Original Article
Effectiveness of cognitive-behavioral therapy on nutrition improvement and weight of overweight and obese adolescents: A randomized controlled trial

https://doi.org/10.1016/j.dsx.2019.05.010Get rights and content

Abstract

Aim

To assess the effectiveness of a cognitive-behavioral treatment (CBT) program on weight reduction among Iranian adolescents who are overweight.

Methods

Using a randomized controlled trial design, 55 adolescents who were overweight (mean [SD] age = 14.64 [1.69] years; zBMI = 2.18 [0.65]) were recruited in the CBT program and 55 in the treatment as usual (TAU; mean age = 14.88 [1.50]; zBMI = 2.09 [0.57]) group. All the participants completed several questionnaires (Child Dietary Self-Efficacy Scale; Weight Efficacy Lifestyle questionnaire; Physical Exercise Self-Efficacy Scale; Pediatric Quality of Life Inventory; and self-reported physical activity and diet) and had their anthropometrics measured (height, weight, waist and hip circumferences, and body fat).

Results

The CBT group consumed significantly more fruits and juice, vegetables, and dairy in the 6-month follow-up as compared with the TAU group (p-values <0.001). The CBT group consumed significantly less sweet snacks, salty snacks, sweet drinks, sausages/processed meat, and oils in the six-month follow-up compared with the TAU group (p-values<0.001). Additionally, the waist circumference, BMI, waist-hip ratio, and fat mass were significantly decreased in the CBT group in the six-month follow-up compared with the TAU group (p-values<0.005). The CBT group significantly improved their psychosocial health, physical activity, and health-related quality of life (p-values<0.001).

Conclusion

The CBT program showed its effectiveness in reducing weight among Iranian adolescents who were overweight. Healthcare providers may want to adopt this program to treat excess weight problems among adolescents.

Introduction

The number of individuals that are overweight and obese is expanding rapidly worldwide [1]. It is estimated that 57.8% of the adults in the world will be overweight or obese by 2030 [1]. Moreover, excess weight as indicated by a high body mass index (BMI) has increased in both genders in Eastern and Southern Asia, and for females in Southeast Asia [2]. Being overweight is the most common risk factor for non-communicable diseases [3]. Along with adolescent obesity, childhood obesity has also become a pandemic health problem in developing countries [4]. Consequently, obesity is one of the most serious public health challenges in the present century [5]. The problem also exists in Iran (where the present study was carried out) [3]. The prevalence of being overweight and obese in children is 21% and 18.3% respectively. In addition, abdominal obesity has been reported to be prevalent in 17.6% of the Iranian adolescents [6]. Being overweight and obesity have increased dramatically among Iranian children since 2000 (3). Given that about 80% of obese adolescents will remain obese in adulthood [7,8], healthcare providers in Iran need to pay additional attention to the issue of obesity.

Evidence suggests that the burden of obesity on physical health starts in early life, and contributes to the development of risk factors for metabolic heart diseases during childhood and adolescence [9]. It is also associated with early death in adulthood [10]. Childhood obesity has complex causes, including genetic, environmental, physiological, and psychosocial factors [10]. More specifically, environmental factors such as lifestyle preferences and the cultural situation are important determinants in the increased prevalence of obesity globally [11]. In general, being overweight and obesity are the results of increased calorie and fat intake [11]. Also, over-consumption of sugar in non-alcoholic beverages and the continuous decline in physical activity have also contributed to the increased rate of obesity worldwide [11].

Several systematic reviews and meta-analyses have shown that weight control is possible using various interventions concerning environmental factors, such as changing a child's eating habits, lifestyles, and modifying the whole family and environment (school and community) [12,13]. The treatment of children who are overweight and obese appears easy as it typically involves advising children and their families to eat less and do more exercise [14]. However, in practical terms, the treatment of childhood obesity is time consuming, boring, difficult, and expensive. In fact, choosing the best method to treat being overweight and obesity in children is very complicated [14] and requires multicomponent interventions including medical and lifestyle interventions, psychosocial support, self-management programs, and pharmacological strategies, as well as bariatric medical procedures in extreme cases [15]. Fortunately, when obesity is treated at an early age, even a relatively low weight loss can dramatically improve child's health [16].

Therefore, interventions for overweight children are needed. One recommended treatment by the US Prevention Services Work Group is the use of lifestyle interventions [17]. Lifestyle interventions include behavioral components and cognitive skills training that focus on weight-related behaviors [18,19]. In most programs, weight-management aspects are the main components, but programs that consider behavioral approaches, cognitive rehabilitation, and prevention methods can also increase treatment efficacy [18,19]. Interventions with behavioral components that change diet and activity such as improvement of physical activity and reduction of immobility have the greatest impact on weight reduction in overweight adolescents [20,21]. Another key component of lifestyle interventions is family involvement and support. Family behavior interventions including parent involvement in the treatment process have been effective in controlling weight and developing healthy eating habits over the past 30 years [22,23].

The most successful multi-dimensional approach that influences diet, physical activity, and behavior change is the family-based approach [24,25]. Family-based behavioral intervention is an effective and safe treatment for childhood obesity, and should be considered the first treatment option [24,25]. It can ensure that parents are provided with a better access to healthy foods. Family-based weight loss programs are valuable methods for adolescents to choose healthier foods [26] and weight loss remains durable for two years [27]. Therefore, parental involvement in weight loss programs appears necessary in achieving weight-reduction goals.

One of the most up-to-date approaches to managing obesity is cognitive-behavioral therapy (CBT) [28]. More specifically, CBT can be used to reschedule the lifestyle of an individual who is overweight [29]. Children and adolescents with obesity require appropriate clinical considerations. Eating and weight problems are recognized as abnormal daily patterns including distorted cognitive and behavioral cycles [30]. The treatment of weight control issues requires a comprehensive approach, because the problem occurs in the individual, home, and social environment [30]. CBT emphasizes the process of changing habits and attitudes that sustain mental disorders. Therefore, CBT is an appropriate method in treating obesity [30]. Moreover, CBT can be incorporated with family-based therapy to achieve maximum treatment efficacy [31,32].

There are evidence-based strategies for weight loss, and many of them are beneficial for improving quality of life, and overcoming depression and unhealthy eating behaviors [33]. Given the nature of obesity and mental health, it is suggested that weight loss interventions simultaneously focus on evidence-based interventions that target weight loss (lifestyle interventions, medications or surgery depending on the individual's condition) along with a behavioral health and mental health-based intervention. This second component should include a continuous assessment of maladaptive behaviors and psychological harm [33]. There is not enough single treatment intervention to manage obesity due to its complexity [34]. Integration of psychological approaches in the clinical management of obesity in children and adolescents to effectively address the global epidemic of childhood obesity is recommended [34].

In a meta-analysis study in 2017 to evaluate the effect of psychological treatments on weight loss in obese people with eating disorders, CBT was shown to be very effective [35]. Another meta-analysis and systematic review suggested that clinical trials conducted on the effect of CBT on eating disorders were of poor quality [36]. Although the extant literature has discussed the efficacy of CBT on weight loss and health promotion among obese adolescents [37], the evidence is weak, especially for Iranian adolescents. Therefore, the present study assessed the effect of CBT on the improvement of nutritional status and weight among overweight and obese adolescents.

Section snippets

Design and setting

The present study was a prospective randomized controlled trial (RCT) comparing the effect of CBT on weight reduction among overweight and obese Iranian adolescents. The adolescents were recruited from four outpatient pediatric clinics in Qazvin (Iran). Participants were randomly divided into two groups (the treatment as usual [TAU] control group and the CBT intervention group) stratified by the outpatient pediatric clinics (Fig. 1). The inclusion criteria were as follows: age 13–18 years, BMI

Results

With a response rate of 75.9%, 110 adolescents participated in the study (55 in the CBT and 55 in the TAU). Eight adolescents in both groups were lost to follow-up due to migration, transfer to another school, or unwillingness to continue the study (Fig. 1). The difference in the drop-out rate was not significant between the groups (p > 0.05). The mean age was 14.88 years (SD = 1.69) in the CBT group and 14.64 years in the TAU group (SD = 1.5). No statistically significant differences were

Discussion

The results of the present study demonstrated that the six-week CBT intervention program for adolescents alongside two sessions for parents was effective in improving the nutritional behaviors, body composition, physical activity, psychosocial health, and quality of life among obese and overweight adolescents. Moreover, the findings are consistent with previous studies using CBT on adults who are overweight and obese [18,30,[52], [53], [54], [55]]: Consequently, CBT programs appear to be one of

Author disclosure statement

No competing financial interests exist for any of the authors.

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    These authors contributed equally to this work.

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