + telehealth                        
Flodmark, C Sweden <5 Control 93 10–11 OW+ 18 18/28                       
  <5 Conventional                            
  5–25 FBT                         
Hofsteenge, G The Netherlands <5 Control 122 11–18 OW+ 6/18                       
  5–25 Go4It                        
Kalavainen, M Finland <5 Routine 70 7–9 OB+ 24/36                      
  5–25 Group                           
Kalavainen Finland <5 Routine school 70 7–9 OB+ 6/12                      
  5–25 Group treatment                           
Martinez-Andrade, G. Mexico <5 UC 306 2–5 OW+ 1.5 3/6                       
  5–25 Intervention                        
Nova, A Italy <5 General 186 3–12 OB+ 24 6/12                      
  5–25 Specific info                             
O'Connor, T USA <5 WLC  40 5–8 OW/OB 7–8                       
  5–25 Helping HAND                          
Saelens, B USA <5 UC  44 12–16 OW+                      
  5–25 Healthy Habits                            
Shelton, D Australia <5 UC  43 3–10 OW+                       
  5–25 Intervention                         
Stark, L USA <5 UC  151 2–5 OB                       
  5–25 LAUNCH                         
  5–25 MI                          
Truby, H Australia <5 Control  87 10–17 OW+                      
  5–25 LF                           
  5–25 Low carb                           
Verbeken, S Belgium <5 UC  44 9–14 SO                       
  5–25 Executive function                              
Wake, M Australia <5 UC  118 5–10 OW 12                       
  5–25 Intervention                           
Wilfley, D USA <5 Control 150 7–12 OW+                       
  5–25 Behavioral skills                           
  5–25 Social facilitation                           
Wright, J USA <5 WLC  50 9–12 OB+                       
  5–25 HEAT                            
Yackobovitch-Gavan, M Israel <5 Control 247 5–11 OW/OB 3/24                       
  5–25 Parent only                           
  5–25 Parent + child                           
Fedele, D. 2018 USA 5–25 CHAMP 24 6–12 OW+ 4/6                   
  5–25 Control                           
Sherwood, N. 2019 USA 5–25 Obesity prevention 421 5–10 OW 12 12/24                     
  5–25 Injury prevention                             
Comparison is 26–51 h 
Bocca, G The Netherlands 26–51 Multidisc.  75 3–5 OW+ 36                
  <5 UC                             
Bocca, G The Netherlands 26–51 Multidisc. 75 3–5 OW+ 4/12                
  <5 UC                             
Bocca, G The Netherlands 26–51 Multidisc. 75 3–5 OW+ 4/12                
  <5 UC                             
Nemet, D. 2005 Israel <5 Control 46 6–16 OB+ 3/12                     
  26–51 Intervention                          
Nemet, D. 2013 Israel <5 Control  41 6–13 OB+                     
  26–51 Intervention                          
Vos, R The Netherlands <5 WLC 79 8–17 SO 24 3/12                       
  26–51 FBT                      
Vos, R The Netherlands <5 WLC 81 8–17 SO 12 3/12                      
  26–51 FBT                        
Comparison is 52+ hours 
Weigel, C Germany <5 Control 73 7–15 OB+ 12 6/12                     
  ≥52 Intervention                       
Provider TypesComponents
AuthorsCountryIntensityDifference T1Difference T2NAgesWeightLength (months)Outcome (months)PCPSubspecialistNutritionMental HealthPsychosocialExerciseResearchOtherUC OnlyNutrition CounselingActivity CounselingNutrition TrainingActivity TrainingMIPsychosocialMental healthParentingCommunity Rec CenterTexting and TechnologyTelemedicineSpecific dietIncentivesSleepOther
Comparison is less than 5 h 
Broccoli, S Italy <5 UC 372 4–7 OW 12 12/24                       
  <5 MI                              
Davis, A USA <5 Telemedicine  17 10 OW+ 12                   
  <5 In person                             
Davoli, A Italy <5 MI  372 4–7 OW 12 12                       
  <5 UC                              
Grieken, A The Netherlands <5 UC  637 OW 24 24                       
  <5 Intervention                            
Kong, A USA <5 ACTION  51 14–17 OW+                     
  <5 UC                              
Love-Osborne, K USA <5 Control  165 Mean 16 OW+                       
  <5 Intervention                           
McCallum, Z Australia <5 UC 163 Mean 7 OW 9/15                       
  <5 Solution-focused                            
Novotny, R USA <5 Attention control 85 5–8 HW/OW 6/15                      
  <5 PacDASH                           
Parra-Medina, D USA <5 Standard  118 5–14 OB+ 4.5 4.5                      
  <5 Intervention                            
Resnicow, K USA <5 UC  645 2–8 OW/OB 24 24                       
  <5 PCP                            
  <5 PCP + RD                           
Rifas-Shiman, S USA <5 UC  445 2–5 OW+ 12 24                       
  <5 High Five                            
Sherwood, N USA <5 Busy bodies  60 Mean 3 OW+                   
  <5 Healthy tots                             
Small, L USA <5 Treatment 60 4–8 OW+ 3/6                    
  <5 Attention control                             
Stovitz, S USA <5 Attention control  71 4–9 OW+                      
  <5 Prevention plus                           
Taveras, E USA <5 UC  445 2–6 OW+ 12 12                       
  <5 Intervention                           
Taveras, E USA <5 UC  549 6–12 OW+ 12 12                       
  <5 CDS                            
  <5 CDS + Coach                          
Taylor, R New Zealand <5 UC  206 4–8 OW+ 24 24                     
  <5 Tailored                       
Wake, M Australia <5 UC 258 5–10 OW 6/12                       
  <5 Solution-focused                             
Crespo N 2018 USA 5–25 Luces  291 5–10 OW+ 12 12                    
  <5 UC       Varied                       
Moschonis G 2019 Greece <5 Decision support  65 6–12 OW+ 1(?)                    
  <5 Control      1(?)                        
Comparison is 5–25 h 
Arauz Boudreau, A USA <5 WLC  26 9–12 OW+                       
  5–25 Power Up                       
Boutelle, K USA <5 WLC  50 8–12 OW+                        
  5–25 Self-help                            
Crabtree, V USA <5 UC  19 8–12 OB+                    
  5–25 Case mgmt                              
Croker, H UK <5 WLC  72 8–12 OW+                       
  5–25 FBT                         
Davis, A USA <5 In person  58 Mean 9 OW+                      
  5–25 Telemedicine                           
DeBar, L USA <5 UC  208 12–17 OB+ 12                       
  5–25 Intervention                      
Deforche, B Belgium <5 UC  20 11–18 OB+                       
  5–25 Maintenance                            
Fleischman, A USA <5 PCP 40 10–17 OB+ 3/6                      
  5–25 PCP + telehealth                        
Flodmark, C Sweden <5 Control 93 10–11 OW+ 18 18/28                       
  <5 Conventional                            
  5–25 FBT                         
Hofsteenge, G The Netherlands <5 Control 122 11–18 OW+ 6/18                       
  5–25 Go4It                        
Kalavainen, M Finland <5 Routine 70 7–9 OB+ 24/36                      
  5–25 Group                           
Kalavainen Finland <5 Routine school 70 7–9 OB+ 6/12                      
  5–25 Group treatment                           
Martinez-Andrade, G. Mexico <5 UC 306 2–5 OW+ 1.5 3/6                       
  5–25 Intervention                        
Nova, A Italy <5 General 186 3–12 OB+ 24 6/12                      
  5–25 Specific info                             
O'Connor, T USA <5 WLC  40 5–8 OW/OB 7–8                       
  5–25 Helping HAND                          
Saelens, B USA <5 UC  44 12–16 OW+                      
  5–25 Healthy Habits                            
Shelton, D Australia <5 UC  43 3–10 OW+                       
  5–25 Intervention                         
Stark, L USA <5 UC  151 2–5 OB                       
  5–25 LAUNCH                         
  5–25 MI                          
Truby, H Australia <5 Control  87 10–17 OW+                      
  5–25 LF                           
  5–25 Low carb                           
Verbeken, S Belgium <5 UC  44 9–14 SO                       
  5–25 Executive function                              
Wake, M Australia <5 UC  118 5–10 OW 12                       
  5–25 Intervention                           
Wilfley, D USA <5 Control 150 7–12 OW+                       
  5–25 Behavioral skills                           
  5–25 Social facilitation                           
Wright, J USA <5 WLC  50 9–12 OB+                       
  5–25 HEAT                            
Yackobovitch-Gavan, M Israel <5 Control 247 5–11 OW/OB 3/24                       
  5–25 Parent only                           
  5–25 Parent + child                           
Fedele, D. 2018 USA 5–25 CHAMP 24 6–12 OW+ 4/6                   
  5–25 Control                           
Sherwood, N. 2019 USA 5–25 Obesity prevention 421 5–10 OW 12 12/24                     
  5–25 Injury prevention                             
Comparison is 26–51 h 
Bocca, G The Netherlands 26–51 Multidisc.  75 3–5 OW+ 36                
  <5 UC                             
Bocca, G The Netherlands 26–51 Multidisc. 75 3–5 OW+ 4/12                
  <5 UC                             
Bocca, G The Netherlands 26–51 Multidisc. 75 3–5 OW+ 4/12                
  <5 UC                             
Nemet, D. 2005 Israel <5 Control 46 6–16 OB+ 3/12                     
  26–51 Intervention                          
Nemet, D. 2013 Israel <5 Control  41 6–13 OB+                     
  26–51 Intervention                          
Vos, R The Netherlands <5 WLC 79 8–17 SO 24 3/12                       
  26–51 FBT                      
Vos, R The Netherlands <5 WLC 81 8–17 SO 12 3/12                      
  26–51 FBT                        
Comparison is 52+ hours 
Weigel, C Germany <5 Control 73 7–15 OB+ 12 6/12                     
  ≥52 Intervention                       

CDS, clinical decision support; FBT, family-based behavioral treatment; HW, healthy weight; LF, low fat; MI, motivational interviewing; OB, obese; OW, overweight; PCP, primary care provider; RD, registered dietitian; SO, severe obesity; UC, usual care; WLC, wait list control.

TABLE 3

Description of Lifestyle and Diet Comparative Effectiveness Trials

Provider TypesComponents
AuthorsCountryIntensityDifference T1Difference T2NAgesWeightLength (months)Outcomes (months)PCPSubspecialistNutritionMental HealthPsychosocialExerciseResearchOtherUC OnlyNutrition CounselingActivity CounselingNutrition TrainingActivity TrainingMIPsychosocialMental HealthParentingCommunity Rec CenterTexting and TechnologyTelemedicineSpecific dietOther
Most intense comparator is less than 5 h 
Armstrong, S USA <5 HL +Text  101 5–12 OB+                  
  <5 HL                          
Chen, J USA <5 iStart Smart 40 13–18 OW+ 3/6                   
  <5 Control                           
Fonseca Portugal <5 Intervention  80 12–18 OW+                
  <5 Control                        
Gourlan, M France <5 Standard 62 11–18 OB+ 3/6                    
  <5 Standard + MI                         
Looney, S USA <5 Mailer  22 4–10 OW+                     
  <5 Growth monitoring                            
  <5 Mailer + GM                          
Macdonell, K USA <5 MI  44 13–17 OW+                   
  <5 Nutrition                            
Taveras, E USA <5 Enhanced PC  721 2–12 OW+ 12 12                    
  <5 EPC + Coach                        
Walpole, B Canada <5 Social skills training  40 10–18 OW+                   
  <5 MI                          
Bean 2018 USA <5 MI + TEENS 99 11–18 OW+ 10 wk 3/6                   
  <5 TEENS Only                          
Most intense comparator is 5–25 h versus lower intensity 
Bohlin, A Sweden <5 UC 37 5–14 OB+ 18 18/36               
  5–25 Telephone                           
Ford, A UK <5 Standard  106 9–18 OB+ 12 12                  
  5–25 Mandometer                         
Garipağaoğlu 2009, M Turkey <5 Individual 80 6–14 OB+ 3/12                   
  5–25 Group                          
Hills, A Australia <5 Control  20 NR OB+                     
  5–25 Experimental                        
Hughes, A UK <5 Standard 134 5–11 OB+ 6/12                  
  5-25 Intervention                          
Norman, G USA <5 EUC  106 11–13 OB+ 12 12                   
  5–25 Stepped                          
Pedrosa, C Portugal <5 Individual  61 Mean 8 OW+ 12 12                    
  5–25 Group                           
Stark, L USA <5 PC 33 2–5 OB 6/12                    
  5–25 LAUNCH home                       
  5–25 LAUNCH clinic                       
Koziol- Kozakowska 2019 Poland 5–25 Intensive  40 6–11 OB                   
  <5 Standard                         
Kumar 2018 USA <5 Standard 21 14–17 OB+ 3/6                    
  5–25 Mindfulness      10 wk                     
Most intense comparator is 5–25 h versus same intensity 
Akgul Gundogdu, N Turkey 5–25 SFA  32 12–13 OW+                  
  5–25 UC                             
Banks, J UK 5–25 Hospital  68 5–16 SO 12 12                  
  5–25 Primary care                         
Bathrellou, E Greece 5–25 Child alone 36 7–12 OW+ 3/18                  
  5–25 Child and parent                         
Berkowitz, R USA 5–25 Conventional 113 13–17 OB+ 12 4/12                
  5–25 MR                       
  5–25 MR ≥ Conv.                       
Berkowitz, R USA 5-25 Group  169 12–16 OB+ 12 12                 
  5–25 Self-guided                        
Casazza, K USA 5–25 Standard  26 9–14 OW+                   
  5–25 Low carb                          
Davis, A USA 5–25 Telemedicine  103 Mean 9 OW+                  
  5–25 Telephone                         
de Ferranti, S USA 5–25 Low fat  27 8–21 OW+                  
  5–25 LGL                         
de Niet, J The Netherlands 5–25 SMS  141 Mean 10 OW+ 12             
  5–25 UC                     
Demol, S Israel 5–25 LC/LF 55 12–18 OB+ 3/12                 
  5–25 LC/HF                        
  5–25 HC/LF                        
Ebbeling, C USA 5–25 Reduced GL  14 13–21 OB+ 12 12                 
  5–25 Low fat                        
Krebs, N USA 5–25 HP/LC 46 Mean 14 OB+ 6/9                  
  5–25 LF                         
Larsen, L Denmark 5–25 model 1  80 5–9 OW+ 24 24                    
  5–25 Model 2                        
Mirza, N USA 5–25 LGL 113 7–15 OB+ 12/24                
  5–25 LF                       
Parillo, M Italy 5–25 HGI  22 Mean 10 OB+                   
  5–25 LGI                          
Partsalaki, I Greece 5–25 Keto  58 8–18 OB+                  
  5–25 Low cal                         
Quattrin, T USA 5–25 Intervention 96 2–5 OW+ 3/6                 
  5–25 Attention control                          
Quattrin, T USA 5–25 Attention control  96 2–5 OW+ 12 24                   
  5–25 FBT                         
Quattrin, T USA 5–25 Attention control 96 2–5 OW+ 12 18/24                    
  5–25 Intervention                         
Stettler, N USA 5–25 Control  172 8–12 OW 12 12                     
  5–25 Beverage                            
  5–25 Multiple                           
Tjønna, A Norway 5–25 Multidisc. 54 mean 14 OW+ 3/12                 
  5–25 Interval training                         
Williams, C USA 5–25 Free snack  38 11–15 OB+                   
  5–25 Restricted snack                          
Yackobovitch- Gavan Israel 5–25 LCLF  71 12–18 OB+                    
  5–25 LCHF                           
  5–25 HCLF                           
Banos 2019 Spain 5–25 CBT  27 Mean 10.4 OW+ 10 wk                   
  5–25 CBT-E                          
Ek 2019 Sweden 5–25 Booster  174 4–6 OB 12 12                   
  5–25 No booster                          
  <5 Standard                           
Forsell 2019 Sweden 5–25 NDPT  56 8–13 OB 12 4 years                
  5–25 NDT                        
Njardvik 2018 Iceland 5–25 FBT-AAT 84 8–12 OB+ 18 wk 12/24                
  5–25 FBT      18 wk                  
Stark 2019 USA 5–25 LAUNCH 151 2–5 OB+ 6/12               
  5–25 MI                        
  <5 Standard care                           
Most intense comparator is 26–51 h vs lower intensity 
DÃaz, R Mexico <5 Control 43 9–17 OB+ 12 6/12                    
  26–51 Lifestyle                          
Naar-King, S USA 5–25 Shapedown  49 12–17 OB+                   
  26–51 Multisystemic                        
Stark, L USA <5 UC 18 2–5 OB 6/12                    
  26–51 LAUNCH                       
Wilfley, D USA 5–25 Control  172 7–11 OW+                  
  5–25 LOW                          
  26–51 HIGH                          
Most intense comparator is 26–51 h versus same intensity 
Garnett, S Australia 26–51 Mod carb/hi pro 111 10–17 OW+ 12 3/6                
  26–51 Hi carb/LF                       
Garnett, S Australia 26–51 Mod carb/hi pro 111 10–17 OW+ 12 6/12                
  26–51 Hi carb/LF                       
Hystad, H Norway 26–51 Therapist 83 7–12 OB+ 24 6/24                
  26–51 Self help                          
Farpour- Lambert 2019 Switzerland 26–51 Individual 74 7–11 SO 6/12                 
  26–51 Group                      
  <5 Control      12                      
Sepulveda 2020 Spain 26–51 ENT REN 51 8–12 OW+ Post/6                
  26–51 ENT REN-F                      
                                 
Most intense comparator is 52+ hours versus lower intensity 
Anderson, Y New Zealand <5 Minimal intervention 138 5–16 SO 12 6/12                   
  ≥52 Whanau Pakari                    
Baan-Slootweg, O The Netherlands 5-25 Ambulatory 90 8–18 SO 6/30             
  ≥52 Inpatient                    
Butte, N USA 5–25 Next Steps 549 2–12 OW+ 12 3/12                   
  26–51 MEND                      
  ≥52 MEND/CAT CH                      
Hoffman, J USA 5–25 HL 97 5–11 OB+                
  ≥52 HL + BCF                     
Kokkvoll, A Norway 5–25 Single family 91 6–12 OB+ 12 3/12                    
  ≥52 Multifamily                     
Kokkvoll, A Norway 5–25  91 6–12 OB+ 24 12/24                  
  ≥52                        
Lison, J Spain <5 Control  110 6–16 OW+                     
  <5 Home based                          
  ≥52 Group                         
Savoye, M USA <5 PWMP 174 8–16 OB+ 12 12/24                  
  ≥52 Bright Bodies                     
Savoye, M USA <5 PWMP 174 8–16 OB+ 12 6/12                 
  ≥52 Bright Bodies                     
Serra-Paya, N Spain <5 Counseling  113 6–12 OW+                    
  ≥52 Nereu                        
Kokkvoll 2020 Norway 5–25 Individual  91 6–12 OW+ 24 36                   
  ≥52 Group                        
Most intense comparator is 52+ hours versus same intensity 
Makkes, S The Netherlands ≥52 Short stay 80 8–19 SO 12 6/12                 
  ≥52 Long stay                        
Rolland- Cachera, M France ≥52 PROT - 121 11–16 SO 11/35             
  ≥52 PROT +                    
Warschburger, P Germany ≥52 CBT 523 7–12 SO 6/12               
  ≥52 Information                      
Miguet 2019 France ≥52 MICT  43 11–15 OB+               
  ≥52 HIIT                     
Warschburger 2018 Germany ≥52 AAT 232 8–16 SO 6 wk 6/12                   
  ≥52 Placebo training                          
Provider TypesComponents
AuthorsCountryIntensityDifference T1Difference T2NAgesWeightLength (months)Outcomes (months)PCPSubspecialistNutritionMental HealthPsychosocialExerciseResearchOtherUC OnlyNutrition CounselingActivity CounselingNutrition TrainingActivity TrainingMIPsychosocialMental HealthParentingCommunity Rec CenterTexting and TechnologyTelemedicineSpecific dietOther
Most intense comparator is less than 5 h 
Armstrong, S USA <5 HL +Text  101 5–12 OB+                  
  <5 HL                          
Chen, J USA <5 iStart Smart 40 13–18 OW+ 3/6                   
  <5 Control                           
Fonseca Portugal <5 Intervention  80 12–18 OW+                
  <5 Control                        
Gourlan, M France <5 Standard 62 11–18 OB+ 3/6                    
  <5 Standard + MI                         
Looney, S USA <5 Mailer  22 4–10 OW+                     
  <5 Growth monitoring                            
  <5 Mailer + GM                          
Macdonell, K USA <5 MI  44 13–17 OW+                   
  <5 Nutrition                            
Taveras, E USA <5 Enhanced PC  721 2–12 OW+ 12 12                    
  <5 EPC + Coach                        
Walpole, B Canada <5 Social skills training  40 10–18 OW+                   
  <5 MI                          
Bean 2018 USA <5 MI + TEENS 99 11–18 OW+ 10 wk 3/6                   
  <5 TEENS Only                          
Most intense comparator is 5–25 h versus lower intensity 
Bohlin, A Sweden <5 UC 37 5–14 OB+ 18 18/36               
  5–25 Telephone                           
Ford, A UK <5 Standard  106 9–18 OB+ 12 12                  
  5–25 Mandometer                         
Garipağaoğlu 2009, M Turkey <5 Individual 80 6–14 OB+ 3/12                   
  5–25 Group                          
Hills, A Australia <5 Control  20 NR OB+                     
  5–25 Experimental                        
Hughes, A UK <5 Standard 134 5–11 OB+ 6/12                  
  5-25 Intervention                          
Norman, G USA <5 EUC  106 11–13 OB+ 12 12                   
  5–25 Stepped                          
Pedrosa, C Portugal <5 Individual  61 Mean 8 OW+ 12 12                    
  5–25 Group                           
Stark, L USA <5 PC 33 2–5 OB 6/12                    
  5–25 LAUNCH home                       
  5–25 LAUNCH clinic                       
Koziol- Kozakowska 2019 Poland 5–25 Intensive  40 6–11 OB                   
  <5 Standard                         
Kumar 2018 USA <5 Standard 21 14–17 OB+ 3/6                    
  5–25 Mindfulness      10 wk                     
Most intense comparator is 5–25 h versus same intensity 
Akgul Gundogdu, N Turkey 5–25 SFA  32 12–13 OW+                  
  5–25 UC                             
Banks, J UK 5–25 Hospital  68 5–16 SO 12 12                  
  5–25 Primary care                         
Bathrellou, E Greece 5–25 Child alone 36 7–12 OW+ 3/18                  
  5–25 Child and parent                         
Berkowitz, R USA 5–25 Conventional 113 13–17 OB+ 12 4/12                
  5–25 MR                       
  5–25 MR ≥ Conv.                       
Berkowitz, R USA 5-25 Group  169 12–16 OB+ 12 12                 
  5–25 Self-guided                        
Casazza, K USA 5–25 Standard  26 9–14 OW+                   
  5–25 Low carb                          
Davis, A USA 5–25 Telemedicine  103 Mean 9 OW+                  
  5–25 Telephone                         
de Ferranti, S USA 5–25 Low fat  27 8–21 OW+                  
  5–25 LGL                         
de Niet, J The Netherlands 5–25 SMS  141 Mean 10 OW+ 12             
  5–25 UC                     
Demol, S Israel 5–25 LC/LF 55 12–18 OB+ 3/12                 
  5–25 LC/HF                        
  5–25 HC/LF                        
Ebbeling, C USA 5–25 Reduced GL  14 13–21 OB+ 12 12                 
  5–25 Low fat                        
Krebs, N USA 5–25 HP/LC 46 Mean 14 OB+ 6/9                  
  5–25 LF                         
Larsen, L Denmark 5–25 model 1  80 5–9 OW+ 24 24                    
  5–25 Model 2                        
Mirza, N USA 5–25 LGL 113 7–15 OB+ 12/24                
  5–25 LF                       
Parillo, M Italy 5–25 HGI  22 Mean 10 OB+                   
  5–25 LGI                          
Partsalaki, I Greece 5–25 Keto  58 8–18 OB+                  
  5–25 Low cal                         
Quattrin, T USA 5–25 Intervention 96 2–5 OW+ 3/6                 
  5–25 Attention control                          
Quattrin, T USA 5–25 Attention control  96 2–5 OW+ 12 24                   
  5–25 FBT                         
Quattrin, T USA 5–25 Attention control 96 2–5 OW+ 12 18/24                    
  5–25 Intervention                         
Stettler, N USA 5–25 Control  172 8–12 OW 12 12                     
  5–25 Beverage                            
  5–25 Multiple                           
Tjønna, A Norway 5–25 Multidisc. 54 mean 14 OW+ 3/12                 
  5–25 Interval training                         
Williams, C USA 5–25 Free snack  38 11–15 OB+                   
  5–25 Restricted snack                          
Yackobovitch- Gavan Israel 5–25 LCLF  71 12–18 OB+                    
  5–25 LCHF                           
  5–25 HCLF                           
Banos 2019 Spain 5–25 CBT  27 Mean 10.4 OW+ 10 wk                   
  5–25 CBT-E                          
Ek 2019 Sweden 5–25 Booster  174 4–6 OB 12 12                   
  5–25 No booster                          
  <5 Standard                           
Forsell 2019 Sweden 5–25 NDPT  56 8–13 OB 12 4 years                
  5–25 NDT                        
Njardvik 2018 Iceland 5–25 FBT-AAT 84 8–12 OB+ 18 wk 12/24                
  5–25 FBT      18 wk                  
Stark 2019 USA 5–25 LAUNCH 151 2–5 OB+ 6/12               
  5–25 MI                        
  <5 Standard care                           
Most intense comparator is 26–51 h vs lower intensity 
DÃaz, R Mexico <5 Control 43 9–17 OB+ 12 6/12                    
  26–51 Lifestyle                          
Naar-King, S USA 5–25 Shapedown  49 12–17 OB+                   
  26–51 Multisystemic                        
Stark, L USA <5 UC 18 2–5 OB 6/12                    
  26–51 LAUNCH                       
Wilfley, D USA 5–25 Control  172 7–11 OW+                  
  5–25 LOW                          
  26–51 HIGH                          
Most intense comparator is 26–51 h versus same intensity 
Garnett, S Australia 26–51 Mod carb/hi pro 111 10–17 OW+ 12 3/6                
  26–51 Hi carb/LF                       
Garnett, S Australia 26–51 Mod carb/hi pro 111 10–17 OW+ 12 6/12                
  26–51 Hi carb/LF                       
Hystad, H Norway 26–51 Therapist 83 7–12 OB+ 24 6/24                
  26–51 Self help                          
Farpour- Lambert 2019 Switzerland 26–51 Individual 74 7–11 SO 6/12                 
  26–51 Group                      
  <5 Control      12                      
Sepulveda 2020 Spain 26–51 ENT REN 51 8–12 OW+ Post/6                
  26–51 ENT REN-F                      
                                 
Most intense comparator is 52+ hours versus lower intensity 
Anderson, Y New Zealand <5 Minimal intervention 138 5–16 SO 12 6/12                   
  ≥52 Whanau Pakari                    
Baan-Slootweg, O The Netherlands 5-25 Ambulatory 90 8–18 SO 6/30             
  ≥52 Inpatient                    
Butte, N USA 5–25 Next Steps 549 2–12 OW+ 12 3/12                   
  26–51 MEND                      
  ≥52 MEND/CAT CH                      
Hoffman, J USA 5–25 HL 97 5–11 OB+                
  ≥52 HL + BCF                     
Kokkvoll, A Norway 5–25 Single family 91 6–12 OB+ 12 3/12                    
  ≥52 Multifamily                     
Kokkvoll, A Norway 5–25  91 6–12 OB+ 24 12/24                  
  ≥52                        
Lison, J Spain <5 Control  110 6–16 OW+                     
  <5 Home based                          
  ≥52 Group                         
Savoye, M USA <5 PWMP 174 8–16 OB+ 12 12/24                  
  ≥52 Bright Bodies                     
Savoye, M USA <5 PWMP 174 8–16 OB+ 12 6/12                 
  ≥52 Bright Bodies                     
Serra-Paya, N Spain <5 Counseling  113 6–12 OW+                    
  ≥52 Nereu                        
Kokkvoll 2020 Norway 5–25 Individual  91 6–12 OW+ 24 36                   
  ≥52 Group                        
Most intense comparator is 52+ hours versus same intensity 
Makkes, S The Netherlands ≥52 Short stay 80 8–19 SO 12 6/12                 
  ≥52 Long stay                        
Rolland- Cachera, M France ≥52 PROT - 121 11–16 SO 11/35             
  ≥52 PROT +                    
Warschburger, P Germany ≥52 CBT 523 7–12 SO 6/12               
  ≥52 Information                      
Miguet 2019 France ≥52 MICT  43 11–15 OB+               
  ≥52 HIIT                     
Warschburger 2018 Germany ≥52 AAT 232 8–16 SO 6 wk 6/12                   
  ≥52 Placebo training                          

AAT, appetite awareness training; BCF, Bull City Fit; CBT-E, enhanced cognitive behavior therapy; EPC, enhanced primary care; EUC, enhanced usual care; FBT, family-based treatment; HL, Healthy Lifestyles; HP, high protein; HGI, hypocaloric, low-glycemic-index; HF, high fat; HIIT, high-intensity interval training; GM, growth monitoring; GL, glycemic load; LC, low carbohydrate; LF, low fat; LGL, low glycemic load; LGI, low glycemic index; MI, motivational interviewing; MR, meal replacements; MICT, moderate-intensity continuous training; NDPT, nurse, dietitian, and physiotherapist; NDT, nurse and dietitian; OB, obese; OW, overweight; PC, primary care; PCP, primary care provider; PWMP, personalized weight management program; SMS, short message service; SFA, solution-focused approach; SO, severe obesity; UC, usual care.

A summary of the Cochrane Risk of Bias tool is provided in Fig 2, with further details in Table 4. The majority of studies were of medium to poor quality based on this risk of bias tool. However, the major contributor to the quality assigned to these studies was their inability to blind participants or personnel. Additionally, the reporting of most studies did not allow for complete ascertainment of selective reporting or other sources of bias.

FIGURE 2

Quality of lifestyle RCTs, as assessed using the Cochrane Risk of Bias Tool.

FIGURE 2

Quality of lifestyle RCTs, as assessed using the Cochrane Risk of Bias Tool.

Close modal
TABLE 4

Quality of Lifestyle RCTs, as Assessed Using the Cochrane Risk of Bias Tool

Quality of Lifestyle RCTs, as Assessed Using the Cochrane Risk of Bias Tool
Quality of Lifestyle RCTs, as Assessed Using the Cochrane Risk of Bias Tool
Quality of Lifestyle RCTs, as Assessed Using the Cochrane Risk of Bias Tool
Quality of Lifestyle RCTs, as Assessed Using the Cochrane Risk of Bias Tool
Quality of Lifestyle RCTs, as Assessed Using the Cochrane Risk of Bias Tool
Quality of Lifestyle RCTs, as Assessed Using the Cochrane Risk of Bias Tool

Green arrow = low risk of bias; yellow diamond = unclear risk of bias; red arrow = high risk of bias.

For lifestyle and diet studies with minimal-intervention controls, Table 2 provides additional information on the type of intervention, sample size, age, BMI inclusion, and intervention components. These are categorized by the intensity, in hours, of the comparison group and listed with the intervention intensity. Published articles did not typically quantify dose of intervention in a consistent manner. Therefore, we extrapolated dose based on the number of sessions and average time each session lasted, to the extent this information was available from the published manuscript. We categorized findings using the USPSTF intensities of intervention delivery as <5 hours (n = 20),13,15,17,19,25,29,30,32,33,37,3941, 44,46,4851,56  5 to 25 hours (n = 26),8,11, 14,16,18,2024,2628,31,36,38,42,43,45,47,52,53,57, 5961  and 26 to 51 hours (n = 7).911, 34,35,54,55  There was only 1 RCT with a minimal intervention control in which the intervention arm provided an intensity >51 hours.58  Most studies relied on usual care or primary care provider (PCP)-only as a comparison group. The sample size ranged widely, from 17 to 645.

To understand how intensity of treatment and treatment components were associated with BMI outcomes, we examined patterns noted in Table 2. For studies that provided fewer than 5 hours of contact hours over 2 to 24 months, for children ages 2 to 17 years, 25% demonstrated improvement in BMI outcomes; none of the 5 that included a second measurement time point showed differences at this later time-point. These studies typically included nutrition and physical activity counseling to children who had overweight and/or obesity. Providing additional components, such as addressing sleep or motivational interviewing (MI), did not distinguish effective studies from noneffective studies for this limited number of contact hours. Although virtually all studies resulting in statistically significant BMI reduction included MI, many of the studies without significant effects also included MI.

More than 35% of the studies that provided 5 to 25 hours of contact hours demonstrated a statistically significant change in BMI outcomes in the desired direction. More than half focused on adolescents. The majority of these lifestyle interventions focused on children who had obesity and provided nutrition and physical activity counseling with the assistance of a nutrition provider. Additional components such as sleep or participation of a mental health provider, such as a clinical psychologist, did not distinguish effective from noneffective trials.

Although there were many fewer studies that provided 26 to 51 hours of intervention contact hours (n = 7), 71% demonstrated effective change in BMI over 3 to 24 months. More than half of these included children and adolescents with obesity or severe obesity who were between the ages of 3 and 17 years. In addition to nutrition and physical activity counseling, the interventions provided activity training—that is, the incorporation of exercise during sessions (rather than only counseling on physical activity). Three of the 5 with significant improvements in BMI addressed both mental health and parenting skills.

As referenced above, we identified only 1 RCT with contact hours that exceeded 51 hours. Although this study demonstrated an effective outcome after 1 year, it included a small sample size of 73 children ages 7 to 15 years in Germany. This study provided the components of both nutrition and physical activity counseling and training as well as addressing mental health.

Primary care providers were included in almost all studies, in both the treatment arm and the minimal-intervention comparison arm. Nutrition providers and mental or behavioral health counselors were also common providers. Despite their frequency of use, none of these provider types distinguished interventions with significant improvements in BMI from those showing no differences. Other providers, such as exercise trainers or social workers, were commonly used in high-intensity interventions but did not, on their own, differentiate studies with improvements in BMI.

Overall, as the intensity of the treatment increased, the sample size of the study generally decreased, highlighting the challenges, even in a research setting, of delivering an intensive intervention to a large population. Interventions that were less intensive often included children with both overweight and obesity, whereas more intensive studies predominantly set the cut-point higher, only including children with obesity. The components of the various interventions include medical care, dietary and exercise counseling, psychosocial and mental health counseling, and MI. In addition, there were innovative strategies highlighted as well including text messaging, telehealth, and sleep training. Behavioral components, such as nutrition and activity counseling, were nearly universally present in the interventions. No single intervention component was consistently associated with improved BMI outcomes, nor were any clusters of intervention components associated with improved BMI. Although most trials with statistically significant improvements in BMI included diet and activity counseling, as well as direct activity sessions, many with these components did not demonstrate any significant differences.

The lifestyle and diet comparative effectiveness trials (Table 3) are listed by the most intensive comparator and included the intensity of all groups. The comparator arm of these studies varied, and the most commonly used included enhanced primary care, multidisciplinary clinic treatment, mailers, or group-based education. Many of the studies in this group compared different versions of a similar intervention (primary care versus enhanced primary care versus primary care plus coaching), similar interventions delivered in different settings (inpatient versus outpatient, home versus clinic), or comparison of specific dietary strategies (low-fat versus low-carb). As seen with the studies that included a control group, the interventions that included children with more severe degrees of obesity tended to be more intensive by hours and setting (eg, inpatient) but shorter in duration as compared with less intensive interventions. No outcomes beyond 36 months were reported, although most were reported only at 6 or 12 months. Nearly all the studies included some type of nutrition and activity counseling for all comparator arms.

As with the minimal-intervention control studies, most comparative effectiveness studies included primary care providers in both study arms. Nutrition and mental and behavioral health providers were also common. In more intensive studies, exercise trainers and social workers were often used. No specific provider type was clearly associated with significant improvements in BMI.

Most comparative effectiveness studies included both nutrition and activity counseling, whereas fewer included direct provision of physical activity and nutrition training. These components were not clearly associated with improved BMI outcomes—many studies including activity and nutrition training did not find significant differences. All studies that included parenting training in the comparator demonstrated improved BMI; however, these were limited largely to very young children, 2 to 5 years of age. Otherwise, no single component of the intervention was consistently associated with positive BMI outcomes, regardless of intensity, and no clusters of intervention components distinguished studies demonstrating significant improvements in BMI.

Among the RCTs showing effectiveness, we also examined the magnitude of BMI change (Table 5). The magnitude of change varied widely, with lower-intensity interventions resulting in less BMI change. Several metrics were used to monitor change in children’s relative adiposity during the obesity treatment trials. BMI was the most commonly used metric of weight change among the successful lifestyle and diet trials (n = 30), followed by BMI SDS (n = 29), absolute weight (n = 16), BMI percentile (n = 12), percentage over median BMI or other (n = 6), and percentage of the 95th percentile (n = 1). Table 5 presents detailed information about the magnitude of changes, limited only to the studies showing any statistically significant differences between included groups.

TABLE 5

Magnitude of BMI Effect for Successful Lifestyle and Diet Trials

AuthorsTitleCountryIntensityNAgesWeightLength (months)Outcome (months)BMI ReductionBMI SDS ReductionBMI PercentileKg% of 95th Percentile% Over Median or OtherCalculated From
Most intense comparator is less than 5 h 
Gourlan, M Motivational interviewing as a way to promote physical activity in obese adolescents: a randomized-controlled trial using self- determination theory as an explanatory framework France <5 Standard 62 11–18 OB+  0.31      
   <5 Standard + MI      −1.14      
    Difference     −1.45      
Chen, J Short-term efficacy of an innovative mobile phone technology- based intervention for weight management for overweight and obese adolescents: pilot study USA <5 iStart Smart 40 13–18 OW+  −0.44 −0.18     
   <5 Control      0.83 0.26     
    Difference     −1.27 −0.44     
Most intense comparator is 5–25 h versus lower intensity 
Garipağaoğlu 2009, M Family-based group treatment versus individual treatment in the management of childhood obesity: randomized, prospective clinical trial Turkey <5 Individual 80 6–14 OB+  −1.10 −0.11     
   5–25 Group      −1.20 −0.11     
    Difference     −0.10 0.00     
Norman, G Outcomes of a 1-y randomized controlled trial to evaluate a behavioral “stepped- dow n” weight loss intervention for adolescent patients with obesity USA <5 EUC 106 11–13 OB+ 12  0.60 0.00 −3.2    
   5–25 Stepped      −0.60 −0.10 −10.4    
    Difference     12 −1.20 −0.10 −7.2    
Stark, Lj A pilot randomized controlled trial of a behavioral family-based intervention with and without home visits to decrease obesity in preschoolers USA <5 PC 33 2–5 OB   −0.03 0.2 5.2    
   5–25 LAUNCH home       −0.50 −4 0.8    
   5–25 LAUNCH clinic       −0.59 −5.1 2.3    
    HV versus PC       −0.64 −4.6 −4.4    
    Clinic versus PC     12  −0.50 NS −3.0    
Most intense comparator is 5–25 h versus same intensity 
Akgul Gundogdu, N. The effect of the solution-focused approach on nutrition- exercise attitudes and behaviors of overweight and obese adolescents: randomized controlled trial Turkey 5–25 SFA 32 12–13 OW+        
   5–25 UC         
    Difference     0.67 0.65 0.276 0.77    
Berkowitz, Ri Meal replacements in the treatment of adolescent obesity: a randomized controlled trial USA 5-25 Conventional 113 13–17 OB+ 12  −1.30   −3.6    
   5–25 MR      −2.30   −5.9    
   5–25 MR ≥ Conv.      NA   NA    
    Difference     12 −1.00 NS  −2.3    
Ebbeling, Cb A reduced-glycemic load diet in the treatment of adolescent obesity USA 5–25 Reduced GL 14 13–21 OB+ 12  −1.30       
   5–25 Low fat      0.70       
    Difference     12 −2.00       
Parillo, M Metabolic changes after a hypocaloric, low - glycemic-index diet in obese children Italy 5–25 HGI 22 Mean 10 OB+  −1.60 −0.20      
   5–25 LGI      −3.20 −0.30      
    Difference     −1.60 −0.10      
Quattrin, T. Efficacy of family-based weight control program for preschool children in primary care USA 5–25 Intervention 96 2–5 OW+       −6.4 
   5–25 Attention control           −2.2 
    Difference          −4.2 
Quattrin, T Cost-effectiveness of family-based obesity treatment USA 5–25 Attention control 96 2–5 OW+ 12       4.4  
   5–25 FBT           −2  
    Difference     24      −6.4  
Quattrin, T Treatment outcomes of overweight children and parents in the medical home USA 5–25 Attention control 96 2–5 OW+ 12   −0.25  7.1   
   5–25 Intervention       −0.50  5.5   
    Difference     24  −0.25  −1.6   
Stettler, N. Prevention of excess weight gain in pediatric primary care: beverages only or multiple lifestyle factors. The Smart Step Study, a cluster-randomized clinical trial USA 5–25 Control 172 8–12 OW 12  1.70 0.10  8.6   
   5–25 Beverage      0.90 −0.03  5.6   
   5–25 Multiple behaviors      0.60 −0.06  5.5   
    Bev versus control      NS NS  NS    
    Multi versus control     12 −0.62 −0.10  NS    
Ek 2019 A parent treatment program for preschoolers with obesity: a randomized controlled trial Sweden 5–25 Booster 174 4–6 OB 12  −0.63 −0.54      
   5–25 No booster      0.56 −0.11      
   <5 Standard      0.78 −0.04      
    Booster or no booster vs standard     12 −0.06 −0.02      
Njardvik 2018 Incorporating appetite awareness training within family-based behavioral treatment of pediatric obesity: a randomized controlled pilot study Iceland 5–25 FBT-AAT 84 8–12 OB+ 18 wk   −0.46     
   5–25 FBT    18 wk   −0.25     
    Difference     12  −0.21      
Most intense comparator is 26–51 h versus lower intensity 
DÃaz, Rg Lifestyle intervention in primary care settings improves obesity parameters among Mexican youth Mexico <5 Control 43 9–17 OB+ 12  0.40 −0.09  5.6    
   26–51 Lifestyle      −1.80 −0.29  −0.8    
    Difference     12 −2.20 −0.20  −6.4    
Stark, Lj A pilot randomized controlled trial of a clinic and home-based behavioral intervention to decrease obesity in preschoolers USA <5 UC 18 2–5 OB   1.6     
   26–51 LAUNCH       −0.37 −1.1     
    Difference     12  −0.77 −2.7     
Wilf ley, De Dose, content, and mediators of family- based treatment of childhood obesity: a multisite randomized clinical trial USA 5–25 Control 172 7–11 OW+        
   5–25 LOW            
   26–51 HIGH            
    H versus C           −6.71  
    L versus C           −3.34  
    H versus L     12      −3.37  
Farpour- Lambert 2019 Effectiveness of individual and group programmes to treat obesity and reduce cardiovascular disease risk factors in prepubertal children Sw itzerland 26–51 Individual 74 7–11 SO         
   26–51 Group          
   <5 Control    12       
    Individual vs control      NS NS      
    Group vs control      −0.77 −0.10      
    Individual vs group     12 −1.08 −0.08      
Sepulveda 2020 Feasibility, acceptability, and effectiveness of a multidisciplinary intervention in childhood obesity from primary care: Nutrition, physical activity, emotional regulation, and family Spain 26–51 ENTREN 51 8–12 OW+   −0.4      
   26–51 ENTREN-F       −0.83      
    Difference      −0.43      
Most intense comparator is 52+ hours versus lower intensity 
Butte, Nf Efficacy of a community- versus primary care-centered program for childhood obesity: TX CORD RCT USA 5–25 Next Steps 549 2–12 OW+ 12  0.17   −0.39   
   ≥52 MEND/CATCH     −0.25   −2.32   
    Difference     −0.42   NS −1.93   
Kokkvoll, A. Health in overweight children: 2-y follow - up of Finnmark Activity School–a randomized trial Norway 5–25 Single family 91 6–12 OB+ 24   −0.08     
   ≥52 Multifamily       −0.20     
    Difference     24 NS −0.12     
Lison, Jf Exercise intervention in childhood obesity: a randomized controlled trial comparing hospital-versus home-based groups Spain <5 Control 110 6–16 OW+  1.60 −0.01  7.8   
   <5 Home based      −1.20 −0.23  −0.3   
   ≥52 Group      −0.40 −0.16  1.2   
    C versus home      −2.80 −0.22  −8.1   
    C versus group     −2.00 −0.15  −6.6   
Savoye, M Long-term results of an obesity program in an ethnically diverse pediatric population USA <5 PWMP 174 8–16 OB+ 12  1.90 −0.05  12.0    
   ≥52 Bright Bodies      −0.90 −0.20  5.9    
    Difference     24 −2.80 −0.16  −6.1    
Savoye, M Effects of a w eight management program on body composition and metabolic parameters in overweight children: a randomized controlled trial USA <5 PWMP 174 8–16 OB+ 12  1.60   7.7    
   ≥52 Bright Bodies      −1.70   0.3    
    Difference     12 −3.30   −7.4    
Most intense comparator is 52+ hours versus same intensity 
Makkes, S One-year effects of 2 intensive inpatient treatments for severely obese children and adolescents The Netherlan ds ≥52 Short stay 80 8–19 SO 12   −0.30     
   ≥52 Long stay       −0.50     
    Difference      −0.22      
Comparison is less than 5 h 
Broccoli, S Motivational interviewing to treat overweight children: 24-month follow -up of a randomized controlled trial Italy <5 UC 372 4–7 OW 12  0.78      
   <5 MI      0.46      
    Difference     12 −0.32 NS      
Resnicow, K Motivational interviewing and dietary counseling for obesity in primary care: an RCT USA <5 UC 645 2–8 OW/OB 24    −1.8     
   <5 PCP        −3.8     
   <5 PCP + RD        −4.9     
    UC versus PCP        NS     
    UC versus PCP + RD     24   −3.1     
Kong, As School-based health center intervention improves BMI in overweight and obese adolescents USA <5 ACTION 51 14–17 OW+    −0.3    
   <5 UC        0.2    
    Difference       −0.6 NS    
Taveras, Em Comparative effectiveness of childhood obesity interventions in pediatric primary care: a cluster-randomized clinical trial USA <5 UC 549 6–12 OW+ 12  1.20 −0.04      
   <5 CDS      0.70 −0.10      
   <5 CDS + coach      0.90 −0.08      
    UC versus CDS      −0.51 −0.06      
    UC vs CDS + coach      −0.34 −0.05      
    CDS vs CDS + coach     12 NS NS      
Taylor, Rw A tailored family-based obesity intervention: a randomized trial New Zealand <5 UC 206 4–8 OW+ 24  1.20 −0.12     
   <5 Tailored      0.80 −0.27     
    Difference     24 −0.34 −0.12      
Comparison is 5–25 h 
Crabtree, V A transtheoretical, case management approach to the treatment of pediatric obesity USA <5 UC 19 8–12 OB+   −0.3    
   5–25 Case management       −1.5    
    Difference     NS  −1.2    
DeBar, Ll A primary care-based, multicomponent lifestyle intervention for overweight adolescent females USA <5 UC 208 12–17 OB+   −0.08    
   5–25 Intervention       −0.15    
    Difference     12  −0.07 NS     
Fleischman, A Creating an integrated care model for childhood obesity: a randomized pilot study utilizing telehealth in a community primary care setting USA <5 PCP 40 10–17 OB+  −0.05 −0.3    
   5–25 PCP + Telehealth      −0.11 −0.8    
    Difference     NS −0.06 −0.6 NS    
Hofsteenge, Gh Long-term effect of the Go4it group treatment for obese adolescents: a randomized controlled trial The Netherlan ds <5 Control 122 11–18 OW+   0.03    
   5–25 Go4It      −0.07    
    Difference     18 NS −0.16  NS    
Kalavainen, M Long-term efficacy of group-based treatment of childhood obesity compared with routinely given individual counseling Finland <5 Routine 70 7–9 OB+  0.00 −0.20  1.8  −1.8  
   5–25 Group      −0.80 −0.30  0.5  −6.8  
    Difference     −0.80 −0.10  No P  −5.00  
Nova, A Long-term management of obesity in pediatric office practice: experimental evaluation of 2 different types of intervention Italy <5 General 186 3–12 OB+ 24       −2.92  
   5–25 Specific info           −8.5  
    Difference     12      −5.58  
Shelton, D Randomized controlled trial: a parent-based group education program for overweight children Australia <5 UC 43 3–10 OW+  0.10      
   5–25 Intervention      −1.60      
    Difference     −1.70      
Stark, Lj Clinic and home-based behavioral intervention for obesity in preschoolers: a randomized trial USA <5 UC 151 2–5 OB  −0.13       
   5–25 LAUNCH      −0.32       
   5–25 MI      −0.05       
    LAUNCH vs MI      −0.27       
    LAUNCH vs UC     −0.19       
Truby, H A randomized controlled trial of 2 different macronutrient profiles on weight, body composition and metabolic parameters in obese adolescents seeking weight loss Australia <5 Control 87 10–17 OW+        
   5–25 LF            
   5–25 Low carb            
    C vs SLF      −1.58 −0.13  NS    
    C vs LC      −1.75 −0.14  NS    
    SLF vs LC      NS NS  NS    
Verbeken, S Executive function training with game elements for obese children: a novel treatment to enhance self-regulatory abilities for weight-control Belgium <5 UC 44 9–14 SO       1.2 
   5–25 Executive function           −0.5 
    Difference          −1.7 
Comparison is 26–51hours 
Bocca, G Results of a multidisciplinary treatment program in 3- year-old to 5-y-old overweight or obese children: a randomized controlled clinical trial The Netherlands <5 Multidisc. 75 3–5 OW+  0.00 −0.30     
   26–51 UC      −1.00 −0.60     
    Difference     12 −1.00 −0.30  NS    
Bocca, G A multidisciplinary intervention program has positive effects on quality of life in overweight and obese preschool children The Netherlands <5 Multidisc. 75 3–5 OW+   −0.30      
   26–51 UC       −0.60      
    Difference     12  −0.30      
Vos, R. C. Long-term effect of lifestyle intervention on adiposity, metabolic parameters, inflammation and physical fitness in obese children: a randomized controlled trial The Netherlands <5 WLC 79 8–17 SO 24   −0.10      
   26–51 FBT       −0.40      
    Difference     12  −0.20      
Comparison is 52+ hours 
Weigel, C. Childhood obesity: concept, feasibility, and interim results of a local group-based, long-term treatment program Germany <5 Control 73 7–15 OB+ 12  2.80 0.26     
   ≥52 Intervention      −1.50 −0.34     
    Difference     12 −4.30 −0.60     
AuthorsTitleCountryIntensityNAgesWeightLength (months)Outcome (months)BMI ReductionBMI SDS ReductionBMI PercentileKg% of 95th Percentile% Over Median or OtherCalculated From
Most intense comparator is less than 5 h 
Gourlan, M Motivational interviewing as a way to promote physical activity in obese adolescents: a randomized-controlled trial using self- determination theory as an explanatory framework France <5 Standard 62 11–18 OB+  0.31      
   <5 Standard + MI      −1.14      
    Difference     −1.45      
Chen, J Short-term efficacy of an innovative mobile phone technology- based intervention for weight management for overweight and obese adolescents: pilot study USA <5 iStart Smart 40 13–18 OW+  −0.44 −0.18     
   <5 Control      0.83 0.26     
    Difference     −1.27 −0.44     
Most intense comparator is 5–25 h versus lower intensity 
Garipağaoğlu 2009, M Family-based group treatment versus individual treatment in the management of childhood obesity: randomized, prospective clinical trial Turkey <5 Individual 80 6–14 OB+  −1.10 −0.11     
   5–25 Group      −1.20 −0.11     
    Difference     −0.10 0.00     
Norman, G Outcomes of a 1-y randomized controlled trial to evaluate a behavioral “stepped- dow n” weight loss intervention for adolescent patients with obesity USA <5 EUC 106 11–13 OB+ 12  0.60 0.00 −3.2    
   5–25 Stepped      −0.60 −0.10 −10.4    
    Difference     12 −1.20 −0.10 −7.2    
Stark, Lj A pilot randomized controlled trial of a behavioral family-based intervention with and without home visits to decrease obesity in preschoolers USA <5 PC 33 2–5 OB   −0.03 0.2 5.2    
   5–25 LAUNCH home       −0.50 −4 0.8    
   5–25 LAUNCH clinic       −0.59 −5.1 2.3    
    HV versus PC       −0.64 −4.6 −4.4    
    Clinic versus PC     12  −0.50 NS −3.0    
Most intense comparator is 5–25 h versus same intensity 
Akgul Gundogdu, N. The effect of the solution-focused approach on nutrition- exercise attitudes and behaviors of overweight and obese adolescents: randomized controlled trial Turkey 5–25 SFA 32 12–13 OW+        
   5–25 UC         
    Difference     0.67 0.65 0.276 0.77    
Berkowitz, Ri Meal replacements in the treatment of adolescent obesity: a randomized controlled trial USA 5-25 Conventional 113 13–17 OB+ 12  −1.30   −3.6    
   5–25 MR      −2.30   −5.9    
   5–25 MR ≥ Conv.      NA   NA    
    Difference     12 −1.00 NS  −2.3    
Ebbeling, Cb A reduced-glycemic load diet in the treatment of adolescent obesity USA 5–25 Reduced GL 14 13–21 OB+ 12  −1.30       
   5–25 Low fat      0.70       
    Difference     12 −2.00       
Parillo, M Metabolic changes after a hypocaloric, low - glycemic-index diet in obese children Italy 5–25 HGI 22 Mean 10 OB+  −1.60 −0.20      
   5–25 LGI      −3.20 −0.30      
    Difference     −1.60 −0.10      
Quattrin, T. Efficacy of family-based weight control program for preschool children in primary care USA 5–25 Intervention 96 2–5 OW+       −6.4 
   5–25 Attention control           −2.2 
    Difference          −4.2 
Quattrin, T Cost-effectiveness of family-based obesity treatment USA 5–25 Attention control 96 2–5 OW+ 12       4.4  
   5–25 FBT           −2  
    Difference     24      −6.4  
Quattrin, T Treatment outcomes of overweight children and parents in the medical home USA 5–25 Attention control 96 2–5 OW+ 12   −0.25  7.1   
   5–25 Intervention       −0.50  5.5   
    Difference     24  −0.25  −1.6   
Stettler, N. Prevention of excess weight gain in pediatric primary care: beverages only or multiple lifestyle factors. The Smart Step Study, a cluster-randomized clinical trial USA 5–25 Control 172 8–12 OW 12  1.70 0.10  8.6   
   5–25 Beverage      0.90 −0.03  5.6   
   5–25 Multiple behaviors      0.60 −0.06  5.5   
    Bev versus control      NS NS  NS    
    Multi versus control     12 −0.62 −0.10  NS    
Ek 2019 A parent treatment program for preschoolers with obesity: a randomized controlled trial Sweden 5–25 Booster 174 4–6 OB 12  −0.63 −0.54      
   5–25 No booster      0.56 −0.11      
   <5 Standard      0.78 −0.04      
    Booster or no booster vs standard     12 −0.06 −0.02      
Njardvik 2018 Incorporating appetite awareness training within family-based behavioral treatment of pediatric obesity: a randomized controlled pilot study Iceland 5–25 FBT-AAT 84 8–12 OB+ 18 wk   −0.46     
   5–25 FBT    18 wk   −0.25     
    Difference     12  −0.21      
Most intense comparator is 26–51 h versus lower intensity 
DÃaz, Rg Lifestyle intervention in primary care settings improves obesity parameters among Mexican youth Mexico <5 Control 43 9–17 OB+ 12  0.40 −0.09  5.6    
   26–51 Lifestyle      −1.80 −0.29  −0.8    
    Difference     12 −2.20 −0.20  −6.4    
Stark, Lj A pilot randomized controlled trial of a clinic and home-based behavioral intervention to decrease obesity in preschoolers USA <5 UC 18 2–5 OB   1.6     
   26–51 LAUNCH       −0.37 −1.1     
    Difference     12  −0.77 −2.7     
Wilf ley, De Dose, content, and mediators of family- based treatment of childhood obesity: a multisite randomized clinical trial USA 5–25 Control 172 7–11 OW+        
   5–25 LOW            
   26–51 HIGH            
    H versus C           −6.71  
    L versus C           −3.34  
    H versus L     12      −3.37  
Farpour- Lambert 2019 Effectiveness of individual and group programmes to treat obesity and reduce cardiovascular disease risk factors in prepubertal children Sw itzerland 26–51 Individual 74 7–11 SO         
   26–51 Group          
   <5 Control    12       
    Individual vs control      NS NS      
    Group vs control      −0.77 −0.10      
    Individual vs group     12 −1.08 −0.08      
Sepulveda 2020 Feasibility, acceptability, and effectiveness of a multidisciplinary intervention in childhood obesity from primary care: Nutrition, physical activity, emotional regulation, and family Spain 26–51 ENTREN 51 8–12 OW+   −0.4      
   26–51 ENTREN-F       −0.83      
    Difference      −0.43      
Most intense comparator is 52+ hours versus lower intensity 
Butte, Nf Efficacy of a community- versus primary care-centered program for childhood obesity: TX CORD RCT USA 5–25 Next Steps 549 2–12 OW+ 12  0.17   −0.39   
   ≥52 MEND/CATCH     −0.25   −2.32   
    Difference     −0.42   NS −1.93   
Kokkvoll, A. Health in overweight children: 2-y follow - up of Finnmark Activity School–a randomized trial Norway 5–25 Single family 91 6–12 OB+ 24   −0.08     
   ≥52 Multifamily       −0.20     
    Difference     24 NS −0.12     
Lison, Jf Exercise intervention in childhood obesity: a randomized controlled trial comparing hospital-versus home-based groups Spain <5 Control 110 6–16 OW+  1.60 −0.01  7.8   
   <5 Home based      −1.20 −0.23  −0.3   
   ≥52 Group      −0.40 −0.16  1.2   
    C versus home      −2.80 −0.22  −8.1   
    C versus group     −2.00 −0.15  −6.6   
Savoye, M Long-term results of an obesity program in an ethnically diverse pediatric population USA <5 PWMP 174 8–16 OB+ 12  1.90 −0.05  12.0    
   ≥52 Bright Bodies      −0.90 −0.20  5.9    
    Difference     24 −2.80 −0.16  −6.1    
Savoye, M Effects of a w eight management program on body composition and metabolic parameters in overweight children: a randomized controlled trial USA <5 PWMP 174 8–16 OB+ 12  1.60   7.7    
   ≥52 Bright Bodies      −1.70   0.3    
    Difference     12 −3.30   −7.4    
Most intense comparator is 52+ hours versus same intensity 
Makkes, S One-year effects of 2 intensive inpatient treatments for severely obese children and adolescents The Netherlan ds ≥52 Short stay 80 8–19 SO 12   −0.30     
   ≥52 Long stay       −0.50     
    Difference      −0.22      
Comparison is less than 5 h 
Broccoli, S Motivational interviewing to treat overweight children: 24-month follow -up of a randomized controlled trial Italy <5 UC 372 4–7 OW 12  0.78      
   <5 MI      0.46      
    Difference     12 −0.32 NS      
Resnicow, K Motivational interviewing and dietary counseling for obesity in primary care: an RCT USA <5 UC 645 2–8 OW/OB 24    −1.8     
   <5 PCP        −3.8     
   <5 PCP + RD        −4.9     
    UC versus PCP        NS     
    UC versus PCP + RD     24   −3.1     
Kong, As School-based health center intervention improves BMI in overweight and obese adolescents USA <5 ACTION 51 14–17 OW+    −0.3    
   <5 UC        0.2    
    Difference       −0.6 NS    
Taveras, Em Comparative effectiveness of childhood obesity interventions in pediatric primary care: a cluster-randomized clinical trial USA <5 UC 549 6–12 OW+ 12  1.20 −0.04      
   <5 CDS      0.70 −0.10      
   <5 CDS + coach      0.90 −0.08      
    UC versus CDS      −0.51 −0.06      
    UC vs CDS + coach      −0.34 −0.05      
    CDS vs CDS + coach     12 NS NS      
Taylor, Rw A tailored family-based obesity intervention: a randomized trial New Zealand <5 UC 206 4–8 OW+ 24  1.20 −0.12     
   <5 Tailored      0.80 −0.27     
    Difference     24 −0.34 −0.12      
Comparison is 5–25 h 
Crabtree, V A transtheoretical, case management approach to the treatment of pediatric obesity USA <5 UC 19 8–12 OB+   −0.3    
   5–25 Case management       −1.5    
    Difference     NS  −1.2    
DeBar, Ll A primary care-based, multicomponent lifestyle intervention for overweight adolescent females USA <5 UC 208 12–17 OB+   −0.08    
   5–25 Intervention       −0.15    
    Difference     12  −0.07 NS     
Fleischman, A Creating an integrated care model for childhood obesity: a randomized pilot study utilizing telehealth in a community primary care setting USA <5 PCP 40 10–17 OB+  −0.05 −0.3    
   5–25 PCP + Telehealth      −0.11 −0.8    
    Difference     NS −0.06 −0.6 NS    
Hofsteenge, Gh Long-term effect of the Go4it group treatment for obese adolescents: a randomized controlled trial The Netherlan ds <5 Control 122 11–18 OW+   0.03    
   5–25 Go4It      −0.07    
    Difference     18 NS −0.16  NS    
Kalavainen, M Long-term efficacy of group-based treatment of childhood obesity compared with routinely given individual counseling Finland <5 Routine 70 7–9 OB+  0.00 −0.20  1.8  −1.8  
   5–25 Group      −0.80 −0.30  0.5  −6.8  
    Difference     −0.80 −0.10  No P  −5.00  
Nova, A Long-term management of obesity in pediatric office practice: experimental evaluation of 2 different types of intervention Italy <5 General 186 3–12 OB+ 24       −2.92  
   5–25 Specific info           −8.5  
    Difference     12      −5.58  
Shelton, D Randomized controlled trial: a parent-based group education program for overweight children Australia <5 UC 43 3–10 OW+  0.10      
   5–25 Intervention      −1.60      
    Difference     −1.70      
Stark, Lj Clinic and home-based behavioral intervention for obesity in preschoolers: a randomized trial USA <5 UC 151 2–5 OB  −0.13       
   5–25 LAUNCH      −0.32       
   5–25 MI      −0.05       
    LAUNCH vs MI      −0.27       
    LAUNCH vs UC     −0.19       
Truby, H A randomized controlled trial of 2 different macronutrient profiles on weight, body composition and metabolic parameters in obese adolescents seeking weight loss Australia <5 Control 87 10–17 OW+        
   5–25 LF            
   5–25 Low carb            
    C vs SLF      −1.58 −0.13  NS    
    C vs LC      −1.75 −0.14  NS    
    SLF vs LC      NS NS  NS    
Verbeken, S Executive function training with game elements for obese children: a novel treatment to enhance self-regulatory abilities for weight-control Belgium <5 UC 44 9–14 SO       1.2 
   5–25 Executive function           −0.5 
    Difference          −1.7 
Comparison is 26–51hours 
Bocca, G Results of a multidisciplinary treatment program in 3- year-old to 5-y-old overweight or obese children: a randomized controlled clinical trial The Netherlands <5 Multidisc. 75 3–5 OW+  0.00 −0.30     
   26–51 UC      −1.00 −0.60     
    Difference     12 −1.00 −0.30  NS    
Bocca, G A multidisciplinary intervention program has positive effects on quality of life in overweight and obese preschool children The Netherlands <5 Multidisc. 75 3–5 OW+   −0.30      
   26–51 UC       −0.60      
    Difference     12  −0.30      
Vos, R. C. Long-term effect of lifestyle intervention on adiposity, metabolic parameters, inflammation and physical fitness in obese children: a randomized controlled trial The Netherlands <5 WLC 79 8–17 SO 24   −0.10      
   26–51 FBT       −0.40      
    Difference     12  −0.20      
Comparison is 52+ hours 
Weigel, C. Childhood obesity: concept, feasibility, and interim results of a local group-based, long-term treatment program Germany <5 Control 73 7–15 OB+ 12  2.80 0.26     
   ≥52 Intervention      −1.50 −0.34     
    Difference     12 −4.30 −0.60     

AAT, appetite awareness training; C, control; CDS, clinical decision support; EUC, enhanced usual care; FBT, family-based treatment; H, high; HV, home visits; HGI, hypocaloric, low-glycemic-index; GL, glycemic load; LC, low carbohydrate; LF, low fat; LGI, low glycemic index; MR, meal replacements; OB, obese; OW, overweight; PC, primary care; PCP, primary care provider; PWMP, personalized weight management program; NS, not significant; SFA, solution-focused approach; SLF, structured low fat; SO, severe obesity; UC, usual care; WLC, wait list control.

Differences in BMI change between treatment arms ranged from −4.30 to −0.10. The greatest BMI changes (>2 BMI unit reduction) were observed in trials of ≥52 contact hours, mostly delivered over 12 months and to children and adolescents with obesity.58,102,118,119  The greatest differences in BMI reduction occurred in studies of older children and adolescents, with smaller reductions seen in younger children, as would be expected based on BMI for these groups. However, many studies included wide age ranges, encompassing early school age through adolescence.

Most BMI SDS changes ranged from −0.10 to −0.25 (14 of 29 studies), although 5 trials produced a BMI SDS change between −0.25 and −0.50,10,11,75,115,120  and 3 trials produced a BMI SDS change >−0.50.47,58,122  A difference of >0.25 BMI SDS has been suggested as a clinically meaningful difference.134,135  Differences between treatment arms in BMI percentile changes ranged from −0.6 to −7.2. Difference between study arms for absolute change in weight (kg) varied from −1.6 to −8.1 kg, with larger weight loss observed in trials with more contact hours and among older children and adolescents who had obesity.

Many of the studies examined other health outcomes, in addition to BMI. Table 6 summarizes the other outcomes reported. These include other obesity-related metrics (eg, waist circumference), behaviors, glucose metabolism, lipids, blood pressure, psychosocial outcomes, other laboratory measures, mental health, and other outcomes.

TABLE 6

Summary of Other Reported Outcomes

Outcomes
Number reporting other obesity 70 (56) 
Percent of these with positive effects 50 
Number reporting behaviors 61 (48) 
Percent of these with positive effects 51 
Number reporting glucose 34 (27) 
Percent of these with positive effects 29 
Number reporting lipids 31 (25) 
Percent of these with positive effects 32 
  
Number reporting blood pressure 29 (23) 
Percent of these with positive effects 17 
  
Number reporting psychosocial outcomes 25 (20) 
Percent of these with positive effects 36 
  
Number reporting other laboratories 8 (6) 
Percent of these with positive effects 13 
  
Number reporting mental health 6 (5) 
Percent of these with positive effects 33 
  
Number reporting other outcomes 23 (18) 
Percent of these with positive effects 39 
Outcomes
Number reporting other obesity 70 (56) 
Percent of these with positive effects 50 
Number reporting behaviors 61 (48) 
Percent of these with positive effects 51 
Number reporting glucose 34 (27) 
Percent of these with positive effects 29 
Number reporting lipids 31 (25) 
Percent of these with positive effects 32 
  
Number reporting blood pressure 29 (23) 
Percent of these with positive effects 17 
  
Number reporting psychosocial outcomes 25 (20) 
Percent of these with positive effects 36 
  
Number reporting other laboratories 8 (6) 
Percent of these with positive effects 13 
  
Number reporting mental health 6 (5) 
Percent of these with positive effects 33 
  
Number reporting other outcomes 23 (18) 
Percent of these with positive effects 39 

Data presented as n (%) unless otherwise noted.

Other Obesity-Related Metrics

The most commonly reported outcomes other than BMI were other measures of obesity, such as waist circumference or body fat percentage, which were reported in 56% of the included studies.911,15,16,2329,3335, 37,39,46,51,55,57,58,63,65,67,70,71,7375,77, 7983,85,86,88,89,91102,105,106,108,110, 112,113,117121,124,127,128,132,133  Of these studies, 50% (n = 35) noted some significant reduction in obesity-related measures attributable to the intervention. These interventions are listed in Table 7. Of the studies showing significant changes, 16 reported improvements in waist circumference, 8 reported improvements in waist circumference-to-height ratio, and 8 reported improvements in body fat percentage. Other studies reported improved outcomes in fat mass, weight, skinfold, and waist circumference-to-height ratio. Fewer studies focusing primarily on adolescents demonstrated significant improvements in obesity-related metrics, compared with those primarily including younger children. However, many studies included a wide age range (eg, 6–17 years).

TABLE 7

Trials Reporting Other Obesity Outcomes

AuthorsTitleCountryNAgesWeightLength (Months)Positive OutcomeMeasure
Anderson 2017 A novel home-based intervention for child and adolescent obesity: the results of the Whanau Pakari Randomized Controlled Trial New Zealand 138 5–16 SO 12  
Baan-Slootweg 2014 Inpatient treatment of children and adolescents with severe obesity in the Netherlands: a randomized clinical trial The Netherlands 90 8–18 SO FM 
Berkowitz 2013 Treatment of adolescent obesity comparing self-guided and group lifestyle modification programs: a potential model for primary care USA 169 12–16 OB+ 12  
Berkowitz 2011 Meal replacements in the treatment of adolescent obesity: a randomized controlled trial USA 113 13–17 OB+ 12  
Bocca 2014 Three-year follow-up of 3-y-old to 5-y-old children after participation in a multidisciplinary or a usual-care obesity treatment program The Netherlands 75 3–5 OW+ Multiple 
Bocca 2012 Results of a multidisciplinary treatment program in 3-y-old to 5-y-old overweight or obese children: a randomized controlled clinical trial The Netherlands 75 3–5 OW+ WC 
Bocca 2014 A multidisciplinary intervention program has positive effects on quality of life in overweight and obese preschool children The Netherlands 75 3–5 OW+ WC 
Butte 2017 Efficacy of a community- versus primary care-centered program for childhood obesity: TX CORD RCT USA 549 2–12 OW+ 12  
Casazza 2012 Reduced carbohydrate diet to improve metabolic outcomes and decrease adiposity in obese peripubertal African American girls USA 26 9–14 OW+  
Chen 2017 Short-term efficacy of an innovative mobile phone technology-based intervention for weight management for overweight and obese adolescents: pilot study USA 40 13–18 OW+  
Croker 2012 Family-based behavioral treatment of childhood obesity in a UK National Health Service setting: randomized controlled trial UK 72 8–12 OW+  
de Ferranti 2015 Providing food to treat adolescents at risk for cardiovascular disease USA 27 8–21 OW+  
Demol 2009 Low-carbohydrate (low and high-fat) versus high-carbohydrate low-fat diets in the treatment of obesity in adolescents Israel 55 12–18 OB+  
Diaz 2010 Lifestyle intervention in primary care settings improves obesity parameters among Mexican youth Mexico 43 9–17 OB+ 12 Multiple 
Ebbeling 2003 A reduced-glycemic load diet in the treatment of adolescent obesity USA 14 13–21 OB+ 12 FM 
Fleischman 2016 Creating an integrated care model for childhood obesity: a randomized pilot study utilizing telehealth in a community primary care setting USA 40 10–17 OB+  
Flodmark 1993 Prevention of progression to severe obesity in a group of obese schoolchildren treated with family therapy Sweden 93 10–11 OW+ 18 Skinfold 
Ford 2009 Treatment of childhood obesity by retraining eating behavior: randomized controlled trial UK 106 9–18 OB+ 12 BF% 
Garnett 2014 Improved insulin sensitivity and body composition, irrespective of macronutrient intake, after a 12 mo intervention in adolescents with prediabetes; RESIST a randomized control trial Australia 111 10–17 OW+ 12  
Garnett 2013 Optimal macronutrient content of the diet for adolescents with prediabetes; RESIST a randomized control trial Australia 111 10–17 OW+ 12 waist to height 
Grieken 2013 Population-based childhood overweight prevention: outcomes of the 'Be Active, Eat Right' Study The Netherlands 637 OW 24  
Hills 1998 Obesity management via diet and exercise intervention Australia 20 NR OB+ Skinfold 
Hoffman 2018 An integrated clinic-community partnership for child obesity treatment: a randomized Pilot Trial USA 97 5–11 OB+ WC 
Hofsteenge 2014 Long-term effect of the Go4it group treatment of obese adolescents: a randomized controlled trial The Netherlands 122 11–18 OW+  
Hughes 2008 Randomized, controlled trial of a best-practice individualized behavioral program for treatment of childhood overweight: Scottish Childhood Overweight Treatment Trial (SCOTT) UK 134 5–11 OB+  
Hystad 2013 A randomized study on the effectiveness of therapist-led v. self-help parental intervention for treating childhood obesity Norway 83 7–12 OB+ 24  
Kalavainen 2007 Clinical efficacy of group-based treatment of childhood obesity compared with routinely given individual counseling Finland 70 7–9 OB+ Weight for height 
Kalavainen 2011 Long-term efficacy of group-based treatment of childhood obesity compared with routinely given individual counseling Finland 70 7–9 OB+ Weigh for height 
Kokkvoll 2014 Single versus multiple-family intervention in childhood overweight–Finnmark Activity School: a randomized trial Norway 91 6–12 OB+ 12 Multiple 
Kokkvoll 2015 Health in overweight children: 2-y follow-up of Finnmark Activity School–a randomized trial Norway 91 6–12 OB+ 24 Multiple 
Kong 2013 School-based health center intervention improves BMI in overweight and obese adolescents USA 51 14–17 OW+ 12 WC 
Krebs 2010 Efficacy and safety of a high protein, low carbohydrate diet for wt loss in severely obese adolescents USA 46 Mean 14 OB+  
Larsen 2015 Early intervention for childhood overweight: a randomized trial in general practice Denmark 80 5–9 OW+ 24 WHtR 
Lison 2012 Exercise intervention in childhood obesity: a randomized controlled trial comparing hospital-versus home-based groups Spain 110 6–16 OW+ BF% 
Makkes 2016 One-year effects of 2 intensive inpatient treatments for severely obese children and adolescents The Netherlands 80 8–19 SO 12  
Naar-King 2009 A randomized pilot study of multisystemic therapy targeting obesity in African-American adolescents USA 49 12–17 OB+  
Nemet 2005 Short- and long-term beneficial effects of a combined dietary-behavioral-physical activity intervention for the treatment of childhood obesity Israel 46 6–16 OB+ BF% 
Nemet 2013 Effects of a multidisciplinary childhood obesity treatment intervention on adipocytokines, inflammatory and growth mediators Israel 41 6–13 OB+ WC 
Norman 2016 Outcomes of a 1-y randomized controlled trial to evaluate a behavioral 'stepped-down' weight loss intervention for adolescent patients with obesity USA 106 11–13 OB+ 12  
Novotny 2015 Pacific kids DASH for health (PacDASH) randomized, controlled trial with DASH eating plan plus physical activity improves fruit and vegetable intake and diastolic blood pressure in children USA 85 5–8 HW/OW  
Parra-Medina 2015 Promoting weight maintenance among overweight and obese Hispanic children in a rural practice USA 118 5–14 OB+ 4.5 WC 
Partsalaki 2012 Metabolic impact of a ketogenic diet compared with a hypocaloric diet in obese children and adolescents Greece 58 8–18 OB+  
Pedrosa 2011 Markers of metabolic syndrome in obese children before and after 1-y lifestyle intervention program Portugal 61 Mean 8 OW+ 12 WC to height 
Rolland-Cachera 2004 Massive obesity in adolescents: dietary interventions and behaviors associated with weight regain at 2 y follow-up France 121 11–16 SO  
Savoye 2011 Long-term results of an obesity program in an ethnically diverse pediatric population USA 174 8–16 OB+ 12 BF% 
Savoye 2007 Effects of a weight management program on body composition and metabolic parameters in overweight children: a randomized controlled trial USA 174 8–16 OB+ 12 BF% 
Serra-Paya 2015 Effectiveness of a multicomponent intervention for overweight and obese children (nereu program): a randomized controlled trial Spain 113 6–12 OW+  
Small 2014 The preliminary effects of a primary care-based randomized treatment trial with overweight and obese young children and their parents USA 60 4–8 OW+ WC 
Stettler 2015 Prevention of excess weight gain in pediatric primary care: beverages only or multiple lifestyle factors. The Smart Step Study, a cluster-randomized clinical trial USA 172 8–12 OW 12 Skinfold 
Taylor 2015 A tailored family-based obesity intervention: a randomized trial New Zealand 206 4–8 OW+ 24 Multiple 
Tjonna 2009 Aerobic interval training reduces cardiovascular risk factors more than a multitreatment approach in overweight adolescents Norway 54 Mean 14 OW+  
Truby 2016 A randomized controlled trial of 2 different macronutrient profiles on weight, body composition and metabolic parameters in obese adolescents seeking weight loss Australia 87 10–17 OW+ Multiple 
Vos 2011 Long-term effect of lifestyle intervention on adiposity, metabolic parameters, inflammation and physical fitness in obese children: a randomized controlled trial The Netherlands 79 8–17 SO 12 WC 
Wake 2013 Shared care obesity management in 3–10 y old children: 12 mo outcomes of HopSCOTCH randomized trial Australia 118 5–10 OW  
Walpole 2013 Motivational interviewing to enhance self-efficacy and promote weight loss in overweight and obese adolescents: a randomized controlled trial Canada 40 10–18 OW+  
Weigel 2008 Childhood obesity: concept, feasibility, and interim results of a local group-based, long-term treatment program Germany 73 7–15 OB+ 12 Fat mass 
Williams 2007 Weight control among obese adolescents: a pilot study USA 38 11–15 OB+  
Yackobovitch-Gavan 2008 Influence of weight-loss diets with different macronutrient compositions on health-related quality of life in obese youth Israel 71 12–18 OB+ Fat mass 
Crespo 2018 A randomized controlled trial to prevent obesity among Latino pediatric patients USA 291 5–10 OW+ 12 DXA % fat 
Moschonis 2019 Assessment of the effectiveness of a computerized decision-support tool for health professionals for the prevention and treatment of childhood obesity. Results from a randomized controlled trial Greece 65 6–12 OW+ 1(?)  
Koziol-Kozakowska 2019 A comparison of the impact of 2 methods of nutrition-behavioral intervention on selected auxological and biochemical parameters in obese prepubertal children- crossover preliminary study Poland 40 6–11 OB W/H % excess, WC 
Kumar 2018 Family-based mindful eating intervention in adolescents with obesity: a pilot randomized clinical trial USA 21 14–17 OB+  
Banos 2019 Efficacy of a cognitive and behavioral treatment of childhood obesity supported by the ETIOBE web platform Spain 27 Mean 10.4 OW+ 10 wee ks  
Ek 2019 A parent treatment program for preschoolers with obesity: a randomized controlled t rial Sweden 174 4–6 OB 12 WC 
Forsell 2019 Four-year outcome of randomly assigned lifestyle treatments in primary care of children with obesity Sweden 56 8–13 OB 12  
Stark 2019 Maintenance following a randomized trial of a clinic and home-based behavioral intervention of obesity in preschoolers USA 151 2–5 OB+ %95th 
Farpour-Lambert 2019 Effectiveness of individual and group programmesto treat obesity and reduce cardiovascular disease risk factors in prepubertal children Switzerland 74 7–11 SO WC, fat % 
Sepulveda 2020 Feasibility, acceptability, and effectiveness of a multidisciplinary intervention in childhood obesity from primary care: Nutrition, physical activity, emotional regulation, and family Spain 51 8–12 OW+  
Kokkvoll 2020 No additional long-term effect of group versus individual family intervention in the treatment of childhood obesity-A randomized trial Norway 91 6–12 OW+ 24  
Miguet 2019 Effect of HIIT versus MICT on body composition and energy intake in dietary restrained and unrestrained adolescents with obesity France 43 11–15 OB+  
AuthorsTitleCountryNAgesWeightLength (Months)Positive OutcomeMeasure
Anderson 2017 A novel home-based intervention for child and adolescent obesity: the results of the Whanau Pakari Randomized Controlled Trial New Zealand 138 5–16 SO 12  
Baan-Slootweg 2014 Inpatient treatment of children and adolescents with severe obesity in the Netherlands: a randomized clinical trial The Netherlands 90 8–18 SO FM 
Berkowitz 2013 Treatment of adolescent obesity comparing self-guided and group lifestyle modification programs: a potential model for primary care USA 169 12–16 OB+ 12  
Berkowitz 2011 Meal replacements in the treatment of adolescent obesity: a randomized controlled trial USA 113 13–17 OB+ 12  
Bocca 2014 Three-year follow-up of 3-y-old to 5-y-old children after participation in a multidisciplinary or a usual-care obesity treatment program The Netherlands 75 3–5 OW+ Multiple 
Bocca 2012 Results of a multidisciplinary treatment program in 3-y-old to 5-y-old overweight or obese children: a randomized controlled clinical trial The Netherlands 75 3–5 OW+ WC 
Bocca 2014 A multidisciplinary intervention program has positive effects on quality of life in overweight and obese preschool children The Netherlands 75 3–5 OW+ WC 
Butte 2017 Efficacy of a community- versus primary care-centered program for childhood obesity: TX CORD RCT USA 549 2–12 OW+ 12  
Casazza 2012 Reduced carbohydrate diet to improve metabolic outcomes and decrease adiposity in obese peripubertal African American girls USA 26 9–14 OW+  
Chen 2017 Short-term efficacy of an innovative mobile phone technology-based intervention for weight management for overweight and obese adolescents: pilot study USA 40 13–18 OW+  
Croker 2012 Family-based behavioral treatment of childhood obesity in a UK National Health Service setting: randomized controlled trial UK 72 8–12 OW+  
de Ferranti 2015 Providing food to treat adolescents at risk for cardiovascular disease USA 27 8–21 OW+  
Demol 2009 Low-carbohydrate (low and high-fat) versus high-carbohydrate low-fat diets in the treatment of obesity in adolescents Israel 55 12–18 OB+  
Diaz 2010 Lifestyle intervention in primary care settings improves obesity parameters among Mexican youth Mexico 43 9–17 OB+ 12 Multiple 
Ebbeling 2003 A reduced-glycemic load diet in the treatment of adolescent obesity USA 14 13–21 OB+ 12 FM 
Fleischman 2016 Creating an integrated care model for childhood obesity: a randomized pilot study utilizing telehealth in a community primary care setting USA 40 10–17 OB+  
Flodmark 1993 Prevention of progression to severe obesity in a group of obese schoolchildren treated with family therapy Sweden 93 10–11 OW+ 18 Skinfold 
Ford 2009 Treatment of childhood obesity by retraining eating behavior: randomized controlled trial UK 106 9–18 OB+ 12 BF% 
Garnett 2014 Improved insulin sensitivity and body composition, irrespective of macronutrient intake, after a 12 mo intervention in adolescents with prediabetes; RESIST a randomized control trial Australia 111 10–17 OW+ 12  
Garnett 2013 Optimal macronutrient content of the diet for adolescents with prediabetes; RESIST a randomized control trial Australia 111 10–17 OW+ 12 waist to height 
Grieken 2013 Population-based childhood overweight prevention: outcomes of the 'Be Active, Eat Right' Study The Netherlands 637 OW 24  
Hills 1998 Obesity management via diet and exercise intervention Australia 20 NR OB+ Skinfold 
Hoffman 2018 An integrated clinic-community partnership for child obesity treatment: a randomized Pilot Trial USA 97 5–11 OB+ WC 
Hofsteenge 2014 Long-term effect of the Go4it group treatment of obese adolescents: a randomized controlled trial The Netherlands 122 11–18 OW+  
Hughes 2008 Randomized, controlled trial of a best-practice individualized behavioral program for treatment of childhood overweight: Scottish Childhood Overweight Treatment Trial (SCOTT) UK 134 5–11 OB+  
Hystad 2013 A randomized study on the effectiveness of therapist-led v. self-help parental intervention for treating childhood obesity Norway 83 7–12 OB+ 24  
Kalavainen 2007 Clinical efficacy of group-based treatment of childhood obesity compared with routinely given individual counseling Finland 70 7–9 OB+ Weight for height 
Kalavainen 2011 Long-term efficacy of group-based treatment of childhood obesity compared with routinely given individual counseling Finland 70 7–9 OB+ Weigh for height 
Kokkvoll 2014 Single versus multiple-family intervention in childhood overweight–Finnmark Activity School: a randomized trial Norway 91 6–12 OB+ 12 Multiple 
Kokkvoll 2015 Health in overweight children: 2-y follow-up of Finnmark Activity School–a randomized trial Norway 91 6–12 OB+ 24 Multiple 
Kong 2013 School-based health center intervention improves BMI in overweight and obese adolescents USA 51 14–17 OW+ 12 WC 
Krebs 2010 Efficacy and safety of a high protein, low carbohydrate diet for wt loss in severely obese adolescents USA 46 Mean 14 OB+  
Larsen 2015 Early intervention for childhood overweight: a randomized trial in general practice Denmark 80 5–9 OW+ 24 WHtR 
Lison 2012 Exercise intervention in childhood obesity: a randomized controlled trial comparing hospital-versus home-based groups Spain 110 6–16 OW+ BF% 
Makkes 2016 One-year effects of 2 intensive inpatient treatments for severely obese children and adolescents The Netherlands 80 8–19 SO 12  
Naar-King 2009 A randomized pilot study of multisystemic therapy targeting obesity in African-American adolescents USA 49 12–17 OB+  
Nemet 2005 Short- and long-term beneficial effects of a combined dietary-behavioral-physical activity intervention for the treatment of childhood obesity Israel 46 6–16 OB+ BF% 
Nemet 2013 Effects of a multidisciplinary childhood obesity treatment intervention on adipocytokines, inflammatory and growth mediators Israel 41 6–13 OB+ WC 
Norman 2016 Outcomes of a 1-y randomized controlled trial to evaluate a behavioral 'stepped-down' weight loss intervention for adolescent patients with obesity USA 106 11–13 OB+ 12  
Novotny 2015 Pacific kids DASH for health (PacDASH) randomized, controlled trial with DASH eating plan plus physical activity improves fruit and vegetable intake and diastolic blood pressure in children USA 85 5–8 HW/OW  
Parra-Medina 2015 Promoting weight maintenance among overweight and obese Hispanic children in a rural practice USA 118 5–14 OB+ 4.5 WC 
Partsalaki 2012 Metabolic impact of a ketogenic diet compared with a hypocaloric diet in obese children and adolescents Greece 58 8–18 OB+  
Pedrosa 2011 Markers of metabolic syndrome in obese children before and after 1-y lifestyle intervention program Portugal 61 Mean 8 OW+ 12 WC to height 
Rolland-Cachera 2004 Massive obesity in adolescents: dietary interventions and behaviors associated with weight regain at 2 y follow-up France 121 11–16 SO  
Savoye 2011 Long-term results of an obesity program in an ethnically diverse pediatric population USA 174 8–16 OB+ 12 BF% 
Savoye 2007 Effects of a weight management program on body composition and metabolic parameters in overweight children: a randomized controlled trial USA 174 8–16 OB+ 12 BF% 
Serra-Paya 2015 Effectiveness of a multicomponent intervention for overweight and obese children (nereu program): a randomized controlled trial Spain 113 6–12 OW+  
Small 2014 The preliminary effects of a primary care-based randomized treatment trial with overweight and obese young children and their parents USA 60 4–8 OW+ WC 
Stettler 2015 Prevention of excess weight gain in pediatric primary care: beverages only or multiple lifestyle factors. The Smart Step Study, a cluster-randomized clinical trial USA 172 8–12 OW 12 Skinfold 
Taylor 2015 A tailored family-based obesity intervention: a randomized trial New Zealand 206 4–8 OW+ 24 Multiple 
Tjonna 2009 Aerobic interval training reduces cardiovascular risk factors more than a multitreatment approach in overweight adolescents Norway 54 Mean 14 OW+  
Truby 2016 A randomized controlled trial of 2 different macronutrient profiles on weight, body composition and metabolic parameters in obese adolescents seeking weight loss Australia 87 10–17 OW+ Multiple 
Vos 2011 Long-term effect of lifestyle intervention on adiposity, metabolic parameters, inflammation and physical fitness in obese children: a randomized controlled trial The Netherlands 79 8–17 SO 12 WC 
Wake 2013 Shared care obesity management in 3–10 y old children: 12 mo outcomes of HopSCOTCH randomized trial Australia 118 5–10 OW  
Walpole 2013 Motivational interviewing to enhance self-efficacy and promote weight loss in overweight and obese adolescents: a randomized controlled trial Canada 40 10–18 OW+  
Weigel 2008 Childhood obesity: concept, feasibility, and interim results of a local group-based, long-term treatment program Germany 73 7–15 OB+ 12 Fat mass 
Williams 2007 Weight control among obese adolescents: a pilot study USA 38 11–15 OB+  
Yackobovitch-Gavan 2008 Influence of weight-loss diets with different macronutrient compositions on health-related quality of life in obese youth Israel 71 12–18 OB+ Fat mass 
Crespo 2018 A randomized controlled trial to prevent obesity among Latino pediatric patients USA 291 5–10 OW+ 12 DXA % fat 
Moschonis 2019 Assessment of the effectiveness of a computerized decision-support tool for health professionals for the prevention and treatment of childhood obesity. Results from a randomized controlled trial Greece 65 6–12 OW+ 1(?)  
Koziol-Kozakowska 2019 A comparison of the impact of 2 methods of nutrition-behavioral intervention on selected auxological and biochemical parameters in obese prepubertal children- crossover preliminary study Poland 40 6–11 OB W/H % excess, WC 
Kumar 2018 Family-based mindful eating intervention in adolescents with obesity: a pilot randomized clinical trial USA 21 14–17 OB+  
Banos 2019 Efficacy of a cognitive and behavioral treatment of childhood obesity supported by the ETIOBE web platform Spain 27 Mean 10.4 OW+ 10 wee ks  
Ek 2019 A parent treatment program for preschoolers with obesity: a randomized controlled t rial Sweden 174 4–6 OB 12 WC 
Forsell 2019 Four-year outcome of randomly assigned lifestyle treatments in primary care of children with obesity Sweden 56 8–13 OB 12  
Stark 2019 Maintenance following a randomized trial of a clinic and home-based behavioral intervention of obesity in preschoolers USA 151 2–5 OB+ %95th 
Farpour-Lambert 2019 Effectiveness of individual and group programmesto treat obesity and reduce cardiovascular disease risk factors in prepubertal children Switzerland 74 7–11 SO WC, fat % 
Sepulveda 2020 Feasibility, acceptability, and effectiveness of a multidisciplinary intervention in childhood obesity from primary care: Nutrition, physical activity, emotional regulation, and family Spain 51 8–12 OW+  
Kokkvoll 2020 No additional long-term effect of group versus individual family intervention in the treatment of childhood obesity-A randomized trial Norway 91 6–12 OW+ 24  
Miguet 2019 Effect of HIIT versus MICT on body composition and energy intake in dietary restrained and unrestrained adolescents with obesity France 43 11–15 OB+  

HW, healthy weight; HIIT, high intensity interval training; MICT, moderate intensity continuous training; OB, obese; OW, overweigh; SO, severe obesity.

Behaviors

Almost half (48%) of included studies reported on changes in obesity-related behaviors, primarily changes in diet or physical activity, virtually all self- or parent-reported.810,1214,1721,23,29, 3138,4145,48,49,51,52,56,57,60,61,63,64, 67,69,7577,85,87,90,93,94,99,103,104,106,107, 113,117,120124,129,130,132  Of these, half (31 of 61) reported significant improvements attributable to the intervention. These interventions are listed in Table 8. Three trials observed significant improvements in multiple behaviors, including both physical activity and diet. Twenty trials observed significant improvements in diet, including reduced caloric intake, fast food consumption, desserts, sugary beverages, sweets, and glycemic load, and improved intake of fiber, family meals, vegetables, and fruit. Finally, 10 trials observed improvements in physical activity, including increased moderate-to-vigorous physical activity and reduced television viewing.

TABLE 8

Trials Reporting Behavior Outcomes

AuthorsTitleCountryNAgesWeightLength (months)Positive OutcomeMeasure
Behaviors
Anderson 2017 A novel home-based intervention for child and adolescent obesity: the results of the Whanau Pakari randomized controlled trial New Zealand 138 5–16 SO 12  
Arauz 2013 Latino families, primary care, and childhood obesity: a randomized controlled trial USA 26 9–12 OW+  
Armstrong 2018 Texting motivational interviewing: a randomized controlled trial of motivational interviewing text messages designed to augment childhood obesity treatment USA 101 5–12 OB+  
Bocca 2014 Three-year follow-up of 3-y-old to 5-y-old children after participation in a multidisciplinary or a usual-care obesity treatment program The Netherlands 75 3–5 OW+  
Bocca 2012 Results of a multidisciplinary treatment program in 3-y-old to 5-y-old overweight or obese children: a randomized controlled clinical trial The Netherlands 75 3–5 OW+ Fiber intake 
Boutelle 2013 Guided self-help for the treatment of pediatric obesity USA 50 8–12 OW+  
Broccoli 2016 Motivational interviewing to treat overweight children: 24-month follow-up of a randomized controlled trial Italy 372 4–7 OW 12 Multiple 
Chen 2017 Short-term efficacy of an innovative mobile phone technology-based intervention for weigh management for overweight and obese adolescents: pilot study USA 40 13–18 OW+  
Crabtree 2010 A transtheoretical, case management approach to the treatment of pediatric obesity USA 19 8–12 OB+  
Davis 2011 The use of TeleMedicine in the treatment of pediatric obesity: feasibility and acceptability USA 17 10 OW+  
Davis 2016 Treating rural pediatric obesity through telemedicine versus telephone: outcomes from a cluster randomized controlled trial USA 103 Mean 9 OW+  
Davis 2013 Treating rural pediatric obesity through telemedicine: outcomes from a small randomized controlled trial USA 58 Mean 9 OW+  
Davoli 2013 Pediatrician-led motivational interviewing to treat overweight children: an RCT Italy 372 4–7 OW 12 Multiple 
de Ferranti 2015 Providing food to treat adolescents at risk for cardiovascular disease USA 27 8–21 OW+ diet 
DeBar 2012 A primary care-based, multicomponent lifestyle intervention for overweight adolescent females USA 208 12–17 OB+ Family meals, fast food 
Deforche 2005 Posttreatment phone contact: a weight maintenance strategy in obese youngsters Belgium 20 11–18 OB+ PA 
Fleischman 2016 Creating an integrated care model for childhood obesity: a randomized pilot study utilizing telehealth in a community primary care setting USA 40 10–17 OB+ GL 
Ford 2009 Treatment of childhood obesity by retraining eating behavior: randomized controlled trial UK 106 9–18 OB+ 12  
Garipağaoğlu 2009 Family-based group treatment versus individual treatment in the management of childhood obesity: randomized, prospective clinical trial Turkey 80 6–14 OB+  
Gourlan 2013 Motivational interviewing as a way to promote physical activity in obese adolescents: a randomized-controlled trial using self-determination theory as an explanatory framework France 62 11–18 OB+ PA 
Hughes 2008 Randomized, controlled trial of a best-practice individualized behavioral program for treatment of childhood overweight: Scottish Childhood Overweight Treatment Trial (SCOTT) UK 134 5–11 OB+ PA 
Hystad 2013 A randomized study on the effectiveness of therapist-led v. self-help parental intervention for treating childhood obesity Norway 83 7–12 OB+ 24  
Kong 2013 School-based health center intervention improves BMI in overweight and obese adolescents USA 51 14–17 OW+ 12 TV 
Krebs 2010 Efficacy and safety of a high protein, low carbohydrate diet for weight loss in severely obese adolescents USA 46 Mean 14 OB+ Diet 
Looney 2014 Examining the effect of 3 low-intensity pediatric obesity interventions: a pilot randomized controlled trial USA 22 4–10 OW+  
Macdonell 2012 A pilot study of motivational interviewing targeting wt-related behaviors in overweight or obese African American adolescents USA 44 13–17 OW+ Fast food 
Martinez-Andrade 2014 Feasibility and impact of Creciendo Sanos, a clinic-based pilot intervention to prevent obesity among preschool children in Mexico City Mexico 306 2–5 OW+ 1.5 Vegetables 
McCallum 2007 Outcome data from the LEAP (Live, Eat and Play) trial: a randomized controlled trial of a primary care intervention for childhood overweight or mild obesity Australia 163 Mean 7 OW Diet 
Mirza 2013 Effects of a low glycemic load or a low-fat dietary intervention on body weight in obese Hispanic American children and adolescents: a randomized controlled trial USA 113 7–15 OB+ GI 
Nemet 2005 Short- and long-term beneficial effects of a combined dietary-behavioral-physical activity intervention for the treatment of childhood obesity Israel 46 6–16 OB+ PA 
Nemet 2013 Effects of a multidisciplinary childhood obesity treatment intervention on adipocytokines, inflammatory and growth mediators Israel 41 6–13 OB+ PA 
Nova 2001 Long-term management of obesity in pediatric office practice: experimental evaluation of 2 different types of intervention Italy 186 3–12 OB+ 24  
Novotny 2015 Pacific kids DASH for health (PacDASH) randomized, controlled trial with DASH eating plan plus physical activity improves fruit and vegetable intake and diastolic blood pressure in children USA 85 5–8 HW/OW F and V 
O'Connor 2013 Feasibility of an obesity intervention for pediatric primary care targeting parenting and children: helping HAND USA 40 5–8 OW/OB TV 
Pedrosa 2011 Markers of metabolic syndrome in obese children before and after 1-y lifestyle intervention program Portugal 61 Mean 8 OW+ 12  
Rifas-Shiman 2017 T wo-year follow-up of a primary care-based intervention to prevent and manage childhood obesity: the High Five for Kids study USA 445 2–5 OW+ 12  
Rolland-Cachera 2004 Massive obesity in adolescents: dietary interventions and behaviors associated with weight regain at 2 y follow-up France 121 11–16 SO  
Saelens 2002 Behavioral weight control for overweight adolescents initiated in primary care USA 44 12–16 OW+  
Serra-Paya 2015 Effectiveness of a multicomponent intervention for overweight and obese children (nereu program): a randomized controlled trial Spain 113 6–12 OW+ Multiple 
Shelton 2007 Randomized controlled trial: a parent-based group education program for overweight children Australia 43 3–10 OW+ Kcal 
Sherwood 2015 Pediatric primary care-based obesity prevention for parents of preschool children: a pilot study USA 60 Mean 3 OW+ MVPA 
Stark 2014 A pilot randomized controlled trial of a behavioral family-based intervention with and without home visits to decrease obesity in preschoolers USA 33 2–5 OB Diet 
Stark 2011 A pilot randomized controlled trial of a clinic and home-based behavioral intervention to decrease obesity in preschoolers USA 18 2–5 OB Diet 
Stovitz 2014 Stage 1 treatment of pediatric overweight and obesity: a pilot and feasibility randomized controlled trial USA 71 4–9 OW+  
Taveras 2011 Randomized controlled trial to improve primary care to prevent and manage childhood obesity: the High Five for Kids study USA 445 2–6 OW+ 12 TV 
Taylor 2015 A tailored family-based obesity intervention: a randomized trial New Zealand 206 4–8 OW+ 24 Multiple 
Truby 2016 A randomized controlled trial of 2 different macronutrient profiles on weight, body composition and metabolic parameters in obese adolescents seeking weight loss Australia 87 10–17 OW+ Diet 
Wake 2009 Outcomes and costs of primary care surveillance and intervention for overweight or obese children: the LEAP 2 randomized controlled trial Australia 258 5–10 OW  
Wake 2013 Shared care obesity management in 3–10 y old children: 12 mo outcomes of HopSCOTCH randomized trial Australia 118 5–10 OW  
Warschburger 2016 Empowering Parents of Obese Children (EPOC): a randomized controlled trial on additional long-term weight effects of parent training Germany 523 7–12 SO  
Williams 2007 Weight control among obese adolescents: a pilot study USA 38 11–15 OB+  
Wright 2013 Randomized trial of a family-based, automated, conversational obesity treatment program for underserved populations USA 50 9–12 OB+  
Yackobovitch-Gavan 2018 Intervention for childhood obesity based on parents only or parents and child compared with follow-up alone Israel 247 5–11 OW/OB  
Moschonis 2019 Assessment of the effectiveness of a computerised decision-support tool for health professionals for the prevention and treatment of childhood obesity. Results from a randomized controlled trial Greece 65 6–12 OW+ 1(?) A few specific dietary behaviors 
Sherwood 2019 The Healthy Homes/Healthy Kids 5-10 Obesity Prevention Trial: 12 and 24-mo outcomes USA 421 5–10 OW 12 Energy intake 
Bean 2018 Impact of motivational interviewing on outcomes of an adolescent obesity treatment: results from the MI Values randomized controlled pilot trial USA 99 11–18 OW+ 10 weeks  
Banos 2019 Efficacy of a cognitive and behavioral treatment of childhood obesity supported by the ETIOBE web platform Spain 27 Mean 10.4 OW+ 10 weeks PA self-efficacy 
Stark 2019 Maintenance following a randomized trial of a clinic and home-based behavioral intervention of obesity in preschoolers USA 151 2–5 OB+ Caloric intake 
Sepulveda 2020 Feasibility, acceptability, and effectiveness of a multidisciplinary intervention in childhood obesity from primary care: Nutrition, physical activity, emotional regulation, and family Spain 51 8–12 OW+  
Miguet 2019 Effect of HIIT versus MICT on body composition and energy intake in dietary restrained and unrestrained adolescents with obesity France 43 11–15 OB+  
Warschburger 2018 Evaluation of an approach-avoidance training intervention for children and adolescents with obesity: a randomized placebo-controlled prospective trial Germany 232 8–16 SO 6 weeks Eating behavior 
AuthorsTitleCountryNAgesWeightLength (months)Positive OutcomeMeasure
Behaviors
Anderson 2017 A novel home-based intervention for child and adolescent obesity: the results of the Whanau Pakari randomized controlled trial New Zealand 138 5–16 SO 12  
Arauz 2013 Latino families, primary care, and childhood obesity: a randomized controlled trial USA 26 9–12 OW+  
Armstrong 2018 Texting motivational interviewing: a randomized controlled trial of motivational interviewing text messages designed to augment childhood obesity treatment USA 101 5–12 OB+  
Bocca 2014 Three-year follow-up of 3-y-old to 5-y-old children after participation in a multidisciplinary or a usual-care obesity treatment program The Netherlands 75 3–5 OW+  
Bocca 2012 Results of a multidisciplinary treatment program in 3-y-old to 5-y-old overweight or obese children: a randomized controlled clinical trial The Netherlands 75 3–5 OW+ Fiber intake 
Boutelle 2013 Guided self-help for the treatment of pediatric obesity USA 50 8–12 OW+  
Broccoli 2016 Motivational interviewing to treat overweight children: 24-month follow-up of a randomized controlled trial Italy 372 4–7 OW 12 Multiple 
Chen 2017 Short-term efficacy of an innovative mobile phone technology-based intervention for weigh management for overweight and obese adolescents: pilot study USA 40 13–18 OW+  
Crabtree 2010 A transtheoretical, case management approach to the treatment of pediatric obesity USA 19 8–12 OB+  
Davis 2011 The use of TeleMedicine in the treatment of pediatric obesity: feasibility and acceptability USA 17 10 OW+  
Davis 2016 Treating rural pediatric obesity through telemedicine versus telephone: outcomes from a cluster randomized controlled trial USA 103 Mean 9 OW+  
Davis 2013 Treating rural pediatric obesity through telemedicine: outcomes from a small randomized controlled trial USA 58 Mean 9 OW+  
Davoli 2013 Pediatrician-led motivational interviewing to treat overweight children: an RCT Italy 372 4–7 OW 12 Multiple 
de Ferranti 2015 Providing food to treat adolescents at risk for cardiovascular disease USA 27 8–21 OW+ diet 
DeBar 2012 A primary care-based, multicomponent lifestyle intervention for overweight adolescent females USA 208 12–17 OB+ Family meals, fast food 
Deforche 2005 Posttreatment phone contact: a weight maintenance strategy in obese youngsters Belgium 20 11–18 OB+ PA 
Fleischman 2016 Creating an integrated care model for childhood obesity: a randomized pilot study utilizing telehealth in a community primary care setting USA 40 10–17 OB+ GL 
Ford 2009 Treatment of childhood obesity by retraining eating behavior: randomized controlled trial UK 106 9–18 OB+ 12  
Garipağaoğlu 2009 Family-based group treatment versus individual treatment in the management of childhood obesity: randomized, prospective clinical trial Turkey 80 6–14 OB+  
Gourlan 2013 Motivational interviewing as a way to promote physical activity in obese adolescents: a randomized-controlled trial using self-determination theory as an explanatory framework France 62 11–18 OB+ PA 
Hughes 2008 Randomized, controlled trial of a best-practice individualized behavioral program for treatment of childhood overweight: Scottish Childhood Overweight Treatment Trial (SCOTT) UK 134 5–11 OB+ PA 
Hystad 2013 A randomized study on the effectiveness of therapist-led v. self-help parental intervention for treating childhood obesity Norway 83 7–12 OB+ 24  
Kong 2013 School-based health center intervention improves BMI in overweight and obese adolescents USA 51 14–17 OW+ 12 TV 
Krebs 2010 Efficacy and safety of a high protein, low carbohydrate diet for weight loss in severely obese adolescents USA 46 Mean 14 OB+ Diet 
Looney 2014 Examining the effect of 3 low-intensity pediatric obesity interventions: a pilot randomized controlled trial USA 22 4–10 OW+  
Macdonell 2012 A pilot study of motivational interviewing targeting wt-related behaviors in overweight or obese African American adolescents USA 44 13–17 OW+ Fast food 
Martinez-Andrade 2014 Feasibility and impact of Creciendo Sanos, a clinic-based pilot intervention to prevent obesity among preschool children in Mexico City Mexico 306 2–5 OW+ 1.5 Vegetables 
McCallum 2007 Outcome data from the LEAP (Live, Eat and Play) trial: a randomized controlled trial of a primary care intervention for childhood overweight or mild obesity Australia 163 Mean 7 OW Diet 
Mirza 2013 Effects of a low glycemic load or a low-fat dietary intervention on body weight in obese Hispanic American children and adolescents: a randomized controlled trial USA 113 7–15 OB+ GI 
Nemet 2005 Short- and long-term beneficial effects of a combined dietary-behavioral-physical activity intervention for the treatment of childhood obesity Israel 46 6–16 OB+ PA 
Nemet 2013 Effects of a multidisciplinary childhood obesity treatment intervention on adipocytokines, inflammatory and growth mediators Israel 41 6–13 OB+ PA 
Nova 2001 Long-term management of obesity in pediatric office practice: experimental evaluation of 2 different types of intervention Italy 186 3–12 OB+ 24  
Novotny 2015 Pacific kids DASH for health (PacDASH) randomized, controlled trial with DASH eating plan plus physical activity improves fruit and vegetable intake and diastolic blood pressure in children USA 85 5–8 HW/OW F and V 
O'Connor 2013 Feasibility of an obesity intervention for pediatric primary care targeting parenting and children: helping HAND USA 40 5–8 OW/OB TV 
Pedrosa 2011 Markers of metabolic syndrome in obese children before and after 1-y lifestyle intervention program Portugal 61 Mean 8 OW+ 12  
Rifas-Shiman 2017 T wo-year follow-up of a primary care-based intervention to prevent and manage childhood obesity: the High Five for Kids study USA 445 2–5 OW+ 12  
Rolland-Cachera 2004 Massive obesity in adolescents: dietary interventions and behaviors associated with weight regain at 2 y follow-up France 121 11–16 SO  
Saelens 2002 Behavioral weight control for overweight adolescents initiated in primary care USA 44 12–16 OW+  
Serra-Paya 2015 Effectiveness of a multicomponent intervention for overweight and obese children (nereu program): a randomized controlled trial Spain 113 6–12 OW+ Multiple 
Shelton 2007 Randomized controlled trial: a parent-based group education program for overweight children Australia 43 3–10 OW+ Kcal 
Sherwood 2015 Pediatric primary care-based obesity prevention for parents of preschool children: a pilot study USA 60 Mean 3 OW+ MVPA 
Stark 2014 A pilot randomized controlled trial of a behavioral family-based intervention with and without home visits to decrease obesity in preschoolers USA 33 2–5 OB Diet 
Stark 2011 A pilot randomized controlled trial of a clinic and home-based behavioral intervention to decrease obesity in preschoolers USA 18 2–5 OB Diet 
Stovitz 2014 Stage 1 treatment of pediatric overweight and obesity: a pilot and feasibility randomized controlled trial USA 71 4–9 OW+  
Taveras 2011 Randomized controlled trial to improve primary care to prevent and manage childhood obesity: the High Five for Kids study USA 445 2–6 OW+ 12 TV 
Taylor 2015 A tailored family-based obesity intervention: a randomized trial New Zealand 206 4–8 OW+ 24 Multiple 
Truby 2016 A randomized controlled trial of 2 different macronutrient profiles on weight, body composition and metabolic parameters in obese adolescents seeking weight loss Australia 87 10–17 OW+ Diet 
Wake 2009 Outcomes and costs of primary care surveillance and intervention for overweight or obese children: the LEAP 2 randomized controlled trial Australia 258 5–10 OW  
Wake 2013 Shared care obesity management in 3–10 y old children: 12 mo outcomes of HopSCOTCH randomized trial Australia 118 5–10 OW  
Warschburger 2016 Empowering Parents of Obese Children (EPOC): a randomized controlled trial on additional long-term weight effects of parent training Germany 523 7–12 SO  
Williams 2007 Weight control among obese adolescents: a pilot study USA 38 11–15 OB+  
Wright 2013 Randomized trial of a family-based, automated, conversational obesity treatment program for underserved populations USA 50 9–12 OB+  
Yackobovitch-Gavan 2018 Intervention for childhood obesity based on parents only or parents and child compared with follow-up alone Israel 247 5–11 OW/OB  
Moschonis 2019 Assessment of the effectiveness of a computerised decision-support tool for health professionals for the prevention and treatment of childhood obesity. Results from a randomized controlled trial Greece 65 6–12 OW+ 1(?) A few specific dietary behaviors 
Sherwood 2019 The Healthy Homes/Healthy Kids 5-10 Obesity Prevention Trial: 12 and 24-mo outcomes USA 421 5–10 OW 12 Energy intake 
Bean 2018 Impact of motivational interviewing on outcomes of an adolescent obesity treatment: results from the MI Values randomized controlled pilot trial USA 99 11–18 OW+ 10 weeks  
Banos 2019 Efficacy of a cognitive and behavioral treatment of childhood obesity supported by the ETIOBE web platform Spain 27 Mean 10.4 OW+ 10 weeks PA self-efficacy 
Stark 2019 Maintenance following a randomized trial of a clinic and home-based behavioral intervention of obesity in preschoolers USA 151 2–5 OB+ Caloric intake 
Sepulveda 2020 Feasibility, acceptability, and effectiveness of a multidisciplinary intervention in childhood obesity from primary care: Nutrition, physical activity, emotional regulation, and family Spain 51 8–12 OW+  
Miguet 2019 Effect of HIIT versus MICT on body composition and energy intake in dietary restrained and unrestrained adolescents with obesity France 43 11–15 OB+  
Warschburger 2018 Evaluation of an approach-avoidance training intervention for children and adolescents with obesity: a randomized placebo-controlled prospective trial Germany 232 8–16 SO 6 weeks Eating behavior 

F, fruits; GI, glycemic index; GL, glycemic load; MVPA, moderate to vigorous physical activity; OB, obese; OW, overweight;  PA, physical activity; SO, severe obesity.

Nearly all of the 31 interventions that noted significant changes in health-related behaviors were led by a primary care provider, and about half of these involved a nutrition provider (13 of 31 trials). Nine of the interventions that changed health behaviors involved other health professionals, including 5 interventions that involved a mental health specialist and 2 interventions that involved an exercise specialist. About half of the interventions that reported significant improvements in dietary intake involved a nutrition provider, and the rest of the interventions that improved eating behaviors were led by a primary care provider. In general, all behaviors were more amenable to change in the preschool-aged children (6 of 9 trials resulted in improved behaviors), with more inconsistency during middle childhood and adolescence (25 of 52 trials resulted in improved behaviors). There were no observable patterns in length of treatment as a determinant of effectively changing behaviors (ie, 16 of 29 interventions ≥6 months in duration noted behavior change vs 14 of 31 interventions <6 months in duration). Additionally, specific behavior changes did not consistently predict studies showing improvements in BMI outcomes.

Glucose Metabolism

Twenty-seven percent of the included studies reported on some form of glucose metabolism, including fasting glucose, insulin, or homeostatic model assessment for insulin resistance.8,20,26,29,35,52, 55,61,63,65,71,74,77,7981,83,85, 88,89,92,97100,105,107,110113,118,119,127  Of these, 10 of 34 studies (29%) observed significant improvements, including 6 of 30 reporting a significant reduction in fasting glucose, insulin, or homeostatic model assessment for insulin resistance attributable to the intervention and 4 additional studies showing significant improvements in multiple measures. These interventions are listed in Table 9. Forty percent (4 of 10) of the trials that reported a significant improvement in glucose or insulin metabolism were specific dietary interventions, 5 trials were intensive lifestyle modification studies, and 1 study occurred in the inpatient setting. Most studies including glucose metabolism as an outcome focused on older children and adolescents. Those focusing on younger children did not typically demonstrate significant improvements in glucose metabolism.

TABLE 9

Trials Reporting Glucose Metabolism Outcomes

AuthorsTitleCountryNAgesWeightLength (months)Positive OutcomeMeasure
Glucose
Anderson 2017 A novel home-based intervention for child and adolescent obesity: the results of the Whanau Pakari randomized controlled trial New Zealand 138 5–16 SO 12  
Arauz 2013 Latino families, primary care, and childhood obesity: a randomized controlled trial USA 26 9–12 OW+  
Baan-Slootweg 2014 Inpatient treatment of children and adolescents with severe obesity in the Netherlands: a randomized clinical trial The Netherlands 90 8–18 SO Insulin 
Berkowitz 2011 Meal replacements in the treatment of adolescent obesity: a randomized controlled trial USA 113 13–17 OB+ 12  
Casazza 2012 Reduced carbohydrate diet to improve metabolic outcomes and decrease adiposity in obese peripubertal African American girls USA 26 9–14 OW+  
de Ferranti 2015 Providing food to treat adolescents at risk for cardiovascular disease USA 27 8–21 OW+ FPG 
DeBar 2012 A primary care-based, multicomponent lifestyle intervention for overweight adolescent females USA 208 12–17 OB+  
Demol 2009 Low-carbohydrate (low and high-fat) versus high-carbohydrate low-fat diets in the treatment of obesity in adolescents Israel 55 12–18 OB+  
Diaz 2010 Lifestyle intervention in primary care settings improves obesity parameters among Mexican youth Mexico 43 9–17 OB+ 12  
Ebbeling 2003 A reduced-glycemic load diet in the treatment of adolescent obesity USA 14 13–21 OB+ 12 HOMA 
Ford 2009 Treatment of childhood obesity by retraining eating behavior: randomized controlled trial UK 106 9–18 OB+ 12  
Garnett 2014 Improved insulin sensitivity and body composition, irrespective of macronutrient intake, after a 12 mo intervention in adolescents with prediabetes; RESIST a randomized control trial Australia 111 10–17 OW+ 12  
Garnett 2013 Optimal macronutrient content of the diet for adolescents with prediabetes; RESIST a randomized control trial Australia 111 10–17 OW+ 12 Multiple 
Hoffman 2018 An integrated clinic-community partnership for child obesity treatment: a randomized pilot trial USA 97 5–11 OB+  
Hofsteenge 2014 Long-term effect of the Go4it group treatment of obese adolescents: a randomized controlled trial The Netherlands 122 11–18 OW+  
Kong 2013 School-based health center intervention improves BMI in overweight and obese adolescents USA 51 14–17 OW+ 12 *Glucose worse 
Krebs 2013 Efficacy and safety of a high protein, low carbohydrate diet for weight loss in severely obese adolescents USA 46 Mean 14 OB+  
Makkes 2016 One-year effects of 2 intensive inpatient treatments for severely obese children and adolescents The Netherlands 80 8–19 SO 12  
Mirza 2013 Effects of a low glycemic load or a low-fat dietary intervention on body weight in obese Hispanic American children and adolescents: a randomized controlled trial USA 113 7–15 OB+  
Nemet 2013 Effects of a multidisciplinary childhood obesity treatment intervention on adipocytokines, inflammatory and growth mediators Israel 41 6–13 OB+ HOMA 
Norman 2016 Outcomes of a 1-y randomized controlled trial to evaluate a behavioral “stepped-down” weight loss intervention for adolescent patients with obesity USA 106 11–13 OB+ 12  
Parillo 2012 Metabolic changes after a hypocaloric, low-glycemic-index diet in obese children Italy 22 Mean 10 OB+  
Partsalaki 2012 Metabolic impact of a ketogenic diet compared with a hypocaloric diet in obese children and adolescents Greece 58 8–18 OB+  
Pedrosa 2011 Markers of metabolic syndrome in obese children before and after 1-y lifestyle intervention program Portugal 61 Mean 8 OW+ 12  
Savoye 2011 Long-term results of an obesity program in an ethnically diverse pediatric population USA 174 8–16 OB+ 12 Multiple 
Savoye 2007 Effects of a weight management program on body composition and metabolic parameters in overweight children: a randomized controlled trial USA 174 8–16 OB+ 12 Multiple 
Tjonna 2009 Aerobic interval training reduces cardiovascular risk factors more than a multitreatment approach in overweight adolescents Norway 54 Mean 14 OW+  
Truby 2006 A randomized controlled trial of 2 different macronutrient profiles on weight, body composition and metabolic parameters in obese adolescents seeking weight loss Australia 87 10–17 OW+ HOMA 
Vos 2011 Long-term effect of lifestyle intervention on adiposity, metabolic parameters, inflammation and physical fitness in obese children: a randomized controlled trial The Netherlands 79 8–17 SO 12 Multiple 
Yackobovitch-Gavan 2018 Intervention for childhood obesity based on parents only or parents and child compared with follow-up alone Israel 247 5–11 OW/OB  
Koziol-Kozakowska 2019 A comparison of the impact of 2 methods of nutrition-behavioral intervention on selected auxological and biochemical parameters in obese prepubertal children- crossover preliminary study Poland 40 6–11 OB  
Kumar 2018 Family-based mindful eating intervention in adolescents with obesity: a pilot randomized clinical trial USA 21 14–17 OB+  
Farpour-Lambert 2019 Effectiveness of individual and group programmes to treat obesity and reduce cardiovascular disease risk factors in prepubertal children Switzerland 74 7–11 SO  
Kokkvoll 2020 No additional long-term effect of group versus individual family intervention in the treatment of childhood obesity-A randomized trial Norway 91 6–12 OW+ 24 Insulin 
AuthorsTitleCountryNAgesWeightLength (months)Positive OutcomeMeasure
Glucose
Anderson 2017 A novel home-based intervention for child and adolescent obesity: the results of the Whanau Pakari randomized controlled trial New Zealand 138 5–16 SO 12  
Arauz 2013 Latino families, primary care, and childhood obesity: a randomized controlled trial USA 26 9–12 OW+  
Baan-Slootweg 2014 Inpatient treatment of children and adolescents with severe obesity in the Netherlands: a randomized clinical trial The Netherlands 90 8–18 SO Insulin 
Berkowitz 2011 Meal replacements in the treatment of adolescent obesity: a randomized controlled trial USA 113 13–17 OB+ 12  
Casazza 2012 Reduced carbohydrate diet to improve metabolic outcomes and decrease adiposity in obese peripubertal African American girls USA 26 9–14 OW+  
de Ferranti 2015 Providing food to treat adolescents at risk for cardiovascular disease USA 27 8–21 OW+ FPG 
DeBar 2012 A primary care-based, multicomponent lifestyle intervention for overweight adolescent females USA 208 12–17 OB+  
Demol 2009 Low-carbohydrate (low and high-fat) versus high-carbohydrate low-fat diets in the treatment of obesity in adolescents Israel 55 12–18 OB+  
Diaz 2010 Lifestyle intervention in primary care settings improves obesity parameters among Mexican youth Mexico 43 9–17 OB+ 12  
Ebbeling 2003 A reduced-glycemic load diet in the treatment of adolescent obesity USA 14 13–21 OB+ 12 HOMA 
Ford 2009 Treatment of childhood obesity by retraining eating behavior: randomized controlled trial UK 106 9–18 OB+ 12  
Garnett 2014 Improved insulin sensitivity and body composition, irrespective of macronutrient intake, after a 12 mo intervention in adolescents with prediabetes; RESIST a randomized control trial Australia 111 10–17 OW+ 12  
Garnett 2013 Optimal macronutrient content of the diet for adolescents with prediabetes; RESIST a randomized control trial Australia 111 10–17 OW+ 12 Multiple 
Hoffman 2018 An integrated clinic-community partnership for child obesity treatment: a randomized pilot trial USA 97 5–11 OB+  
Hofsteenge 2014 Long-term effect of the Go4it group treatment of obese adolescents: a randomized controlled trial The Netherlands 122 11–18 OW+  
Kong 2013 School-based health center intervention improves BMI in overweight and obese adolescents USA 51 14–17 OW+ 12 *Glucose worse 
Krebs 2013 Efficacy and safety of a high protein, low carbohydrate diet for weight loss in severely obese adolescents USA 46 Mean 14 OB+  
Makkes 2016 One-year effects of 2 intensive inpatient treatments for severely obese children and adolescents The Netherlands 80 8–19 SO 12  
Mirza 2013 Effects of a low glycemic load or a low-fat dietary intervention on body weight in obese Hispanic American children and adolescents: a randomized controlled trial USA 113 7–15 OB+  
Nemet 2013 Effects of a multidisciplinary childhood obesity treatment intervention on adipocytokines, inflammatory and growth mediators Israel 41 6–13 OB+ HOMA 
Norman 2016 Outcomes of a 1-y randomized controlled trial to evaluate a behavioral “stepped-down” weight loss intervention for adolescent patients with obesity USA 106 11–13 OB+ 12  
Parillo 2012 Metabolic changes after a hypocaloric, low-glycemic-index diet in obese children Italy 22 Mean 10 OB+  
Partsalaki 2012 Metabolic impact of a ketogenic diet compared with a hypocaloric diet in obese children and adolescents Greece 58 8–18 OB+  
Pedrosa 2011 Markers of metabolic syndrome in obese children before and after 1-y lifestyle intervention program Portugal 61 Mean 8 OW+ 12  
Savoye 2011 Long-term results of an obesity program in an ethnically diverse pediatric population USA 174 8–16 OB+ 12 Multiple 
Savoye 2007 Effects of a weight management program on body composition and metabolic parameters in overweight children: a randomized controlled trial USA 174 8–16 OB+ 12 Multiple 
Tjonna 2009 Aerobic interval training reduces cardiovascular risk factors more than a multitreatment approach in overweight adolescents Norway 54 Mean 14 OW+  
Truby 2006 A randomized controlled trial of 2 different macronutrient profiles on weight, body composition and metabolic parameters in obese adolescents seeking weight loss Australia 87 10–17 OW+ HOMA 
Vos 2011 Long-term effect of lifestyle intervention on adiposity, metabolic parameters, inflammation and physical fitness in obese children: a randomized controlled trial The Netherlands 79 8–17 SO 12 Multiple 
Yackobovitch-Gavan 2018 Intervention for childhood obesity based on parents only or parents and child compared with follow-up alone Israel 247 5–11 OW/OB  
Koziol-Kozakowska 2019 A comparison of the impact of 2 methods of nutrition-behavioral intervention on selected auxological and biochemical parameters in obese prepubertal children- crossover preliminary study Poland 40 6–11 OB  
Kumar 2018 Family-based mindful eating intervention in adolescents with obesity: a pilot randomized clinical trial USA 21 14–17 OB+  
Farpour-Lambert 2019 Effectiveness of individual and group programmes to treat obesity and reduce cardiovascular disease risk factors in prepubertal children Switzerland 74 7–11 SO  
Kokkvoll 2020 No additional long-term effect of group versus individual family intervention in the treatment of childhood obesity-A randomized trial Norway 91 6–12 OW+ 24 Insulin 

FPG, fasting plasma glucose; HOMA, Homeostatic Model Assessment; OB, obese; OW, overweight; SO, severe obesity.

Lipids

Of the included studies, 25% reported on lipid outcomes, including total cholesterol, low-density lipoprotein (LDL), high-density lipoprotein (HDL), or triglycerides.8,20,26,29,52,55,61,65, 71,74,77,79,80,83,85,88,89,92,97100, 105,110113,118,119,127,132  Of these, one-third (10 of 31) reported significant improvements in lipids attributable to the intervention. These interventions are listed in Table 10. The most common lipid improvement observed was a decrease in triglyceride levels, which occurred in 4 of the 10 studies. HDL and LDL were also positively impacted, with an increase in HDL in 5 studies and a decrease in LDL in 4 studies. Total cholesterol improvement was only observed in 3 of the studies. Three studies (1 inpatient and 2 intensive outpatient group intervention studies) demonstrated improvement in 2 or more lipid parameters. Forty of the trials with a significant positive impact on lipids focused on specific dietary interventions, 5 trials were intensive outpatient lifestyle modification studies, and 1 study occurred in the inpatient setting. Of the 21 studies that did not report a significant improvement in lipid outcomes, about half observed a trend in improved lipids, most notably for a decrease in triglyceride levels. As with studies including glucose metabolism, most measuring lipids focused primarily on older children and adolescents.

TABLE 10

Trials Reporting Lipid Outcomes

AuthorsTitleCountryNAgesWeightLength (months)Positive OutcomeMeasure
Arauz 2013 Latino families, primary care, and childhood obesity: a randomized controlled trial USA 26 9–12 OW+  
Baan-Slootweg 2014 Inpatient treatment of children and adolescents with severe obesity in the Netherlands: a randomized clinical trial The Netherlands 90 8–18 SO Multiple 
Berkowitz 2011 Meal replacements in the treatment of adolescent obesity: a randomized controlled trial USA 113 13–17 OB+ 12  
Casazza 2012 Reduced carbohydrate diet to improve metabolic outcomes and decrease adiposity in obese peripubertal African American girls USA 26 9–14 OW+ TG 
de Ferranti 2015 Providing food to treat adolescents at risk for cardiovascular disease USA 27 8–21 OW+ HDL: 
Diaz 2010 Lifestyle intervention in primary care settings improves obesity parameters among Mexican youth Mexico 43 9–17 OB+ 12  
DeBar 2012 A primary care-based, multicomponent lifestyle intervention for overweight adolescent females USA 208 12–17 OB+  
Demol 2019 Low-carbohydrate (low and high-fat) versus high-carbohydrate low-fat diets in the treatment of obesity in adolescents Israel 55 12–18 OB+  
Ford 2009 Treatment of childhood obesity by retraining eating behavior: randomized controlled trial UK 106 9–18 OB+ 12 HDL 
Garnett 2013 Optimal macronutrient content of the diet for adolescents with prediabetes; RESIST a randomized control trial Australia 111 10–17 OW+ 12  
Garnett 2014 Improved insulin sensitivity and body composition, irrespective of macronutrient intake, after a 12 mo intervention in adolescents with prediabetes; RESIST a randomized control trial Australia 111 10–17 OW+ 12  
Hoffman 2018 An integrated clinic-community partnership for child obesity treatment: a randomized pilot trial USA 97 5–11 OB+  
Hofsteenge 2014 Long-term effect of the Go4it group treatment of obese adolescents: a randomized controlled trial The Netherlands 122 11–18 OW+  
Kong 2013 School-based health center intervention improves BMI in overweight and obese adolescents USA 51 14–17 OW+ 12  
Krebs 2010 Efficacy and safety of a high protein, low carbohydrate diet for weight loss in severely obese adolescents USA 46 Mean 14 OB+  
Makkes 2016 One-year effects of 2 intensive inpatient treatments for severely obese children and adolescents The Netherlands 80 8–19 SO 12  
Norman 2016 Outcomes of a 1-y randomized controlled trial to evaluate a behavioral “stepped-down” weight loss intervention for adolescent patients with obesity USA 106 11–13 OB+ 12 LDL (girls) 
Parillo 2012 Metabolic changes after a hypocaloric, low-glycemic-index diet in obese children Italy 22 Mean 10 OB+ TG 
Partsalaki 2012 Metabolic impact of a ketogenic diet compared with a hypocaloric diet in obese children and adolescents Greece 58 8–18 OB+  
Pedrosa 2011 Markers of metabolic syndrome in obese children before and after 1-y lifestyle intervention program Portugal 61 Mean 8 OW+ 12 Multiple 
Savoye 2011 Long-term results of an obesity program in an ethnically diverse pediatric population USA 174 8–16 OB+ 12 Multiple 
Savoye 2007 Effects of a weight management program on body composition and metabolic parameters in overweight children: a randomized controlled trial USA 174 8–16 OB+ 12 Multiple 
Tjonna 2009 Aerobic interval training reduces cardiovascular risk factors more than a multitreatment approach in overweight adolescents Norway 54 Mean 14 OW+  
Truby 2016 A randomized controlled trial of 2 different macronutrient profiles on weigh, body composition and metabolic parameters in obese adolescents seeking weight loss Australia 87 10–17 OW+  
Vos 2011 Long-term effect of lifestyle intervention on adiposity, metabolic parameters, inflammation and physical fitness in obese children: a randomized controlled trial The Netherlands 79 8–17 SO 12  
Williams 2007 Weight control among obese adolescents: a pilot study USA 38 11–15 OB+  
Yackobovitch-Gavan 2018 Intervention for childhood obesity based on parents only or parents and child compared with follow-up alone Israel 247 5–11 OW/OB  
Koziol-Kozakowska 2019 A comparison of the impact of 2 methods of nutrition-behavioral intervention on selected auxological and biochemical parameters in obese prepubertal children- crossover preliminary study Poland 40 6–11 OB  
Kumar 2018 Family-based mindful eating intervention in adolescents with obesity: a pilot randomized clinical trial USA 21 14–17 OB+ HDL 
Farpour-Lambert 2019 Effectiveness of individual and group programmes to treat obesity and reduce cardiovascular disease risk factors in prepubertal children Switzerland 74 7–11 SO  
Kokkvoll 2020 No additional long-term effect of group versus individual family intervention in the treatment of childhood obesity-a randomized trial Norway 91 6–12 OW+ 24 TC, HDL, LDL 
AuthorsTitleCountryNAgesWeightLength (months)Positive OutcomeMeasure
Arauz 2013 Latino families, primary care, and childhood obesity: a randomized controlled trial USA 26 9–12 OW+  
Baan-Slootweg 2014 Inpatient treatment of children and adolescents with severe obesity in the Netherlands: a randomized clinical trial The Netherlands 90 8–18 SO Multiple 
Berkowitz 2011 Meal replacements in the treatment of adolescent obesity: a randomized controlled trial USA 113 13–17 OB+ 12  
Casazza 2012 Reduced carbohydrate diet to improve metabolic outcomes and decrease adiposity in obese peripubertal African American girls USA 26 9–14 OW+ TG 
de Ferranti 2015 Providing food to treat adolescents at risk for cardiovascular disease USA 27 8–21 OW+ HDL: 
Diaz 2010 Lifestyle intervention in primary care settings improves obesity parameters among Mexican youth Mexico 43 9–17 OB+ 12  
DeBar 2012 A primary care-based, multicomponent lifestyle intervention for overweight adolescent females USA 208 12–17 OB+  
Demol 2019 Low-carbohydrate (low and high-fat) versus high-carbohydrate low-fat diets in the treatment of obesity in adolescents Israel 55 12–18 OB+  
Ford 2009 Treatment of childhood obesity by retraining eating behavior: randomized controlled trial UK 106 9–18 OB+ 12 HDL 
Garnett 2013 Optimal macronutrient content of the diet for adolescents with prediabetes; RESIST a randomized control trial Australia 111 10–17 OW+ 12  
Garnett 2014 Improved insulin sensitivity and body composition, irrespective of macronutrient intake, after a 12 mo intervention in adolescents with prediabetes; RESIST a randomized control trial Australia 111 10–17 OW+ 12  
Hoffman 2018 An integrated clinic-community partnership for child obesity treatment: a randomized pilot trial USA 97 5–11 OB+  
Hofsteenge 2014 Long-term effect of the Go4it group treatment of obese adolescents: a randomized controlled trial The Netherlands 122 11–18 OW+  
Kong 2013 School-based health center intervention improves BMI in overweight and obese adolescents USA 51 14–17 OW+ 12  
Krebs 2010 Efficacy and safety of a high protein, low carbohydrate diet for weight loss in severely obese adolescents USA 46 Mean 14 OB+  
Makkes 2016 One-year effects of 2 intensive inpatient treatments for severely obese children and adolescents The Netherlands 80 8–19 SO 12  
Norman 2016 Outcomes of a 1-y randomized controlled trial to evaluate a behavioral “stepped-down” weight loss intervention for adolescent patients with obesity USA 106 11–13 OB+ 12 LDL (girls) 
Parillo 2012 Metabolic changes after a hypocaloric, low-glycemic-index diet in obese children Italy 22 Mean 10 OB+ TG 
Partsalaki 2012 Metabolic impact of a ketogenic diet compared with a hypocaloric diet in obese children and adolescents Greece 58 8–18 OB+  
Pedrosa 2011 Markers of metabolic syndrome in obese children before and after 1-y lifestyle intervention program Portugal 61 Mean 8 OW+ 12 Multiple 
Savoye 2011 Long-term results of an obesity program in an ethnically diverse pediatric population USA 174 8–16 OB+ 12 Multiple 
Savoye 2007 Effects of a weight management program on body composition and metabolic parameters in overweight children: a randomized controlled trial USA 174 8–16 OB+ 12 Multiple 
Tjonna 2009 Aerobic interval training reduces cardiovascular risk factors more than a multitreatment approach in overweight adolescents Norway 54 Mean 14 OW+  
Truby 2016 A randomized controlled trial of 2 different macronutrient profiles on weigh, body composition and metabolic parameters in obese adolescents seeking weight loss Australia 87 10–17 OW+  
Vos 2011 Long-term effect of lifestyle intervention on adiposity, metabolic parameters, inflammation and physical fitness in obese children: a randomized controlled trial The Netherlands 79 8–17 SO 12  
Williams 2007 Weight control among obese adolescents: a pilot study USA 38 11–15 OB+  
Yackobovitch-Gavan 2018 Intervention for childhood obesity based on parents only or parents and child compared with follow-up alone Israel 247 5–11 OW/OB  
Koziol-Kozakowska 2019 A comparison of the impact of 2 methods of nutrition-behavioral intervention on selected auxological and biochemical parameters in obese prepubertal children- crossover preliminary study Poland 40 6–11 OB  
Kumar 2018 Family-based mindful eating intervention in adolescents with obesity: a pilot randomized clinical trial USA 21 14–17 OB+ HDL 
Farpour-Lambert 2019 Effectiveness of individual and group programmes to treat obesity and reduce cardiovascular disease risk factors in prepubertal children Switzerland 74 7–11 SO  
Kokkvoll 2020 No additional long-term effect of group versus individual family intervention in the treatment of childhood obesity-a randomized trial Norway 91 6–12 OW+ 24 TC, HDL, LDL 

OB, obese; OW, overweight; SO, severe obesity; TG, triglycerides; TC, total cholesterol.

Other Laboratory Values

Only 6% of studies reported on other laboratory values, such as alanine aminotransferase (A or aspartate aminotransferase (AST).8,52,65,77,83, 97,98,100  Of these, only reported improvements attributable to the intervention in 1 or more of the measures (C-peptide). These interventions are listed in Table 11.

TABLE 11

Trials Reporting Other Laboratory Outcomes

AuthorsTitleCountryNAgesWeightLength (months)Positive outcomeMeasure
Arauz 2013 Latino families, primary care, and childhood obesity: a randomized controlled trial USA 26 9–12 OW+ AST/ALT 
Baan-Slootweg 2014 Inpatient treatment of children and adolescents with severe obesity in the Netherlands: a randomized clinical trial The Netherlands 90 8–18 SO AST/ALT 
de Ferranti 2015 Providing food to treat adolescents at risk for cardiovascular disease USA 27 8–21 OW+ ALT 
Truby 2016 A randomized controlled trial of 2 different macronutrient profiles on weigh, body composition, and metabolic parameters in obese adolescents seeking weight loss Australia 87 10–17 OW+ ALT 
Koziol-Kozakowska 2019 A comparison of the impact of 2 methods of nutrition-behavioral intervention on selected auxological and biochemical parameters in obese prepubertal children-crossover preliminary study Poland 40 6–11 OB  
Kumar 2018 Family-based mindful eating intervention in adolescents with obesity: a pilot randomized clinical trial USA 21 14–17 OB+  
Farpour-Lambert 2019 Effectiveness of individual and group programmes to treat obesity and reduce cardiovascular disease risk factors in prepubertal children Switzerland 74 7–11 SO  
Kokkvoll 2020 No additional long-term effect of group versus individual family intervention in the treatment of childhood obesity-a randomized trial Norway 91 6–12 OW+ 24 C-peptide 
AuthorsTitleCountryNAgesWeightLength (months)Positive outcomeMeasure
Arauz 2013 Latino families, primary care, and childhood obesity: a randomized controlled trial USA 26 9–12 OW+ AST/ALT 
Baan-Slootweg 2014 Inpatient treatment of children and adolescents with severe obesity in the Netherlands: a randomized clinical trial The Netherlands 90 8–18 SO AST/ALT 
de Ferranti 2015 Providing food to treat adolescents at risk for cardiovascular disease USA 27 8–21 OW+ ALT 
Truby 2016 A randomized controlled trial of 2 different macronutrient profiles on weigh, body composition, and metabolic parameters in obese adolescents seeking weight loss Australia 87 10–17 OW+ ALT 
Koziol-Kozakowska 2019 A comparison of the impact of 2 methods of nutrition-behavioral intervention on selected auxological and biochemical parameters in obese prepubertal children-crossover preliminary study Poland 40 6–11 OB  
Kumar 2018 Family-based mindful eating intervention in adolescents with obesity: a pilot randomized clinical trial USA 21 14–17 OB+  
Farpour-Lambert 2019 Effectiveness of individual and group programmes to treat obesity and reduce cardiovascular disease risk factors in prepubertal children Switzerland 74 7–11 SO  
Kokkvoll 2020 No additional long-term effect of group versus individual family intervention in the treatment of childhood obesity-a randomized trial Norway 91 6–12 OW+ 24 C-peptide 

OB, obese; OW, overweight; SO, severe obesity.

Blood Pressure

Of the included studies, 23% reported on blood pressure outcomes.16,26,29,37,55,58,61,65,71,73,75,77,80,83,85,86,88,89,92,97,105,110113,118,119,127  Of these, 17% reported a positive effect attributable to the intervention in either systolic or diastolic blood pressure. These interventions are listed in Table 12. The 5 interventions that showed improvements targeted different age groups and differing levels of obesity severity. One was focused on macronutrient intake, and the other 4 included substantial physical activity components.

TABLE 12

Trials Reporting Blood Pressure Outcomes

AuthorsTitleCountryNAgesWeightLength (months)Positive outcomeMeasure
Baan-Slootweg 2014 Inpatient treatment of children and adolescents with severe obesity in the Netherlands: a randomized clinical trial The Netherlands 90 8–18 SO  
Berkowitz 2011 Meal replacements in the treatment of adolescent obesity: a randomized controlled trial USA 113 13–17 OB+ 12  
Butte 2017 Efficacy of a community- versus primary care-centered program for childhood obesity: TX CORD RCT USA 549 2–12 OW+ 12 9–12 only 
Chen 2017 Short-term efficacy of an innovative mobile phone technology-based intervention for weight management for overweight and obese adolescents: pilot study USA 40 13–18 OW+  
Croker 2012 Family-based behavioral treatment of childhood obesity in a UK National Health Service setting: randomized controlled trial UK 72 8–12 OW+  
de Ferranti 2015 Providing food to treat adolescents at risk for cardiovascular disease USA 27 8–21 OW+  
Diaz 2010 Lifestyle intervention in primary care settings improves obesity parameters among Mexican youth Mexico 43 9–17 OB+ 12  
Ford 2009 Treatment of childhood obesity by retraining eating behavior: randomized controlled trial UK 106 9–18 OB+ 12  
Garnett 2013 Optimal macronutrient content of the diet for adolescents with prediabetes; RESIST a randomized control trial Australia 111 10–17 OW+ 12  
Garnett 2014 Improved insulin sensitivity and body composition, irrespective of macronutrient intake, after a 12 mo intervention in adolescents with prediabetes; RESIST a randomized control trial Australia 111 10–17 OW+ 12  
Hoffman 2018 An integrated clinic-community partnership for child obesity treatment: a randomized pilot trial USA 97 5–11 OB+  
Hofsteenge 2014 Long-term effect of the Go4it group treatment of obese adolescents: a randomized controlled trial The Netherlands 122 11–18 OW+  
Kong 2013 School-based health center intervention improves BMI in overweight and obese adolescents USA 51 14–17 OW+ 12  
Makkes 2016 One-year effects of 2 intensive inpatient treatments for severely obese children and adolescents The Netherlands 80 8–19 SO 12  
Norman 2016 Outcomes of a 1-y randomized controlled trial to evaluate a behavioral “stepped-down” weight loss intervention for adolescent patients with obesity USA 106 11–13 OB+ 12  
Novotny 2015 Pacific kids DASH for health (PacDASH) randomized, controlled trial with DASH eating plan plus physical activity improves fruit and vegetable intake and diastolic blood pressure in children USA 85 5–8 HW/OW  
Parillo 2012 Metabolic changes after a hypocaloric, low-glycemic-index diet in obese children Italy 22 Mean 10 OB+  
Partsalaki 2012 Metabolic impact of a ketogenic diet compared with a hypocaloric diet in obese children and adolescents Greece 58 8–18 OB+  
Pedrosa 2011 Markers of metabolic syndrome in obese children before and after 1-y lifestyle intervention program Portugal 61 Mean 8 OW+ 12  
Savoye 2011 Long-term results of an obesity program in an ethnically diverse pediatric population USA 174 8–16 OB+ 12  
Savoye 2007 Effects of a weight management program on body composition and metabolic parameters in overweight children: a randomized controlled trial USA 174 8–16 OB+ 12  
Tjonna 2009 Aerobic interval training reduces cardiovascular risk factors more than a multitreatment approach in overweight adolescents Norway 54 Mean 14 OW+  
Vos 2011 Long-term effect of lifestyle intervention on adiposity, metabolic parameters, inflammation and physical fitness in obese children: a randomized controlled trial The Netherlands 79 8–17 SO 12  
Weigel 2008 Childhood obesity: concept, feasibility, and interim results of a local group-based, long-term treatment program Germany 73 7–15 OB+ 12  
Yackobovitch-Gavan 2018 Intervention for childhood obesity based on parents only or parents and child compared with follow-up alone Israel 247 5–11 OW/OB  
Koziol-Kozakowska 2019 A comparison of the impact of 2 methods of nutrition-behavioral intervention on selected auxological and biochemical parameters in obese prepubertal children-crossover preliminary study Poland 40 6–11 OB  
Forsell 2019 Four-year outcome of randomly assigned lifestyle treatments in primary care of children with obesity Sweden 56 8–13 OB 12  
Farpour-Lambert2019 Effectiveness of individual and group programmes to treat obesity and reduce cardiovascular disease risk factors in prepubertal children Switzerland 74 7–11 SO  
Kokkvoll 2020 No additional long-term effect of group versus individual family intervention in the treatment of childhood obesity-a randomized trial Norway 91 6–12 OW+ 24  
AuthorsTitleCountryNAgesWeightLength (months)Positive outcomeMeasure
Baan-Slootweg 2014 Inpatient treatment of children and adolescents with severe obesity in the Netherlands: a randomized clinical trial The Netherlands 90 8–18 SO  
Berkowitz 2011 Meal replacements in the treatment of adolescent obesity: a randomized controlled trial USA 113 13–17 OB+ 12  
Butte 2017 Efficacy of a community- versus primary care-centered program for childhood obesity: TX CORD RCT USA 549 2–12 OW+ 12 9–12 only 
Chen 2017 Short-term efficacy of an innovative mobile phone technology-based intervention for weight management for overweight and obese adolescents: pilot study USA 40 13–18 OW+  
Croker 2012 Family-based behavioral treatment of childhood obesity in a UK National Health Service setting: randomized controlled trial UK 72 8–12 OW+  
de Ferranti 2015 Providing food to treat adolescents at risk for cardiovascular disease USA 27 8–21 OW+  
Diaz 2010 Lifestyle intervention in primary care settings improves obesity parameters among Mexican youth Mexico 43 9–17 OB+ 12  
Ford 2009 Treatment of childhood obesity by retraining eating behavior: randomized controlled trial UK 106 9–18 OB+ 12  
Garnett 2013 Optimal macronutrient content of the diet for adolescents with prediabetes; RESIST a randomized control trial Australia 111 10–17 OW+ 12  
Garnett 2014 Improved insulin sensitivity and body composition, irrespective of macronutrient intake, after a 12 mo intervention in adolescents with prediabetes; RESIST a randomized control trial Australia 111 10–17 OW+ 12  
Hoffman 2018 An integrated clinic-community partnership for child obesity treatment: a randomized pilot trial USA 97 5–11 OB+  
Hofsteenge 2014 Long-term effect of the Go4it group treatment of obese adolescents: a randomized controlled trial The Netherlands 122 11–18 OW+  
Kong 2013 School-based health center intervention improves BMI in overweight and obese adolescents USA 51 14–17 OW+ 12  
Makkes 2016 One-year effects of 2 intensive inpatient treatments for severely obese children and adolescents The Netherlands 80 8–19 SO 12  
Norman 2016 Outcomes of a 1-y randomized controlled trial to evaluate a behavioral “stepped-down” weight loss intervention for adolescent patients with obesity USA 106 11–13 OB+ 12  
Novotny 2015 Pacific kids DASH for health (PacDASH) randomized, controlled trial with DASH eating plan plus physical activity improves fruit and vegetable intake and diastolic blood pressure in children USA 85 5–8 HW/OW  
Parillo 2012 Metabolic changes after a hypocaloric, low-glycemic-index diet in obese children Italy 22 Mean 10 OB+  
Partsalaki 2012 Metabolic impact of a ketogenic diet compared with a hypocaloric diet in obese children and adolescents Greece 58 8–18 OB+  
Pedrosa 2011 Markers of metabolic syndrome in obese children before and after 1-y lifestyle intervention program Portugal 61 Mean 8 OW+ 12  
Savoye 2011 Long-term results of an obesity program in an ethnically diverse pediatric population USA 174 8–16 OB+ 12  
Savoye 2007 Effects of a weight management program on body composition and metabolic parameters in overweight children: a randomized controlled trial USA 174 8–16 OB+ 12  
Tjonna 2009 Aerobic interval training reduces cardiovascular risk factors more than a multitreatment approach in overweight adolescents Norway 54 Mean 14 OW+  
Vos 2011 Long-term effect of lifestyle intervention on adiposity, metabolic parameters, inflammation and physical fitness in obese children: a randomized controlled trial The Netherlands 79 8–17 SO 12  
Weigel 2008 Childhood obesity: concept, feasibility, and interim results of a local group-based, long-term treatment program Germany 73 7–15 OB+ 12  
Yackobovitch-Gavan 2018 Intervention for childhood obesity based on parents only or parents and child compared with follow-up alone Israel 247 5–11 OW/OB  
Koziol-Kozakowska 2019 A comparison of the impact of 2 methods of nutrition-behavioral intervention on selected auxological and biochemical parameters in obese prepubertal children-crossover preliminary study Poland 40 6–11 OB  
Forsell 2019 Four-year outcome of randomly assigned lifestyle treatments in primary care of children with obesity Sweden 56 8–13 OB 12  
Farpour-Lambert2019 Effectiveness of individual and group programmes to treat obesity and reduce cardiovascular disease risk factors in prepubertal children Switzerland 74 7–11 SO  
Kokkvoll 2020 No additional long-term effect of group versus individual family intervention in the treatment of childhood obesity-a randomized trial Norway 91 6–12 OW+ 24  

HW, healthy weight; OB, obese; OW, overweight; SO, severe obesity.

Psychosocial Outcomes

Of the included studies, 20% reported on a psychosocial outcome, most commonly quality of life.8,11, 16,18,20,22,32,42,51,54,56,59,63,66,73, 78,84,90,93,126,128130,133  Of these, 36% reported a positive effect attributable to the intervention. These interventions are listed in Table 13.

TABLE 13

Trials Reporting Psychosocial Outcomes

AuthorsTitleCountryNAgesWeightLength (months)Positive outcomeMeasure
Psychosocial
Anderson 2017 A novel home-based intervention for child and adolescent obesity: the results of the Whanau Pakari randomized controlled trial New Zealand 138 5–16 SO 12 QoL 
Arauz 2013 Latino families, primary care, and childhood obesity: a randomized controlled trial USA 26 9–12 OW+  
Banks 2012 Evaluating the transferability of a hospital-based childhood obesity clinic to primary care: a randomized controlled trial UK 68 5–16 SO 12  
Bocca 2014 A multidisciplinary intervention program has positive effects on quality of life in overweight and obese preschool children The Netherlands 75 3–5 OW+ QoL 
Butte 2017 Efficacy of a community- versus primary care-centered program for childhood obesity: TX CORD RCT USA 549 2–12 OW+ 12 QoL 
Croker 2012 Family-based behavioral treatment of childhood obesity in a UK National Health Service setting: randomized controlled trial UK 72 8–12 OW+ QoL 
Davis 2013 Treating rural pediatric obesity through telemedicine: outcomes from a small randomized controlled trial USA 58 Mean 9 OW+  
DeBar 2012 A primary care-based, multicomponent lifestyle intervention for overweight adolescent females USA 208 12–17 OB+ QoL 
De Niet 2012 The effect of a short message service maintenance treatment on BMI and psychological well-being in overweight and obese children: a randomized controlled trial The Netherlands 141 Mean 10 OW+ CHQ 
Fonseca 2016 Effectiveness analysis of an internet-based intervention for overweight adolescents: next steps for researchers and clinicians Portugal 80 12–18 OW+ QoL 
Gourlan 2013 Motivational interviewing as a way to promote physical activity in obese adolescents: a randomized-controlled trial using self-determination theory as an explanatory framework France 62 11–18 OB+  
Hughes 2008 Randomized, controlled trial of a best-practice individualized behavioral program for treatment of childhood overweight: Scottish Childhood Overweight Treatment Trial (SCOTT) UK 134 5–11 OB+ QoL 
McCallum 2007 Outcome data from the LEAP (Live, Eat and Play) trial: a randomized controlled trial of a primary care intervention for childhood overweight or mild obesity Australia 163 Mean 7 OW  
Saelens 2002 Behavioral weight control for overweight adolescents initiated in primary care USA 44 12–16 OW+ Behavioral skills 
Taveras 2017 Comparative effectiveness of clinical-community childhood obesity interventions a randomized clinical trial USA 721 2–12 OW+ 12  
Taylor 2015 A tailored family-based obesity intervention: a randomized trial New Zealand 206 4–8 OW+ 24 QoL 
Vos 2012 The effect of family-based multidisciplinary cognitive behavioral treatment on health-related quality of life in childhood obesity The Netherlands 81 8–17 SO 12 QoL 
Wake 2013 Shared care obesity management in 3–10 y old children: 12 mo outcomes of HopSCOTCH randomized trial Australia 118 5–10 OW QoL 
Wake 2009 Outcomes and costs of primary care surveillance and intervention for overweight or obese children: the LEAP 2 randomized controlled trial Australia 258 5–10 OW QoL 
Walpole 2013 Motivational interviewing to enhance self-efficacy and promote weight loss in overweight and obese adolescents: a randomized controlled trial Canada 40 10–18 OW+ Self-efficacy 
Warschburger 2016 Empowering Parents of Obese Children (EPOC): a randomized controlled trial on additional long-term weight effects of parent training Germany 523 7–12 SO  
Wilfley 2007 Efficacy of maintenance treatment approaches for childhood overweight: a randomized controlled trial USA 150 7–12 OW+ Multiple 
Yackobovitch-Gavan 2008 Influence of weight-loss diets with different macronutrient compositions on health-related quality of life in obese youth Israel 71 12–18 OB+  
Warschburger 2018 Evaluation of an approach-avoidance training intervention for children and adolescents with obesity: a randomized placebo-controlled prospective trial Germany 232 8–16 SO 6 weeks QoL 
Fedele 2018 A behavioral family intervention for children with overweight and asthma USA 24 6–12 OW+  
AuthorsTitleCountryNAgesWeightLength (months)Positive outcomeMeasure
Psychosocial
Anderson 2017 A novel home-based intervention for child and adolescent obesity: the results of the Whanau Pakari randomized controlled trial New Zealand 138 5–16 SO 12 QoL 
Arauz 2013 Latino families, primary care, and childhood obesity: a randomized controlled trial USA 26 9–12 OW+  
Banks 2012 Evaluating the transferability of a hospital-based childhood obesity clinic to primary care: a randomized controlled trial UK 68 5–16 SO 12  
Bocca 2014 A multidisciplinary intervention program has positive effects on quality of life in overweight and obese preschool children The Netherlands 75 3–5 OW+ QoL 
Butte 2017 Efficacy of a community- versus primary care-centered program for childhood obesity: TX CORD RCT USA 549 2–12 OW+ 12 QoL 
Croker 2012 Family-based behavioral treatment of childhood obesity in a UK National Health Service setting: randomized controlled trial UK 72 8–12 OW+ QoL 
Davis 2013 Treating rural pediatric obesity through telemedicine: outcomes from a small randomized controlled trial USA 58 Mean 9 OW+  
DeBar 2012 A primary care-based, multicomponent lifestyle intervention for overweight adolescent females USA 208 12–17 OB+ QoL 
De Niet 2012 The effect of a short message service maintenance treatment on BMI and psychological well-being in overweight and obese children: a randomized controlled trial The Netherlands 141 Mean 10 OW+ CHQ 
Fonseca 2016 Effectiveness analysis of an internet-based intervention for overweight adolescents: next steps for researchers and clinicians Portugal 80 12–18 OW+ QoL 
Gourlan 2013 Motivational interviewing as a way to promote physical activity in obese adolescents: a randomized-controlled trial using self-determination theory as an explanatory framework France 62 11–18 OB+  
Hughes 2008 Randomized, controlled trial of a best-practice individualized behavioral program for treatment of childhood overweight: Scottish Childhood Overweight Treatment Trial (SCOTT) UK 134 5–11 OB+ QoL 
McCallum 2007 Outcome data from the LEAP (Live, Eat and Play) trial: a randomized controlled trial of a primary care intervention for childhood overweight or mild obesity Australia 163 Mean 7 OW  
Saelens 2002 Behavioral weight control for overweight adolescents initiated in primary care USA 44 12–16 OW+ Behavioral skills 
Taveras 2017 Comparative effectiveness of clinical-community childhood obesity interventions a randomized clinical trial USA 721 2–12 OW+ 12  
Taylor 2015 A tailored family-based obesity intervention: a randomized trial New Zealand 206 4–8 OW+ 24 QoL 
Vos 2012 The effect of family-based multidisciplinary cognitive behavioral treatment on health-related quality of life in childhood obesity The Netherlands 81 8–17 SO 12 QoL 
Wake 2013 Shared care obesity management in 3–10 y old children: 12 mo outcomes of HopSCOTCH randomized trial Australia 118 5–10 OW QoL 
Wake 2009 Outcomes and costs of primary care surveillance and intervention for overweight or obese children: the LEAP 2 randomized controlled trial Australia 258 5–10 OW QoL 
Walpole 2013 Motivational interviewing to enhance self-efficacy and promote weight loss in overweight and obese adolescents: a randomized controlled trial Canada 40 10–18 OW+ Self-efficacy 
Warschburger 2016 Empowering Parents of Obese Children (EPOC): a randomized controlled trial on additional long-term weight effects of parent training Germany 523 7–12 SO  
Wilfley 2007 Efficacy of maintenance treatment approaches for childhood overweight: a randomized controlled trial USA 150 7–12 OW+ Multiple 
Yackobovitch-Gavan 2008 Influence of weight-loss diets with different macronutrient compositions on health-related quality of life in obese youth Israel 71 12–18 OB+  
Warschburger 2018 Evaluation of an approach-avoidance training intervention for children and adolescents with obesity: a randomized placebo-controlled prospective trial Germany 232 8–16 SO 6 weeks QoL 
Fedele 2018 A behavioral family intervention for children with overweight and asthma USA 24 6–12 OW+  

CHQ, Child Health Questionnaire; QoL, quality of life; OB, obese; OW, overweight; SO, severe obesity.

Quality of Life

Of the 19 studies that reported on quality of life, 8 studies observed improvements and 11 studies did not observe any differences; no studies showed a decrease in quality of life. Studies demonstrating improvements were primarily higher-intensity studies with low-intensity comparisons. There were no apparent differences in participant age, weight status, or treatment duration between the studies that did versus did not detect significant changes in quality of life. Thirteen of the studies used the Pediatric Quality of Life (PedsQL), which assesses health-related quality of life in the domains of physical, emotional, social, and school functioning; 4 of these studies observed significant improvements in this scale, whereas 9 did not.

Self-efficacy

Two studies reported on self-efficacy, and both observed improvements. Both studies used the Child Dietary Self-Efficacy Scale; additionally, 1 used the Weight Efficacy Lifestyle questionnaire and 1 used the Self-efficacy Scale for Children’s Physical Activity.

Other Psychosocial Outcomes

Other reported psychosocial outcome results varied. Four studies found no significant difference between the study groups and psychosocial outcomes, including problematic eating behaviors, well-being, mood disorder symptoms, body satisfaction, internalization of social-cultural attitudes toward appearance, and self-esteem. One study showed improvements in intrinsic regulation after a motivational interviewing intervention.

Mental Health

Only 5% of the studies reported on a mental health outcome, most commonly depression.16,20,63,71, 109,120  Interventions are listed in Table 14. Of these, only 2 reported any improvement attributable to the intervention in 1 or more of the measures.63,120  One study observed reductions in both internalizing and externalizing behavioral and emotional problems at 12 months among children ages 5 to 16 years, of age, and the other a reduction in anxiety among those 8 to 12 years of age at 6 months. Interestingly, the participants in all 5 trials were in the healthy range on the mental health assessments; further, each study had eligibility criteria that excluded participants with significant psychological conditions, psychiatric disorders, or mental health problems, or receiving current psychological or psychiatric counseling including medication. None of the studies showed worsening of mental health outcomes.

TABLE 14

Trials Reporting Mental Health Outcomes

AuthorsTitleCountryNAgesWeightLength (months)Positive outcomeMeasure
Mental health
Anderson 2017 A novel home-based intervention for child and adolescent obesity: the results of the Whanau Pakari randomized controlled trial New Zealand 138 5–16 SO 12 CBCL 
Berkowitz 2011 Meal replacements in the treatment of adolescent obesity: a randomized controlled trial USA 113 13–17 OB+ 12  
Croker 2012 Family-based behavioral treatment of childhood obesity in a UK National Health Service setting: randomized controlled trial UK 72 8–12 OW+   
DeBar 2012 A primary care-based, multicomponent lifestyle intervention for overweight adolescent females USA 208 12–17 OB+  
Njardvik 2018 Incorporating appetite awareness training within family-based behavioral treatment of pediatric obesity: a randomized controlled pilot study Iceland 84 8–12 OB+ 18 weeks  
Sepulveda 2020 Feasibility, acceptability, and effectiveness of a multidisciplinary intervention in childhood obesity from primary care: nutrition, physical activity, emotional regulation, and family Spain 51 8–12 OW+ Anxiety 
AuthorsTitleCountryNAgesWeightLength (months)Positive outcomeMeasure
Mental health
Anderson 2017 A novel home-based intervention for child and adolescent obesity: the results of the Whanau Pakari randomized controlled trial New Zealand 138 5–16 SO 12 CBCL 
Berkowitz 2011 Meal replacements in the treatment of adolescent obesity: a randomized controlled trial USA 113 13–17 OB+ 12  
Croker 2012 Family-based behavioral treatment of childhood obesity in a UK National Health Service setting: randomized controlled trial UK 72 8–12 OW+   
DeBar 2012 A primary care-based, multicomponent lifestyle intervention for overweight adolescent females USA 208 12–17 OB+  
Njardvik 2018 Incorporating appetite awareness training within family-based behavioral treatment of pediatric obesity: a randomized controlled pilot study Iceland 84 8–12 OB+ 18 weeks  
Sepulveda 2020 Feasibility, acceptability, and effectiveness of a multidisciplinary intervention in childhood obesity from primary care: nutrition, physical activity, emotional regulation, and family Spain 51 8–12 OW+ Anxiety 

CBCL, Child Behavior Check List; OB, obese; OW, overweight; SO, severe obesity.

Other Outcomes

Of the included studies, 18% reported on other outcomes, primarily parent BMI and child’s cardiovascular fitness (eg, maximal oxygen consumption [VO2 max] or 3-minute step test).12,22,30,43, 5557,64,65,76,83,92,97,98,100, 106,109,114,120,122124,127  These interventions are listed in Table 15. Nine trials measured parental weight or BMI outcomes at the end of the interventions; of these, 2 reported decreases in parental weight or BMI, and the remaining 7 studies reported no significant change. The 2 studies reporting a decrease in parental weight or BMI were family-based interventions in 2- to 5-year-olds, both of which included a parenting component. The remaining studies measuring parent weight and BMI included interventions ranging from self-help to telemedicine, clinic community partnership, parent group education, and primary care. None of the studies that observed no change in parents’ weight and BMI outcomes had a parenting component.

TABLE 15

Trials Reporting Other Outcomes

AuthorsTitleCountryNAgesWeightLength (months)Positive outcomeMeasure
Armstrong 2018 Texting motivational interviewing: a randomized controlled trial of motivational interviewing text messages designed to augment childhood obesity treatment USA 101 5–12 OB+ Parent BMI 
Baan-Slootweg 2014 Inpatient treatment of children and adolescents with severe obesity in the Netherlands: a randomized clinical trial The Netherlands 90 8–18 SO VO2 
Boutelle 2013 Guided self-help for the treatment of pediatric obesity USA 50 8–12 OW+ Parent BMI 
Davis 2016 Treating rural pediatric obesity through telemedicine versus telephone: outcomes from a cluster randomized controlled trial USA 103 Mean 9 OW+ Parent BMI 
Hoffman 2018 An integrated clinic-community partnership for child obesity treatment: a randomized pilot trial USA 97 5–11 OB+ Parent BMI 
Love-Osborne 2014 School-based health center-based treatment of obese adolescents: feasibility and BMI effects USA 165 Mean 16 OW+ Fitness 
Quattrin 2017 Cost-effectiveness of family-based obesity treatment USA 96 2–5 OW+ 12 Parent BMI 
Shelton 2007 Randomized controlled trial: a parent-based group education program for overweight children Australia 43 3–10 OW+ Parent BMI 
Stark 2014 A pilot randomized controlled trial of a behavioral family-based intervention with and without home visits to decrease obesity in preschoolers USA 33 2–5 OB Parenting style 
Stark 2011 A pilot randomized controlled trial of a clinic and home-based behavioral intervention to decrease obesity in preschoolers USA 18 2–5 OB Parent weight 
Tjonna 2009 Aerobic interval training reduces cardiovascular risk factors more than a multitreatment approach in overweight adolescents Norway 54 Mean 14 OW+ Fitness 
Vos 2011 Long-term effect of lifestyle intervention on adiposity, metabolic parameters, inflammation and physical fitness in obese children: a randomized controlled trial The Netherlands 79 8–17 SO 12 Fitness 
Wake 2009 Outcomes and costs of primary care surveillance and intervention for overweight or obese children: the LEAP 2 randomized controlled trial Australia 258 5–10 OW Parent BMI 
Wake 2013 Shared care obesity management in 3-10 y old children: 12 mo outcomes of HopSCOTCH randomized trial Australia 118 5–10 OW Parent BMI 
Fedele 2018 A behavioral family intervention for children with overweight and asthma USA 24 6–12 OW+  
Koziol-Kozakowska 019 A comparison of the impact of 2 methods of nutrition-behavioral intervention on selected auxological and biochemical parameters in obese prepubertal children-crossover preliminary study Poland 40 6–11 OB Jump length 
Kumar 2018 Family-based mindful eating intervention in adolescents with obesity: a pilot randomized clinical trial USA 21 14–17 OB+ Mindful eating 
Njardvik 2018 Incorporating appetite awareness training within family-based behavioral treatment of pediatric obesity: a randomized controlled pilot study Iceland 84 8–12 OB+ 18 weeks  
Stark 2019 Maintenance following a randomized trial of a clinic and home-based behavioral intervention of obesity in preschoolers USA 151 2–5 OB+ Parent caloric intake 
Farpour-Lambert 2019 Effectiveness of individual and group programmes to treat obesity and reduce cardiovascular disease risk factors in prepubertal children Switzerland 74 7–11 SO  
Sepulveda 2020 Feasibility, acceptability, and effectiveness of a multidisciplinary intervention in childhood obesity from primary care: nutrition, physical activity, emotional regulation, and family Spain 51 8–12 OW+ Family functioning 
Kokkvoll 2020 No additional long-term effect of group versus individual family intervention in the treatment of childhood obesity-a randomized trial Norway 91 6–12 OW+ 24  
Miguet 2019 Effect of HIIT versus MICT on body composition and energy intake in dietary restrained and unrestrained adolescents with obesity France 43 11–15 OB+  
AuthorsTitleCountryNAgesWeightLength (months)Positive outcomeMeasure
Armstrong 2018 Texting motivational interviewing: a randomized controlled trial of motivational interviewing text messages designed to augment childhood obesity treatment USA 101 5–12 OB+ Parent BMI 
Baan-Slootweg 2014 Inpatient treatment of children and adolescents with severe obesity in the Netherlands: a randomized clinical trial The Netherlands 90 8–18 SO VO2 
Boutelle 2013 Guided self-help for the treatment of pediatric obesity USA 50 8–12 OW+ Parent BMI 
Davis 2016 Treating rural pediatric obesity through telemedicine versus telephone: outcomes from a cluster randomized controlled trial USA 103 Mean 9 OW+ Parent BMI 
Hoffman 2018 An integrated clinic-community partnership for child obesity treatment: a randomized pilot trial USA 97 5–11 OB+ Parent BMI 
Love-Osborne 2014 School-based health center-based treatment of obese adolescents: feasibility and BMI effects USA 165 Mean 16 OW+ Fitness 
Quattrin 2017 Cost-effectiveness of family-based obesity treatment USA 96 2–5 OW+ 12 Parent BMI 
Shelton 2007 Randomized controlled trial: a parent-based group education program for overweight children Australia 43 3–10 OW+ Parent BMI 
Stark 2014 A pilot randomized controlled trial of a behavioral family-based intervention with and without home visits to decrease obesity in preschoolers USA 33 2–5 OB Parenting style 
Stark 2011 A pilot randomized controlled trial of a clinic and home-based behavioral intervention to decrease obesity in preschoolers USA 18 2–5 OB Parent weight 
Tjonna 2009 Aerobic interval training reduces cardiovascular risk factors more than a multitreatment approach in overweight adolescents Norway 54 Mean 14 OW+ Fitness 
Vos 2011 Long-term effect of lifestyle intervention on adiposity, metabolic parameters, inflammation and physical fitness in obese children: a randomized controlled trial The Netherlands 79 8–17 SO 12 Fitness 
Wake 2009 Outcomes and costs of primary care surveillance and intervention for overweight or obese children: the LEAP 2 randomized controlled trial Australia 258 5–10 OW Parent BMI 
Wake 2013 Shared care obesity management in 3-10 y old children: 12 mo outcomes of HopSCOTCH randomized trial Australia 118 5–10 OW Parent BMI 
Fedele 2018 A behavioral family intervention for children with overweight and asthma USA 24 6–12 OW+  
Koziol-Kozakowska 019 A comparison of the impact of 2 methods of nutrition-behavioral intervention on selected auxological and biochemical parameters in obese prepubertal children-crossover preliminary study Poland 40 6–11 OB Jump length 
Kumar 2018 Family-based mindful eating intervention in adolescents with obesity: a pilot randomized clinical trial USA 21 14–17 OB+ Mindful eating 
Njardvik 2018 Incorporating appetite awareness training within family-based behavioral treatment of pediatric obesity: a randomized controlled pilot study Iceland 84 8–12 OB+ 18 weeks  
Stark 2019 Maintenance following a randomized trial of a clinic and home-based behavioral intervention of obesity in preschoolers USA 151 2–5 OB+ Parent caloric intake 
Farpour-Lambert 2019 Effectiveness of individual and group programmes to treat obesity and reduce cardiovascular disease risk factors in prepubertal children Switzerland 74 7–11 SO  
Sepulveda 2020 Feasibility, acceptability, and effectiveness of a multidisciplinary intervention in childhood obesity from primary care: nutrition, physical activity, emotional regulation, and family Spain 51 8–12 OW+ Family functioning 
Kokkvoll 2020 No additional long-term effect of group versus individual family intervention in the treatment of childhood obesity-a randomized trial Norway 91 6–12 OW+ 24  
Miguet 2019 Effect of HIIT versus MICT on body composition and energy intake in dietary restrained and unrestrained adolescents with obesity France 43 11–15 OB+  

OB, obese; OW, overweight; SO, severe obesity.

Randomized trials of pharmaceutical treatments, primarily metformin, demonstrated greater BMI reduction than lifestyle intervention alone. Of the 27 included studies (Table 16),136162  74% showed some positive effect of the medication on BMI or BMI SDS.

TABLE 16

Summary of Randomized Pharmaceutical Trials

AuthorsTitleCountryNWeightAgesDrugPlaceboOtherDifference T1Difference T2Other ObesityLipidsGlucoseBPOther LaboratoriesPsychosocialMental HealthBehaviorsOther
Aa 2016 Long-term treatment with metformin in obese, insulin-resistant adolescents: results of a randomized double-blinded placebo-controlled trial The Netherlands 42 SO 10–16 Metformin        
Akcam 2011 Therapeutic effect of metformin and vitamin E versus prescriptive diet in obese adolescents with fatty liver Turkey 67 OB+ 9–17 Metformin        
Allen 2005 Randomized controlled trial evaluating response to metformin versus standard therapy in the treatment of adolescents with polycystic ovary syndrome USA 31 OB+ 12–21 Metformin versus OCP         
Atabek 2008 Use of metformin in obese adolescents with hyperinsulinemia: a 6-mo, randomized, double- blind, placebo-controlled clinical trial Turkey 120 OB+ 9–17 Metformin       
Burgert 2008 Short-term metabolic and cardiovascular effects of metformin in markedly obese adolescents with normal glucose tolerance USA 28 NR 13–18 Metformin       
Canas 2017 Effects of mixed carotenoids on adipokines and abdominal adiposity in children: a pilot study USA 17 OB+ 8–11 Mixed carotenoids         
Casteels 2010 Metformin therapy to reduce weight gain and visceral adiposity in children and adolescents with neurogenic or myogenic motor deficit Belgium 36 OB+ 8+ Metformin         
Chanoine 2005 Effect of orlistat on weight and body composition in obese adolescents: a randomized controlled trial USA and Canada 533 SO 12–16 Orlistat        
Clarson 2009 Metformin in combination with structured lifestyle intervention improved BMI in obese adolescents, but did not improve insulin resistance Canada 25 OB+ 10–16 Metformin          
Evia-Viscarra 2012 The effects of metformin on inflammatory mediators in obese adolescents with insulin resistance: controlled randomized clinical trial Mexico 26 OB+ 9–18 Metformin          
Fox 2016 Meal replacements followed by topiramate for the treatment of adolescent severe obesity: a pilot randomized controlled trial USA 28 SO 12–18 Topirimate       
Freemark 2001 The effects of metformin on BMI and glucose tolerance in obese adolescents with fasting hyperinsulinemia and a family history of type 2 diabetes USA 29 OB+ 12–19 Metformin         
Kelly 2012 Exenatide as a weight-loss therapy in extreme pediatric obesity: a randomized, controlled pilot study USA 11 SO 8–19 Exenatide       
Kelly 2013 The effect of Glucagon-like peptide-1 receptor agonist therapy on BMI in adolescents with severe obesity USA 22 SO 12–19 Exenatide         
Kendall 2013 Metformin in obese children and adolescents: the MOCA trial UK 124 SO 8–18 Metformin      
Mauras 2012 Metformin use in children with obesity and normal glucose tolerance-effects on cardiovascular markers and intrahepatic fat USA 42 OB+ 7–18 Metformin        
Molnar 2000 Safety and efficacy of treatment with an ephedrine and caffeine mixture. The first double-blind placebo-controlled pilot study in adolescents Hungary 26 OB+ 14–18 Ephedrine        
Ozkan 2004 Addition of orlistat to conventional treatment in adolescents with severe obesity Turkey 30 SO 10–16 Orlistat          
Pastor-Villaescusa 2017 Metformin for obesity in prepubertal and pubertal children: a randomized controlled trial Spain 67 OB+ 7–14 Metformin        
Rynders 2012 Lifestyle intervention improves fitness independent of metformin in obese adolescents USA 16 OB+ 10–17 Metformin         
Slattery 2014 Effects of recombinant human growth hormone (rhGH) administration on body composition and cardiovascular risk factors in obese adolescent girls USA 12 OB+ 13–21 rhGH        
Srinivasan 2006 Randomized, controlled trial of metformin for obesity and insulin resistance in children and adolescents: improvement in body composition and fasting insulin Australia 22 OB+ 9–18 Metformin         
Stagi 2015 Policaptil Gel Retard significantly reduces body mass index and hyperinsulinism and may decrease the risk of type 2 diabetes mellitus (T 2DM) in obese Italy 120 OB+ 8–14 Metformin + Policaptil Gel Retard       
 children and adolescents with family history of obesity and T 2DM                   
Wilson 2010 Metformin extended release treatment of adolescent obesity: a 48-wk randomized, double-blind, placebo-controlled trial with 48-wk follow-up USA 54 OB+ 13–18 Metformin        
Yanovski 2011 Effects of metformin on body weight and body composition in obese insulin-resistant children: a randomized clinical trial USA 100 OB+ 6–12 Metformin       
TODAY Study Group 2013 Treatment effects on measures of body composition in the TODAY clinical trial USA NR OW+ 10–17 Metformin + Rosiglitazon e          
Bassols 2019 Effects of metformin administration on endocrine- metabolic parameters, visceral adiposity and cardiovascular risk factors in children with obesity and risk markers for metabolic syndrome: A pilot study Spain 18 SO 6–13 Metformin Yes        
AuthorsTitleCountryNWeightAgesDrugPlaceboOtherDifference T1Difference T2Other ObesityLipidsGlucoseBPOther LaboratoriesPsychosocialMental HealthBehaviorsOther
Aa 2016 Long-term treatment with metformin in obese, insulin-resistant adolescents: results of a randomized double-blinded placebo-controlled trial The Netherlands 42 SO 10–16 Metformin        
Akcam 2011 Therapeutic effect of metformin and vitamin E versus prescriptive diet in obese adolescents with fatty liver Turkey 67 OB+ 9–17 Metformin        
Allen 2005 Randomized controlled trial evaluating response to metformin versus standard therapy in the treatment of adolescents with polycystic ovary syndrome USA 31 OB+ 12–21 Metformin versus OCP         
Atabek 2008 Use of metformin in obese adolescents with hyperinsulinemia: a 6-mo, randomized, double- blind, placebo-controlled clinical trial Turkey 120 OB+ 9–17 Metformin       
Burgert 2008 Short-term metabolic and cardiovascular effects of metformin in markedly obese adolescents with normal glucose tolerance USA 28 NR 13–18 Metformin       
Canas 2017 Effects of mixed carotenoids on adipokines and abdominal adiposity in children: a pilot study USA 17 OB+ 8–11 Mixed carotenoids         
Casteels 2010 Metformin therapy to reduce weight gain and visceral adiposity in children and adolescents with neurogenic or myogenic motor deficit Belgium 36 OB+ 8+ Metformin         
Chanoine 2005 Effect of orlistat on weight and body composition in obese adolescents: a randomized controlled trial USA and Canada 533 SO 12–16 Orlistat        
Clarson 2009 Metformin in combination with structured lifestyle intervention improved BMI in obese adolescents, but did not improve insulin resistance Canada 25 OB+ 10–16 Metformin          
Evia-Viscarra 2012 The effects of metformin on inflammatory mediators in obese adolescents with insulin resistance: controlled randomized clinical trial Mexico 26 OB+ 9–18 Metformin          
Fox 2016 Meal replacements followed by topiramate for the treatment of adolescent severe obesity: a pilot randomized controlled trial USA 28 SO 12–18 Topirimate       
Freemark 2001 The effects of metformin on BMI and glucose tolerance in obese adolescents with fasting hyperinsulinemia and a family history of type 2 diabetes USA 29 OB+ 12–19 Metformin         
Kelly 2012 Exenatide as a weight-loss therapy in extreme pediatric obesity: a randomized, controlled pilot study USA 11 SO 8–19 Exenatide       
Kelly 2013 The effect of Glucagon-like peptide-1 receptor agonist therapy on BMI in adolescents with severe obesity USA 22 SO 12–19 Exenatide         
Kendall 2013 Metformin in obese children and adolescents: the MOCA trial UK 124 SO 8–18 Metformin      
Mauras 2012 Metformin use in children with obesity and normal glucose tolerance-effects on cardiovascular markers and intrahepatic fat USA 42 OB+ 7–18 Metformin        
Molnar 2000 Safety and efficacy of treatment with an ephedrine and caffeine mixture. The first double-blind placebo-controlled pilot study in adolescents Hungary 26 OB+ 14–18 Ephedrine        
Ozkan 2004 Addition of orlistat to conventional treatment in adolescents with severe obesity Turkey 30 SO 10–16 Orlistat          
Pastor-Villaescusa 2017 Metformin for obesity in prepubertal and pubertal children: a randomized controlled trial Spain 67 OB+ 7–14 Metformin        
Rynders 2012 Lifestyle intervention improves fitness independent of metformin in obese adolescents USA 16 OB+ 10–17 Metformin         
Slattery 2014 Effects of recombinant human growth hormone (rhGH) administration on body composition and cardiovascular risk factors in obese adolescent girls USA 12 OB+ 13–21 rhGH        
Srinivasan 2006 Randomized, controlled trial of metformin for obesity and insulin resistance in children and adolescents: improvement in body composition and fasting insulin Australia 22 OB+ 9–18 Metformin         
Stagi 2015 Policaptil Gel Retard significantly reduces body mass index and hyperinsulinism and may decrease the risk of type 2 diabetes mellitus (T 2DM) in obese Italy 120 OB+ 8–14 Metformin + Policaptil Gel Retard       
 children and adolescents with family history of obesity and T 2DM                   
Wilson 2010 Metformin extended release treatment of adolescent obesity: a 48-wk randomized, double-blind, placebo-controlled trial with 48-wk follow-up USA 54 OB+ 13–18 Metformin        
Yanovski 2011 Effects of metformin on body weight and body composition in obese insulin-resistant children: a randomized clinical trial USA 100 OB+ 6–12 Metformin       
TODAY Study Group 2013 Treatment effects on measures of body composition in the TODAY clinical trial USA NR OW+ 10–17 Metformin + Rosiglitazon e          
Bassols 2019 Effects of metformin administration on endocrine- metabolic parameters, visceral adiposity and cardiovascular risk factors in children with obesity and risk markers for metabolic syndrome: A pilot study Spain 18 SO 6–13 Metformin Yes        

NR, not reported; OB, obese; OW, overweight; SO, severe obesity.

Quality of Pharmaceutical RCTs

Overall, the quality of the pharmaceutical RCTs exceeded that of the lifestyle interventions, because participants could be blinded. Despite this, in nearly half of studies, participants and personnel were not blinded. See Fig 3 for the summary and Table 17 for additional details.

FIGURE 3

Quality of pharmaceutical RCTs, as assessed using the Cochrane Risk of Bias Tool.

FIGURE 3

Quality of pharmaceutical RCTs, as assessed using the Cochrane Risk of Bias Tool.

Close modal
TABLE 17

Quality of Pharmaceutical RCTs, as Assessed Using the Cochrane Risk of Bias Tool

Quality of Pharmaceutical RCTs, as Assessed Using the Cochrane Risk of Bias Tool
Quality of Pharmaceutical RCTs, as Assessed Using the Cochrane Risk of Bias Tool

Green arrow = low risk of bias; yellow diamond = unclear risk of bias; red arrow = high risk of bias.

Metformin was the most commonly studied medication, with 12 placebo-controlled trials137,141, 143,146,148,151,152,155,158,160162  and 5 additional trials without placebo (most commonly lifestyle-only).138140,145,156  No study examined children younger than 6 years, and most focused on adolescents. All studies required children to have obesity, with many limiting to children with severe obesity. In 12 of these 17 studies, metformin showed improved BMI in metformin compared with the comparison group, including both placebo controls and lifestyle comparison137,138,140,141,143,145, 148,151,156,158,160,161 ; 1 showed no improvement compared with oral contraceptive pills.139  Other studies showed reduced BMI using mixed carotenoids (n = 1),142  orlistat (n = 2),144,154  exenatide (n = 2),149,150  ephedrine + caffeine (n = 1),153  metformin + Policaptil Gel Retard (n = 1),159  and metformin + rosiglitazone (n = 1).136  Two showed no difference using topiramate (n = 1)147  or rhGH (n = 1; no difference).157  Only 5 studies included results beyond 6 months, showing improved BMI with metformin at 12 months160  and 18 months,137  improved BMI with orlistat at 12 months,144  improved BMI with Policaptil Gel Retard at 24 months,159  and improved BMI with metformin + rosiglitazone at 2 years.161  Magnitudes of BMI reduction were generally similar to those of lifestyle interventions.

Observational studies of lifestyle and diet were often based on reports of clinical experience. Of the 43 included studies,163206  54% (n = 23) showed some improvement in BMI outcomes compared with the nonintervention group (Table 18). Many of these studies used nonrandomized waitlist controls, historical controls, or an identified group of children seen by PCPs.

TABLE 18

Summary of Observational Lifestyle and Diet Studies

AuthorsTitleCountryNWeightAgesDifference T1Difference T2Other ObesityLipidsGlucoseBPOther LaboratoriesPsychosocialMental HealthBehaviors
Adam 2009 Effects of a combined inpatient-outpatient treatment of obese children and adolescents Germany 237 OB+ 8–15         
Anderson 2015 Effectiveness of current interventions in obese New Zealand children and adolescents New Zealand 290 SO 3–16          
Braet 2003 Inpatient treatment of obese children: a multicomponent program without stringent calorie restriction Belgium 66 OB+ 10–17       
Braet 1997 Follow-up results of different treatment programs for obese children Belgium 259 OW+ 7–16         
Bruyndonckx 2015 Diet, exercise, and endothelial function in obese adolescents Belgium 48 SO 12–18      
Chamay-Weber 2016 Obesity management in adolescents: comparison of a low-intensity face-to-face therapy provided by a trained pediatrician with an intensive multidisciplinary group therapy Switzerland 231 OB+ 11–18          
Chen 2013 iStart smart: a primary-care based and community partnered childhood obesity management program for Chinese-American children: feasibility study USA 41 OW+ 7–12       
Cheng 2014 2-year BMI changes of children referred for multidisciplinary weigh management USA 583 OW+ 2–18         
Cloutier 2015 Outcomes from a pediatric primary care weight management program: steps to growing up healthy USA 418 NR 2–4         
Danielsson 2016 Five-year outpatient program that provided children with continuous behavioral obesity treatment enjoyed high success rate Sweden 213 OB+ 4–13          
Eliakim 2004 Parental obesity and higher preintervention BMI reduce the likelihood of a multidisciplinary childhood obesity program to succeed–a clinical observation Israel 114 OB+ 6–16        
Eliakim 2002 The effect of a combined intervention on BMI and fitness in obese children and adolescents - a clinical experience Israel 202 OB+ Children and adolescents        
Endevelt 2014 An intensive family intervention clinic for reducing childhood obesity Israel 1043 OW+ 5–14         
Gortmaker 2015 Evaluation of a primary care intervention on BMI: the Maine Youth Overweight Collaborative USA 506 NR 2–18          
Hinchman 2006 Kaiser Permanente Georgia's experience with operation zero: a group medical appointment to address pediatric overweight USA 42 NR 11–17         
Lipana 2013 Telemedicine and face-to-face care for pediatric obesity USA 112 NR NR         
Marild 2013 A controlled study of lifestyle treatment in primary care for children with obesity Sweden 193 OB+ 8–13      
Nemet 2014 A combined nutritional-behavioral-physical activity intervention for the treatment of childhood obesity–a 7-y summary Israel 816 OB+ 6–16        
Nowicka 2008 Family Weight School treatment: 1-y results in obese adolescents Sweden 88 OB+ 12–19          
Nuutinen 1991 Long-term effects of dietary counseling on nutrient intake and weight loss in obese children Finland 45 OB+ 6–16         
Nuutinen 1992 Weight loss, body composition and risk factors for cardiovascular disease in obese children: long-term effects of two treatment strategies Finland 28 OW+ 6–15      
Reinehr 2003 Long-term follow-up of overweight children: after training, after a single consultation session, and without treatment Germany 247 OW+ 6–15         
Reinehr 2009 Lifestyle intervention in obese children is associated with a decrease of the metabolic syndrome prevalence Germany 474 OB+ 10–16       
Reybrouck 1990 Exercise therapy and hypocaloric diet in the treatment of obese children and adolescents Belgium 25 OB+ 3.9–16.4          
Schwartz 2007 Office-based motivational interviewing to prevent childhood obesity: a feasibility study USA 61 OW 3–7         
Sousa 2015 Controlled trial of an Internet-based intervention for overweight teens (Next.Step): effectiveness analysis Portugal 71 OB+ 12–18       
Spieth 2000 A low-glycemic index diet in the treatment of pediatric obesity USA 97 NR Mean 10         
Tanas 2007 A family-based education program for obesity: a 3-year study Italy 190 OW+ 3–18          
Taveras 2017 Clinical effectiveness of the Massachusetts childhood obesity research demonstration initiative among low-income children USA 3765 OW+ 2–12          
Tripicchio 2017 Technology components as adjuncts to family-based pediatric obesity treatment in low-income minority youth USA 48 OW+ 2–18         
Tucker 2013 Reducing pediatric overweight: nurse-delivered motivational interviewing in primary care USA 125 OW+ 4–18        
Tyler 2016 A primary care intervention to improve weight in obese children: A feasibility study USA 47 OB+ 8–12    
Uysal 2014 Components of the metabolic syndrome are negative predictors of weight loss in obese children with lifestyle intervention Germany 1017 OB+ Median 11.1      
Van Helst 2011 Effects of a multidisciplinary rehabilitation program on pediatric obesity: the CEMHaVi program France 74 OB+ 7–17         
Videira-Silva 2017 The effect of a physical activity consultation on BMI z- score of overweight adolescents: results from a pediatric outpatient obesity clinic Portugal 396 OW+ 10–17         
Wald 2011 Treating childhood obesity in primary care USA 78 OB+ 9–12         
Warschburger 2001 Conceptualization and evaluation of a cognitive-behavioral training program for children and adolescents with obesity Germany 197 OW+ 9+          
Yoshinaga 2004 Prevention of mildly overweight children from development of more overweight condition Japan 280 OB+ 6–11       
Bailey-Davis 2019 Feasibility of enhancing well-child visits with family nutrition and physical activity risk assessment on BMI USA 6048 Unclear 2–9          
Coles 2018 Breaking barriers: adjunctive use of the Ontario Telemedicine Network (OTN) to reach adolescents with obesity living in remote locations Canada 100 SO 12–18         
Derwig 2019 Child-centred health dialogue for primary prevention of obesity in Child Health Services - a feasibility study Sweden 776 OW          
Hagman 2020 Promising results from an implemented treatment model for pediatric obesity Sweden 3762 OB 6–12      
Tucker 2019 Evaluation of a primary care weight management program in children aged 2(–)5 y: changes in feeding practices, health behaviors, and BMI USA 119 OW+ 2–5         
AuthorsTitleCountryNWeightAgesDifference T1Difference T2Other ObesityLipidsGlucoseBPOther LaboratoriesPsychosocialMental HealthBehaviors
Adam 2009 Effects of a combined inpatient-outpatient treatment of obese children and adolescents Germany 237 OB+ 8–15         
Anderson 2015 Effectiveness of current interventions in obese New Zealand children and adolescents New Zealand 290 SO 3–16          
Braet 2003 Inpatient treatment of obese children: a multicomponent program without stringent calorie restriction Belgium 66 OB+ 10–17       
Braet 1997 Follow-up results of different treatment programs for obese children Belgium 259 OW+ 7–16         
Bruyndonckx 2015 Diet, exercise, and endothelial function in obese adolescents Belgium 48 SO 12–18      
Chamay-Weber 2016 Obesity management in adolescents: comparison of a low-intensity face-to-face therapy provided by a trained pediatrician with an intensive multidisciplinary group therapy Switzerland 231 OB+ 11–18          
Chen 2013 iStart smart: a primary-care based and community partnered childhood obesity management program for Chinese-American children: feasibility study USA 41 OW+ 7–12       
Cheng 2014 2-year BMI changes of children referred for multidisciplinary weigh management USA 583 OW+ 2–18         
Cloutier 2015 Outcomes from a pediatric primary care weight management program: steps to growing up healthy USA 418 NR 2–4         
Danielsson 2016 Five-year outpatient program that provided children with continuous behavioral obesity treatment enjoyed high success rate Sweden 213 OB+ 4–13          
Eliakim 2004 Parental obesity and higher preintervention BMI reduce the likelihood of a multidisciplinary childhood obesity program to succeed–a clinical observation Israel 114 OB+ 6–16        
Eliakim 2002 The effect of a combined intervention on BMI and fitness in obese children and adolescents - a clinical experience Israel 202 OB+ Children and adolescents        
Endevelt 2014 An intensive family intervention clinic for reducing childhood obesity Israel 1043 OW+ 5–14         
Gortmaker 2015 Evaluation of a primary care intervention on BMI: the Maine Youth Overweight Collaborative USA 506 NR 2–18          
Hinchman 2006 Kaiser Permanente Georgia's experience with operation zero: a group medical appointment to address pediatric overweight USA 42 NR 11–17         
Lipana 2013 Telemedicine and face-to-face care for pediatric obesity USA 112 NR NR         
Marild 2013 A controlled study of lifestyle treatment in primary care for children with obesity Sweden 193 OB+ 8–13      
Nemet 2014 A combined nutritional-behavioral-physical activity intervention for the treatment of childhood obesity–a 7-y summary Israel 816 OB+ 6–16        
Nowicka 2008 Family Weight School treatment: 1-y results in obese adolescents Sweden 88 OB+ 12–19          
Nuutinen 1991 Long-term effects of dietary counseling on nutrient intake and weight loss in obese children Finland 45 OB+ 6–16         
Nuutinen 1992 Weight loss, body composition and risk factors for cardiovascular disease in obese children: long-term effects of two treatment strategies Finland 28 OW+ 6–15      
Reinehr 2003 Long-term follow-up of overweight children: after training, after a single consultation session, and without treatment Germany 247 OW+ 6–15         
Reinehr 2009 Lifestyle intervention in obese children is associated with a decrease of the metabolic syndrome prevalence Germany 474 OB+ 10–16       
Reybrouck 1990 Exercise therapy and hypocaloric diet in the treatment of obese children and adolescents Belgium 25 OB+ 3.9–16.4          
Schwartz 2007 Office-based motivational interviewing to prevent childhood obesity: a feasibility study USA 61 OW 3–7         
Sousa 2015 Controlled trial of an Internet-based intervention for overweight teens (Next.Step): effectiveness analysis Portugal 71 OB+ 12–18       
Spieth 2000 A low-glycemic index diet in the treatment of pediatric obesity USA 97 NR Mean 10         
Tanas 2007 A family-based education program for obesity: a 3-year study Italy 190 OW+ 3–18          
Taveras 2017 Clinical effectiveness of the Massachusetts childhood obesity research demonstration initiative among low-income children USA 3765 OW+ 2–12          
Tripicchio 2017 Technology components as adjuncts to family-based pediatric obesity treatment in low-income minority youth USA 48 OW+ 2–18         
Tucker 2013 Reducing pediatric overweight: nurse-delivered motivational interviewing in primary care USA 125 OW+ 4–18        
Tyler 2016 A primary care intervention to improve weight in obese children: A feasibility study USA 47 OB+ 8–12    
Uysal 2014 Components of the metabolic syndrome are negative predictors of weight loss in obese children with lifestyle intervention Germany 1017 OB+ Median 11.1      
Van Helst 2011 Effects of a multidisciplinary rehabilitation program on pediatric obesity: the CEMHaVi program France 74 OB+ 7–17         
Videira-Silva 2017 The effect of a physical activity consultation on BMI z- score of overweight adolescents: results from a pediatric outpatient obesity clinic Portugal 396 OW+ 10–17         
Wald 2011 Treating childhood obesity in primary care USA 78 OB+ 9–12         
Warschburger 2001 Conceptualization and evaluation of a cognitive-behavioral training program for children and adolescents with obesity Germany 197 OW+ 9+          
Yoshinaga 2004 Prevention of mildly overweight children from development of more overweight condition Japan 280 OB+ 6–11       
Bailey-Davis 2019 Feasibility of enhancing well-child visits with family nutrition and physical activity risk assessment on BMI USA 6048 Unclear 2–9          
Coles 2018 Breaking barriers: adjunctive use of the Ontario Telemedicine Network (OTN) to reach adolescents with obesity living in remote locations Canada 100 SO 12–18         
Derwig 2019 Child-centred health dialogue for primary prevention of obesity in Child Health Services - a feasibility study Sweden 776 OW          
Hagman 2020 Promising results from an implemented treatment model for pediatric obesity Sweden 3762 OB 6–12      
Tucker 2019 Evaluation of a primary care weight management program in children aged 2(–)5 y: changes in feeding practices, health behaviors, and BMI USA 119 OW+ 2–5         

NR, not reported; OB, obese; OW, overweight; SO, severe obesity.

As detailed in Appendix 5, studies often showed significant reductions in BMI measures within groups, even if between-group differences were not significant. Compared with the RCTs of lifestyle and diet, the observational studies typically had larger sample sizes and longer follow-up periods, although this was not universal. Studies with the longest follow-up periods varied: 5 showed no effect at 2 years,164,183185  5 showed improvement at 2 years,170,192,197,201,205  1 showed improvement at 3 years,191  and 1 showed improvement at 5 years.172  Because these studies are observational, selection effects should be carefully considered, particularly when comparison groups comprise children who were not referred for treatment or who declined to participate in treatment. The marked difference in the number of observational studies showing BMI improvement (54%) compared with the RCTs (35%) may reflect this selection bias or may indicate publication bias.

Observational studies of pharmaceutical treatment were often based on reports of children receiving different clinical care. Of the 8 included studies,207214  50% showed some effectiveness compared with the nonintervention group (Table 19). In these studies, 4 compared metformin to lifestyle207,208,210212 ; 2 of these showed improved BMI for those using metformin.208,210  Metformin was not significantly different from omega-3 fatty acid supplements.209  Metformin + Policaptil Gel Retard was associated with greater BMI loss than metformin alone,213  as was phentermine compared with lifestyle intervention.212  These studies were primarily conducted with adolescents with obesity and some included diets with low glycemic indices as well as medication.

TABLE 19

Summary of Observational Pharmaceutical Studies

AuthorsTitleCountryNWeightAgesComparison 1Comparison 2Difference t1?Difference t2?Other ObesityLipidsGlucoseBPOther LaboratoriesPsychosocialMental HealthBehaviorsOther
Aa 2016 The effect of eighteen-month metformin treatment in obese adolescents: comparison of results obtained in daily practice with results from a clinical trial The Netherlands 42 OB+ 10–16 Metformin Lifestyle          
Harden 2007 Effects of lifestyle intervention and metformin on weight management and markers of metabolic syndrome in obese adolescents USA 63 OB+ 11–18 Metformin Lifestyle      
Juarez-Lopez 2013 Omega-3 polyunsaturated fatty acids reduce insulin resistance and triglycerides in obese children and adolescents Mexico 201 OB+ 10–12 Metformin Omega-3       
Krzystek- Korpacka 2011 The effect of a 1-year weight reduction program on serum uric acid in overweight and obese children and adolescents Poland 113 OW+ 10–17 Metformin Lifestyle       
Marques 2016 Metformin effectiveness and safety in the management of overweight and obese nondiabetic children and adolescents: metabolic benefits of the continuous exposure to metformin at 12 and 24 mo Portugal 74 OW+ 8–17 Metformin Lifestyle        
Ryder 2017 Effect of phentermine on weight reduction in a pediatric weight management clinic USA 191 OB+ 11.9–17.7 Phentermine Lifestyle         
Stagi 2017 Retrospective evaluation of metformin and/or metformin plus a new polysaccharide complex in treating severe hyperinsulinism and insulin resistance in obese children and adolescents with metabolic syndrome Italy 120 OB+ 8.2–14.5 Metformin Metformin + Policaptil Gel Retard           
Lentferink 2018 Long-term metformin treatment in adolescents with obesity and insulin resistance, results of an open label extension study Netherlands 31 OB  Metformin extension No metformin    
AuthorsTitleCountryNWeightAgesComparison 1Comparison 2Difference t1?Difference t2?Other ObesityLipidsGlucoseBPOther LaboratoriesPsychosocialMental HealthBehaviorsOther
Aa 2016 The effect of eighteen-month metformin treatment in obese adolescents: comparison of results obtained in daily practice with results from a clinical trial The Netherlands 42 OB+ 10–16 Metformin Lifestyle          
Harden 2007 Effects of lifestyle intervention and metformin on weight management and markers of metabolic syndrome in obese adolescents USA 63 OB+ 11–18 Metformin Lifestyle      
Juarez-Lopez 2013 Omega-3 polyunsaturated fatty acids reduce insulin resistance and triglycerides in obese children and adolescents Mexico 201 OB+ 10–12 Metformin Omega-3       
Krzystek- Korpacka 2011 The effect of a 1-year weight reduction program on serum uric acid in overweight and obese children and adolescents Poland 113 OW+ 10–17 Metformin Lifestyle       
Marques 2016 Metformin effectiveness and safety in the management of overweight and obese nondiabetic children and adolescents: metabolic benefits of the continuous exposure to metformin at 12 and 24 mo Portugal 74 OW+ 8–17 Metformin Lifestyle        
Ryder 2017 Effect of phentermine on weight reduction in a pediatric weight management clinic USA 191 OB+ 11.9–17.7 Phentermine Lifestyle         
Stagi 2017 Retrospective evaluation of metformin and/or metformin plus a new polysaccharide complex in treating severe hyperinsulinism and insulin resistance in obese children and adolescents with metabolic syndrome Italy 120 OB+ 8.2–14.5 Metformin Metformin + Policaptil Gel Retard           
Lentferink 2018 Long-term metformin treatment in adolescents with obesity and insulin resistance, results of an open label extension study Netherlands 31 OB  Metformin extension No metformin    

OB, obese; OW, overweight.

Most studies of surgical interventions were observational in nature (Table 20). Of the 11 included studies,215225  7 compared surgical intervention (eg, Roux-en-Y bypass or laparoscopic adjustable gastric band [LAGB]) to lifestyle-only intervention or controls. All of these studies demonstrated significant reduced BMI among those receiving surgical treatment compared with lifestyle. One study showed greater BMI reduction at 2 years among adolescents receiving vertical sleeve gastrectomy (VSG), compared with intragastric weight loss device or lifestyle, although the difference across all 3 groups was not significant. Three additional studies compared 2 surgical interventions. One study showed greater BMI reduction at 3 years for those receiving gastric bypass compared with VSG. A second showed much greater BMI reduction at 12 months for VSG compared with LAGB. The third shows greater BMI reduction at 5 years for gastric bypass and VSG compared with LAGB. Most surgical interventions resulted in significant BMI loss—consistently about 15 BMI units or 30% BMI reduction.

TABLE 20

Summary of Surgical Studies

AuthorsTitleCountryNWeightAgesComparison 1Comparison 2Comparison 3Difference t1?Difference t2?Other ObesityLipidsGlucoseBPOther LaboratoriesPsychosocialMental HealthBehaviorsOther
Gothberg 2014 Laparoscopic Roux-en-Y gastric bypass in adolescents with morbid obesity–surgical aspects and clinical outcome Sweden 162 SO 13–18 Bypass Controls           
Inge 2016 Weight loss and health status 3 years after bariatric surgery in adolescents USA 273 SO 13–19 RNY SG         
Inge 2018 Comparison of surgical and medical therapy for type 2 diabetes in severely obese adolescents USA 93 SO 13–18 RNY Metformin       
Manco 2017 The benefit of sleeve gastrectomy in obese adolescents on nonalcoholic steatohepatitis and hepatic fibrosis Italy 62 SO 13–17 SG Device      
O’Brien 2010 Laparoscopic adjustable gastric banding in severely obese adolescents: a randomized trial Australia 50 SO 14–18 Band Lifestyle        
Olbers 2012 T wo-year outcome of laparoscopic Roux-en-Y gastric bypass in adolescents with severe obesity: results from a Swedish Nationwide Study (AMOS) Sweden 162 SO 13–18 Bypass Lifestyle       
Olbers 2017 Laparoscopic Roux-en-Y gastric bypass in adolescents with severe obesity (AMOS): a prospective, 5-year, Swedish nationwide study Sweden 153 SO 13–18 RYGB Controls       
Pedroso 2015 Laparoscopic vertical sleeve gastrectomy significantly improves short term weight loss as compared with laparoscopic adjustable gastric band placement in morbidly obese adolescent patients USA 132 SO 12.7–21.4 LAGB VSG          
Ryder 2018 Factors associated with long-term weight-loss maintenance following bariatric surgery in adolescents with severe obesity USA 80 SO <21 RNY Lifestyle            
Henfridsson 2019  Sweden 147 SO Mean 16 LRYGB Lifestyle          
Inge 2018  USA 544 SO 12–19 AGB RYGB Sleeve         
AuthorsTitleCountryNWeightAgesComparison 1Comparison 2Comparison 3Difference t1?Difference t2?Other ObesityLipidsGlucoseBPOther LaboratoriesPsychosocialMental HealthBehaviorsOther
Gothberg 2014 Laparoscopic Roux-en-Y gastric bypass in adolescents with morbid obesity–surgical aspects and clinical outcome Sweden 162 SO 13–18 Bypass Controls           
Inge 2016 Weight loss and health status 3 years after bariatric surgery in adolescents USA 273 SO 13–19 RNY SG         
Inge 2018 Comparison of surgical and medical therapy for type 2 diabetes in severely obese adolescents USA 93 SO 13–18 RNY Metformin       
Manco 2017 The benefit of sleeve gastrectomy in obese adolescents on nonalcoholic steatohepatitis and hepatic fibrosis Italy 62 SO 13–17 SG Device      
O’Brien 2010 Laparoscopic adjustable gastric banding in severely obese adolescents: a randomized trial Australia 50 SO 14–18 Band Lifestyle        
Olbers 2012 T wo-year outcome of laparoscopic Roux-en-Y gastric bypass in adolescents with severe obesity: results from a Swedish Nationwide Study (AMOS) Sweden 162 SO 13–18 Bypass Lifestyle       
Olbers 2017 Laparoscopic Roux-en-Y gastric bypass in adolescents with severe obesity (AMOS): a prospective, 5-year, Swedish nationwide study Sweden 153 SO 13–18 RYGB Controls       
Pedroso 2015 Laparoscopic vertical sleeve gastrectomy significantly improves short term weight loss as compared with laparoscopic adjustable gastric band placement in morbidly obese adolescent patients USA 132 SO 12.7–21.4 LAGB VSG          
Ryder 2018 Factors associated with long-term weight-loss maintenance following bariatric surgery in adolescents with severe obesity USA 80 SO <21 RNY Lifestyle            
Henfridsson 2019  Sweden 147 SO Mean 16 LRYGB Lifestyle          
Inge 2018  USA 544 SO 12–19 AGB RYGB Sleeve         

SO, severe obesity.

Effects for Specific Subgroups

Few interventions specifically analyzed the effects of their interventions on subgroups, such as by age, sex, or obesity severity classification. Some studies showed differences by sex, but the findings were inconsistent. Often children with obesity were considered as 1 group, regardless of severity, making it difficult to understand differential effects based on classes of obesity.

Sustained Treatment Effect

Of the lifestyle RCTs, 57 included at least 1 follow-up measure. There was a lower likelihood of success at a subsequent time point (33%) than at the first time point (35%). However, several studies (n = 26) reported outcomes beyond 12 months; 22 reported outcomes at 2 years or later, with 36 months being the longest time frame. Only 6 of these studies showed any success of the intervention at this later time point. Two of these were primary-care based MI studies with <5 hours of contact.40,51  Two others were high-intensity (≥52 hours) family-based interventions.96,118  An additional 2 reports of the same population demonstrated success among 2- to 5-year-olds in medium-intensity (5–25 hours) family-based treatment.114,115 

Barriers, Engagement, and Attrition

Overall, attrition from the interventions was high. Attrition of greater than 25% was not uncommon. Although global attrition was usually reported, factors associated with attrition were not. Lack of follow-up data on dropouts prevents a clear understanding of whether attrition is related to obesity severity or initial success in treatment. Many studies commented on barriers to participation in the interventions, but few specifically measured these. One study specifically measured barriers to adherence, identifying transportation time and expenses as barriers.31 

Most of the studies (n = 109) included in this review were randomized trials of lifestyle or diet interventions, with fewer studies on pharmaceutical treatments or surgical interventions. Following the guidelines endorsed by the American Academy of Pediatrics in 2007,226  the interventions would largely qualify as stage 1 (those with minimal intervention comparators of <5 hours) or stages 2 or 3 (those utilizing a multidisciplinary team including dietitians and nutritionists and multicomponent behavioral treatment approach with higher intensity), with few examining stage 4 (pharmaceutical or surgical intervention, with no very low calorie diets). We did not assess interventions that occurred entirely outside of the clinical setting but instead focused on those approaches that included the pediatric outpatient clinical setting in some meaningful way. Most of the clinical settings were pediatric primary care practices, although pediatric weight management programs were also common. Although we included prevention studies in our search strategy, only treatment studies including children with overweight or obesity met criteria.

Almost half of the lifestyle and diet RCTs demonstrated clinically significant changes in BMI or BMI SDS. Interventions demonstrating improved BMI typically including a nutritionist along with physical activity and nutrition counseling (if less than 26 hours of contact time), or actual physical activity training as part of the visit along with behavioral health support (if at least 26 hours of contact hours). The more intense studies typically included only children and adolescents with obesity, and those studies with fewer contact hours included children and adolescents who had overweight or obesity. Higher-intensity studies were more effective in reducing BMI. However, the few studies demonstrating long-term effectiveness included low-intensity MI in primary care as well as high-intensity family-based treatment. No other intervention components were consistently associated with positive results. Some studies tested novel strategies to deliver counseling to families, including telehealth and sleep training, which represent promising areas of future research to fill the gap in supporting families in between face-to-face counseling sessions, but these were not clearly associated with BMI reduction.

The most notable finding of the RCTs of interventional lifestyle treatment studies (both with controls and comparative effectiveness studies) is simply how few (n = 28) of them meet the currently recommended USPSTF standard of at least 26 hours of contact time. The implication is twofold. First, many published studies do not clearly calculate contact hours. Clear standards should be set to consistently operationalize and report the delivered dose. Second, it demonstrates the difficulty of successfully translating the high-intensity research-setting interventions into real-world situations. In fact, even in ideal research conditions, there was significant attrition of participants, evidence of the difficulty in consistently delivering a higher number of contact hours.

Obesity is a chronic disease, but very few of the interventions delivered care consistent with the chronic care model.227  This model considers not just health care provision, but patient factors, accessibility of healthy food and activity spaces, and the broader social context in which people live, as well as the importance ongoing connection between health care and community. Interventions in all categories of intensity delivered the intervention over the short-term (2 months) to midterm (24 months). Interestingly, lower-intensity studies, largely based in primary care, tended to be longer-term as compared with the more intensive interventions delivered in specialty settings. Although that finding likely reflects the resources required to deliver an intervention, the result is that children with less severe degrees of obesity in effect are receiving less intensive, longer-term care than children with severe obesity who are receiving more intensive, shorter-term care. Although this strategy might be acceptable for low-risk patients, a chronic disease approach would suggest that children with severe obesity should receive intensive and long-term care.

This review prioritized a reduction in BMI or BMI SDS as the primary outcome and traditional comorbidities as secondary outcomes. However, there may have been unmeasured factors that would better predict response to treatment in addition to basic demographic information. Several studies collected psychosocial variables at baseline and at varying endpoints; these variables may be used also as predictors or moderators of outcomes to learn who is most likely to benefit from obesity treatment. In addition, several factors related to long-term progression of obesity were not collected by any of the studies contained in this review. For example, weight bias—and in particular, internalization of weight bias—is known to negatively impact an individual’s likelihood of seeking care, which may limit their ability to obtain treatment of obesity and related illnesses into the future. A recent systematic review identified 74 studies assessing the relationship between weight bias internalization and health; this review identified a strong, negative relationship between weight bias and mental health.228 

The majority of interventions used patient or family education about health behaviors, provider education, and experiential exercise and/or nutrition opportunities. However, additional strategies may be important to understand who benefits from child obesity interventions but were not consistently observed in this review. For example, in a meta-analysis of interventions used in chronic-disease programs among adults, the factors most closely related to positive outcomes were not patient or provider education, but digital engagement strategies, such as text-message reminders, and a host of social and financial incentives inspired by the field of behavioral economics.229 

It is also important to consider other outcomes based on the family’s expectations, culture, and desired changes. Family-centered outcomes may include improving the child’s self-esteem, coping with bullying, and quality of life, which were measured to some extent in the studies reviewed but with no consistent pattern of improvement. Further, the way to quantify and track children’s weight remains a subject of controversy. Improvements in health (blood pressure, glycemic control) and in fitness might also be important outcomes to collect. Although some studies reported these as secondary outcomes, the lack of power reporting makes it difficult to understand the true impact of interventions.

Anthropometric measurements, such as height and weight, are easiest to obtain in a clinical setting, yet these have limitations in tracking changes in adiposity over time.230  Absolute change in BMI or weight (kg) are useful indicators in short-term trials when height is stable, but because children’s height rapidly changes over time, BMI needs to be adjusted based on age and biological sex.231  BMI was the most commonly used metric in the present review but was also used in long-term trials, including those over 12 to 24 months, without adjustment for age or biological sex. Although BMI SDS was the second most frequently used metric of weight change in the included interventions, BMI SDS is not recommended for detecting changes in weight at the upper end of the spectrum among children with severe obesity.232  Absolute BMI, BMI percentage of the 95th percentile, change in percentage of the 95th percentile, and BMI as a percentage of the median BMI for age and biological sex are indicated as useful to monitor patient-level change in severe obesity over time.231  An important future direction is to integrate these more sensitive weight metrics into electronic health record portals in a way that providers and families understand and can monitor, alongside other outcomes that both the family and health care provider deem to be important.

A unique contribution of this review is the inclusion of comparative effectiveness studies; indeed, half of the lifestyle interventions were comparative effectiveness trials. The USPSTF 2018 report only included trials that had a minimal or control comparator arm. Comparative effectiveness studies can reveal important findings on differential effects of treatments based on adjunct components, specific dietary plans, delivery of treatment in different settings, or directly comparing interventions of different intensity or content. Although the interventions with higher intensity in terms of contact hours typically produced greater weight loss, there were no specific intervention components that consistently explained stronger effects. Therefore, more comparative effectiveness trials are required to identify the critical ingredients of lifestyle or diet interventions, to compare pharmaceutical versus lifestyle versus surgical approaches as well as combinations, and to understand whether some intervention approaches are more effective among certain populations or patients. In general, it is challenging to interpret findings from comparative effectiveness studies without an established margin of equivalence (ie, what is a meaningful difference in BMI change between the 2 comparator arms) or an established threshold for a clinically meaningful reduction in BMI or BMI SDS (ie, 1 intervention achieved clinically meaningful reduction whereas the other did not).

Trials faced problems with high attrition and low adherence, particularly among the more intensive interventions with more frequent contacts. Multicomponent approaches had smaller sample sizes indicative of the challenges of deploying a large-scale pragmatic clinical trial. For example, none of the minimal-intervention control studies that examined interventions with more than 25 hours of contact had a sample size larger than 100. Research studies do pose additional burdens to families and providers beyond clinical treatment, including strictly following a clinical protocol that includes eligibility screening, consenting, and assessment visits. However, the adherence and motivation challenges will persist outside of research studies in traditional clinical practices, particularly the logistical challenges of high-intensity treatment.233,234  Future studies should gather more information on the predictors of treatment success as well as the facilitators and barriers to adherence, both in terms of families meeting their commitment to scheduled counseling sessions as well as families changing their behaviors and sustaining this outside of the sessions. Moreover, more accessible strategies that link patients to providers, such as telehealth or phone call counseling and texting, could be important to consider to realistically achieve additional contact hours. With the emergence of additional health technologies, opportunities will exist that did not at the time that these studies were conducted.

Short Follow-up Periods

Few studies included follow-up visits to determine whether weight loss was sustained, and the longest study period involved 36 months of follow-up, which is a stark contrast to the data available on adult weight loss interventions out to 10 years. In children, the desired outcomes may be to plateau weight gain or to arrest the development of obesity-related cardiovascular and metabolic disease until adulthood. Longer-term data are needed to establish sufficient weight loss or cardiovascular improvements than can affect health into adulthood. Also, most of the lifestyle, diet, pharmaceutical, and surgery trials excluded children with mobility impairments, chronic diseases, and mental health conditions; therefore, there is less evidence on effective weight management approaches for these populations despite their elevated risk for obesity.

Limited Description of Intervention Components, Dose, and Duration

Published intervention studies often provided limited information about the dose, duration, and specifics of the intervention components and implementation procedures. This lack of detail significantly limits the opportunity to inform recommendations in practice. More details are needed on what is effective intervention content, behavior change techniques, and successful efforts to improve retention and family motivation. This information is critical if we are to create replicable findings and application of evidence. Drilling down to the essential ingredients of an effective lifestyle or diet intervention and how those components affect comorbidities is also important so that providers can focus on the critical content. This is particularly important when faced with limited contact hours because of family transportation or scheduling barriers or limited personnel or resources and financial constraints. Further, determining potential synergies among diet, lifestyle, pharmaceutical, and surgical interventions is important to develop individualized treatment plans that may start with more or less aggressive strategies depending on the child’s weight and health status, motivation, and readiness. Lifestyle interventions are core to good health but need to exist in context.

Inclusion Criteria Limit Translation to Clinical Care

Additionally, many studies had relatively restrictive inclusion criteria, excluding children with comorbidities (including mental health conditions), children with physical activity limitations, or those using medications. In clinical practice, these children often have the greatest need for support in addressing obesity.

This review identified several critical gaps in the field that should be considered in the development of future studies. The most important gaps include: (1) systems context for interventions, (2) assessment of harms, (3) economics and sustainability, (4) heterogeneity of treatment effects, and (5) patient engagement.

First, current intervention studies include minimal consideration of the systems surrounding them. Although the goal of most research is to limit the influence of external factors, child obesity results from the interactions within a complex system. The social context for families will be critical to understanding which interventions work, for whom they work, and the situations in which they work.

Second, most studies provided no or very limited assessment of harms or unintended consequences. In general, behavioral interventions carry low risk of harms; however, this is not well-documented in the existing literature, as few studies report adverse events. Restrictive dieting is known to lead to disordered eating patterns, is associated with adult obesity, and may worsen the quality of a child’s food intake. Likewise, short-term weight loss has been shown to lead to weight regain above the initial weight, making it less clear whether a short period of weight loss adds more benefit than the likely common weight regain. These unintended consequences are less likely for nonrestrictive eating interventions; however, failure to assess and report this does not allow for reassurance and may ultimately limit dissemination. In addition, families living in low-resource environments may suffer financially by switching to foods that cost more and may lead to unintended consequences. Little is known about the psychological effects on children of increasing their awareness of their own condition of obesity.

Third, the economics of the interventions were rarely considered, including challenges with sustainability and payment mechanisms. Access to care is severely limited by inconsistent and insufficient payment for effective treatment options.235  In the United States, the USPSTF is authorized by Congress to assign grades to the state of the evidence regarding treatment options for diseases; grades of A or B are mandated by the Affordable Care Act that patients pay no deductibles or copayments and do not participate in cost-sharing.236  The USPSTF assigned a B grade to recommend clinicians screen children 6 years and older for obesity and offer or refer them to comprehensive, intensive behavioral interventions to promote improvements in weight status.1  Despite this mandate, many insurance providers are not paying for these services. For example, a Children’s Hospital Association survey conducted in 2013 surveyed 218 children’s hospitals.237  Of the 118 that responded, only 52 reported providing comprehensive, multidisciplinary weight management consistent with USPSTF recommendations, and half of these programs were fewer than 20 weeks in length. Importantly, 84% of children’s hospitals that had weight management programs reported operating at a financial loss, with about half of physicians being fully reimbursed by Medicaid or commercial plans and far less reimbursement available for other health care providers, such as registered dietitians or behavioral counselors. However, as payment models shift from fee-for-service toward population-based payment models, there are promising avenues toward securing reimbursement consistent with legislative mandates for comprehensive obesity treatment.235 

Fourth, the current research does not provide sufficient information about the heterogeneity of treatment effects for obesity interventions. Studies generally did not identify demographic or social factors beyond biological sex, age, race, and ethnicity. Geographical region, food insecurity, poverty, and adverse childhood experiences (ACEs) may all be important and possibly salient factors in explaining treatment outcomes. Identifying clusters of comorbidities and obesity risk behaviors as well as duration and timing of onset of obesity during childhood and adolescence would also allow within-study results to be analyzed for potential heterogeneous responses to obesity treatment. Family and child readiness to change would also be useful to characterize the population entering the study and the potential for efficacy by these factors. Finally, severity of obesity must be considered in understanding treatment effects. Given that severe forms of obesity have increased, examining this group in future studies, rather than condensing all forms of obesity together, will be important.

Finally, current interventions include limited input from children, families, and caregivers regarding development, refinement, and implementation. Few studies included patients and families in the development of interventions, limiting the ability to ensure they are meeting the preferences and unique needs of the populations. True patient engagement could bring new insight and improve the quality of interventions and their effectiveness. This patient perspective is particularly important for the Medicaid population with their limited financial resources and unmet social needs. Despite the implementation of strong, evidence-based interventions and engagement of kids and families, overcoming financial and social barriers is critical to the success of interventions.

Contrary to the conventional wisdom that childhood and adolescent obesity interventions are ineffective, almost half of the diet and lifestyle RCTs included in this review were effective in reducing adiposity, at least in the short-term. Given the heterogeneity of the intervention types, intensity, duration, and individuals involved in delivering the intervention, it is nearly impossible at this time to specify the “optimal” childhood obesity treatment. However, it is clear that the more intense the intervention, based on hours of contact, the greater the benefit to the child in terms of BMI reduction, while keeping in mind that the more intense interventions are more costly and can impact fewer total number of people. This report highlights the promise of childhood obesity treatment but also the challenging way forward. Interventions must be sustained financially to be effective and must leverage innovative strategies to keep families engaged throughout treatment. It is also reassuring to see some benefit of lower-intensity interventions delivered in primary care, particularly those that use MI. Moving forward, a shared resource of metrics by which to compare interventions but also to predict success at the individual level will advance the science more rapidly.

We thank Chelsea Kracht, PhD, for her help in reviewing abstracts.

Technical reports from the American Academy of Pediatrics benefit from expertise and resources of liaisons and internal (AAP) and external reviewers. However, technical reports from the American Academy of Pediatrics may not reflect the views of the liaisons or the organizations or government agencies that they represent.

The guidance in this report does not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate.

All technical reports from the American Academy of Pediatrics automatically expire 5 years after publication unless reaffirmed, revised, or retired at or before that time.

This document is copyrighted and is property of the American Academy of Pediatrics and its Board of Directors. All authors have filed conflict of interest statements with the American Academy of Pediatrics. Any conflicts have been resolved through a process approved by the Board of Directors. The American Academy of Pediatrics has neither solicited nor accepted any commercial involvement in the development of the content of this publication.

FUNDING: Some support for the technical report came from the Strengthening Public Health Systems and Services QT18-1802 through the National Partnerships to Improve and Protect the Nation's Health grant from the Centers for Disease Control and Prevention.

ALT

alanine aminotransferase

AST

aspartate aminotransferase

HDL

high-density lipoprotein

KQ

key question

LAGB

laparoscopic adjustable gastric band

LDL

low-density lipoprotein

MI

motivational interviewing

PCP

primary care provider

RCT

randomized controlled trial

SDS

standard deviation score

USPSTF

US Preventive Services Task Force

VSG

vertical sleeve gastrectomy

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