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Nutrición Hospitalaria

On-line version ISSN 1699-5198Print version ISSN 0212-1611

Nutr. Hosp. vol.27 n.1 Madrid Jan./Feb. 2012

 

ORIGINAL

 

Design of the nutritional therapy for overweight and obese Spanish adolescents conducted by registered dieticians; the EVASYON study

Diseño de terapia nutricional para adolescentes españoles con sobrepeso y obesidad realizado por dietistas titulados; el estudio EVASYON

 

 

M.a Marqués1, A. Moleres2, T. Rendo-Urteaga2, S. Gómez-Martínez3, B. Zapatera3, P. Romero4, P. de Miguel-Etayo4, C. Campoy5, J. Alfredo Martínez2, C. Azcona-San Julián6, A. Marcos3, A. Marti2, J. Warnberg3; for the EVASYON group

1Department of Preventive Medicine and Public Health. University of Navarra. Pamplona. Spain.
2Department of Nutrition and Food Sciences, Physiology, and Toxicology. University of Navarra. Pamplona. Spain.
3Department of Metabolism and Nutrition. Institute of Food Science and Technology and Nutrition (ICTAN). Spanish National Research Council (CSIC). Madrid. Spain.
4GENUD (Growth, Exercise, Nutrition and Development) Research Group. EU. Health Science. Department of Physiotherapy and Nursing. School of Health Science. University of Zaragoza. Zaragoza. Spain.
5Department of Paediatrics. University of Granada. Granada. Spain.
6Department of Paediatrics. University of Navarra. Pamplona. Spain.

The work was completed with the funding from Spanish Ministry of Health and Consumption (Carlos III Institute of Health. FIS. Grant PI 051080, PI 051579). AdM was supported by a grant from the Departamento de Educación del Gobierno de Navarra.

Correspondence

 

 


ABSTRACT

Background: Dietary treatment for obese adolescents should aim to ensure adequate growth and development, by reducing excessive fat mass accumulation, avoiding loss of lean body mass, improving well-being and self-esteem and preventing cyclical weight regain. The aim of this article is to describe the dietary intervention design and the methods used to evaluate nutritional knowledge and behavior in the EVASYON study (Development, implementation and evaluation of the efficacy of a therapeutic programme for overweight/obese adolescents).
Methods/design: EVASYON is a multi-centre study conducted in 5 Spanish hospital settings (Granada, Madrid, Pamplona, Santander and Zaragoza), where 204 overweight/obese Spanish adolescents were treated in groups of 9 to 11 subjects over 20 visits. The study was implemented in two stages: an intensive, calorie-restricted period for the first 9 weeks, and an extensive body-weight follow-up period for the last 11 months. A moderate energy intake restriction was applied in the intensive period according to the degree of obesity, on the basis of a balanced diet supplying 50-55% of daily energy as carbohydrates; 30-35% as fats and 10-15% as proteins. In the intensive period, adolescents were prescribed both a fixed full-day meal plan for the first three weeks and a full day meal plan with different food-choices for 6 weeks. Later, adolescents received a flexible meal plan based on food exchanges for the follow-up period until the end of the trial.
Data on food intake, dietary and meal-related habits and behavior were collected by means of dietary questionnaires. To analyse nutritional knowledge, adolescents were examined regarding nutrient concepts and food adoitems for a healthy diet with the appropriate tools. Participants were given nutritional information with complementary teaching material, which was available on the EVASYON website (www.estudioevasyon.com).
Discussion: The dietary intervention of the EVASYON programme with a moderate calorie restriction for a limited period of time could be a good strategy in treating overweight and obese adolescents and that will be tested further. Moreover, combining fixed plan with free-choice menus may help adolescents and their families to make right decisions for every day meals.

Key words: Adolescence. Multidisciplinary intervention. Nutritional education. EVASYON.


RESUMEN

Antecedentes: El tratamiento dietético para los adolescentes obesos debería asegurar el crecimiento y desarrollo adecuados al reducir la acumulación excesiva de masa grasa, evitar la pérdida de masa magra corporal, mejorar el bienestar y la autoestima y prevenir la ganancia cíclica de peso. El objetivo de este artículo es el de describir el diseño de la intervención dietética y los métodos empleados para evaluar el conocimiento y la conducta nutricionales del estudio EVASYON (Desarrollo, implantación y evaluación de la eficacia de un programa terapéutico para adolescentes con sobrepeso/obesidad).
Métodos/diseño: EVASYON es un estudio multicéntrico realizado en 5 hospitales españoles (Granada, Madrid, Pamplona, Santander y Zaragoza), en el que se trató a 204 adolescentes españoles con sobrepeso/obesidad en grupos de 9 a 11 individuos a lo largo de 20 visitas. El estudio se implantó en dos etapas: un período intensivo de restricción calórica durante las 9 primeras visitas y un período extensivo de seguimiento del peso corporal durante los últimos 11 meses. Se aplicó una restricción moderada de consumo de energía durante el período intensivo en función del grado de obesidad, sobre la base de una dieta equilibrada que aporta el 50-55% de la energía diaria en forma de carbohidratos; 30-35% como grasas y 10-15% como proteínas. En el período intensivo, se prescribió a los adolescentes un régimen de comidas fijo para todo el día durante las 3 primeras semanas y un plan de comidas para todo el día con diferentes opciones durante 6 semanas. Posteriormente, los adolescentes recibieron un régimen de comidas flexible sobre la base de los intercambios de alimentos durante el período de seguimiento hasta el final del ensayo.
Se recogieron los datos de consumo de alimentos, dietéticos y hábitos relacionados con las comidas mediante cuestionarios de dieta. Para analizar el conocimiento nutricional, se examinó a los adolescentes con respecto a conceptos de nutrición y alimentos concretos para una dieta sana con las herramientas adecuadas. Se proporcionó a los participantes información nutricional con material educativo complementario que estaba disponible en la página web del estudio (www.estudioevasyon.com).
Discusión: La intervención dietética del programa EVASYON con una restricción calórica moderada durante un período de tiempo limitado podría ser una buena estrategia para el tratamiento de los adolescentes con sobrepeso y obesidad y se probará más adelante. Además, el combinar el plan fijo con menús de elección libre podría ayudar a los adolescentes y sus familias a tomar las decisiones correctas para las comidas de todos los días.

Palabras clave: Obesidad. Adolescencia. Intervención multidisciplinar. Educación nutricional. EVASYON.


 

Background

Adolescence is a period of the life cycle characterized by important changes in body size and composition as well as in lifestyle habits.1,2 The prevalence of overweight and obesity among adolescents is dramatically increasing all over the world3,4,5. This alarming trend is seen as a burden by public health professionals and government agencies and there is now a clear need to develop well founded standardized interventions to treat overweight/obese adolescents, following evidence-based practice criteria.

The risk of obesity depends on the interaction of genetic predisposition and exposure to obesogenic (environmental) risk factors such as inappropriate eating habits and food choice, poor nutritional knowledge, sedentary behavior and low physical activity, all of which are becoming major social problems in many countries.6,7,8,9 These etiological factors are associated with clinically important co-morbidities (cardiovascular disease, hypertension, type 2 diabetes mellitus, eating disorders, cancer...) in adult life.10 It is unlikely that a single-sided intervention can be targeted against all these multi-causal agents. Indeed, lifestyle changes require a high degree of commitment and active participation from adolescents and their relatives. Therefore, parents are central agents for change in the promotion of healthy eating and activity habits and their involvement in the programme is essential for an intervention to be successful.11,12 A multi-disciplinary approach is necessary with the participation of dieticians, doctors, psychologists and physical activity experts among other professionals as a single team.13-14

Interventions that combined behavioral therapy with dietary and physical activity changes are widely used, and appear to be the most successful strategies for improving long-term weight maintenance and health status.14,15,16 Ideally, dietary treatment for obese children and adolescents should aim to ensure adequate growth and development, by reducing excessive fat mass accumulation, avoiding loss of lean body mass, improving well-being and self-esteem and preventing cyclical weight regain.13

Balanced food patterns constitute a model for healthy living, based on foods to eat rather than foods to avoid, and an understanding of suitable weight-control measures.17 Promoting weekly menus with food variety is also the best defense for avoiding nutritional deficiencies and excess, as well as meeting micronutrient requirements.1,18 Moreover, meal plans with food exchanges represent a useful tool to encourage adolescents to keep to balanced diets.

The timetable for different meals throughout the day and their calorie distribution are also important issues as ways to improve nutritional education and food behavior in this population. Adolescents tend to have high energy density meals and snacks, therefore an important goal is to reduce calorie content.19 This practice involves a wide range of fresh and seasonal food, with a high proportion of vegetables, grains, fresh fruit and pulses, principal sources of vitamins, minerals, carbohydrates and fiber, which could play an important role in weight control and in decreasing dietary energydensity. 13,20-21

The aims of the EVASYON study were: 1) to develop a treatment programme including education on nutrition and physical activity patterns, 2) to implement this programme during one year in overweight/obese Spanish adolescents and 3) to evaluate the efficacy and limitations of the programme. For dissemination and comparative purposes with previous and future studies, detailed information concerning the design, development and evaluation of the dietary intervention of the EVASYON study is provided here.

 

Methods/design

Experimental design

The EVASYON programme is an interventional study implemented in a cohort of overweight/obese adoitems lescents aged 13 to 16 years as described by Martínez-Gómez et al.7 The initial treatment programme was conducted in 5 Paediatric hospitals from different cities in Spain (Granada, Madrid, Pamplona, Santander and Zaragoza) in small groups of nine to eleven patients. During the programme period, adolescents made twenty visits over approximately one year, within two specific stages (fig. 1): an intensive intervention period including 9 weekly visits for two months, and the extensive body weight maintenance intervention period including 11 monthly visits. Information on inclusion criteria is given in the work of Martínez-Gómez et al.7 Written consent to participate was obtained from both parents and adolescents. The complete study protocol was conducted in accordance with the ethical standards of the Helsinki Declaration (revised in Hong-Kong in 1989, in Edinburgh in 2000 and in Korea in 2008), following the European Community´s guidelines for Good Clinical Practice (document EEC 111/3976/88 of July 1990) and current Spanish law regulating clinical research in humans (RD 561/1993 regarding clinical trials). The study was approved by the Ethics Committee of each hospital participating in this project and by the Ethics Committee of the Spanish National Research Council (CSIC). Data obtained during the intervention was confidential and restricted to the participating investigators. Health authorities had full access rights to the database for inspection purposes.

Nutritional therapy and an educational programme on diet and food knowledge, psychological and eating behavior assessment, physical activity and family involvement, were covered throughout the programme. Nine measurement categories were established: Diet and food habits; physical activity and health-related physical fitness; psychological profile; anthropometry; body composition; haematological profile; biochemistry and metabolic profiles; mineral and vitamin profile; immunological profile and genetic profile. All the parameters in each measurement category, excluding genetic profile, were assessed at least at four points: baseline (visit 1), at the end of the intensive intervention (visit 9), at mid point of the overall intervention (visit 13), and at the end of the EVASYON treatment programme (visit 20).7

Measurement of food intake

The EVASYON food and nutrition programme involved trained registered dietitians (RD), professionals who were directly responsible for the dietary and nutrition education programme.

At baseline, participants were personally interviewed by an EVASYON Registered Dietician (RD) to evaluate their meal patterns, appetite, food choices and snacking, with specific dietary questionnaires. A detailed dietary history collected information about the family food-shop organization, usual location for meals during the week and week-ends, meal-related habits before starting the therapy or the personal beliefs about the role of food in the family, among others (Additional file 1). It was important for clinicians and RDs to inquire about specific disordered eating attitudes to assess whether they were likely to increase the risk of further eating disorders or weight gain.22,23

 

 

Moreover, a semi-quantitative food frequency questionnaire (FFQ), previously validated in Spain, was administered at the beginning, at six months and at the end of the programme. This tool was used to record usual food frequency consumption according to the standard portion size, energy and nutrient intake, and to detect possible nutritional risks and misbehaviors.24

Additionally, a visual analogue scale (VAS score) was used for the measurement of appetite and anxietyrelated eating habits25 (Additional file 2).

 

 

After personal interview at visit 1, adolescents and their families received a group session where the RD explained how to complete a 24 h-dietary recall. Pictures of food portion sizes and tables of equivalences were used to illustrate the size of usual servings. This information helped the participants to fill in the 72 h dietary record. The data were transformed into grams or milliliters and were processed with an "ad hoc" computer programme, using validated food composition tables from Spain.26,27

In different patient assessments (visits 1, 9, 13 and 20) other dietary questionnaires were used to survey information on the adherence and challenges to the programme. A specific dietary record explored food habits that could be modified during the therapy (Additional file 3). Also, the survey for compliance with the diet contained two sections. The first part collected information on the food frequency intake of the main food groups, and favorite foods (but supposedly not healthy items) for adolescents such as sweet drinks, alcohol, cakes and fast food. The second part gathered information on meal-related habits and psychological aspects (Additional file 4). A brand name FFQ and also, the VAS score and the 72 h dietary record were completed in each assessment.

 

 

 

Assessing energy, nutritional requirements and calorie restriction

The International Obesity Task Force (IOTF) body mass index (BMI) cut-off values were used for the diagnosis of overweight and obesity in the adolescents. 28 To determine basal metabolism rate (BMR), Schofield´s et al. (1985) equation was used,29 where the value of 1.3 was assumed as the activity factor to obtain the total daily energy expenditure (TEE) for most subjects.

The BMI value was normalised to the standard deviation score. The restriction percentage was calculated as follows: If Z = 2-3, the TEE was reduced by 20%; if Z = 3-4, it was reduced by 30%; and if Z > 4, TEE was reduced by 40% and on this basis, a daily calorie restriction range was established. In no case were the diets lower than 1,300 kcal or higher than 2,200 kcal. Furthermore, energy restriction acted as a method to correct the excessive food portions consumed with reference to age, sex and physical activity level. At the end of each dietary period, it was necessary to adjust the equations according to the current body weight and the basal metabolism rate was measured to identify possible shifts in energy consumption/expenditure. 30

Dietary intervention strategy and exchange list guidelines

The intensive treatment programme with a moderate calorie restriction was divided into two subphases: three weeks (visits 1 to 3) consisting of fixed full-day meal plan according to the criteria described above, and the next six weeks (visits 4 to 9) consisting of fixed full-day meal plan with food choices. During the extensive intervention period (visits 10 to 20), the adolescents were assigned to a flexible meal plan with food exchanges, maintaining a balanced diet according to sex and age. Daily energy distribution was based on the school period promoting breakfast and avoiding multiple snack consumption along the day. Therefore, dietary patterns maintained a typical distribution of 3 main meals (breakfast providing 20% of daily calories, lunch with 30-35%, and dinner with 20-25% of daily calories) and 2 snacks (mid-morning 5-10%, and afternoon 10-15% of daily calories).20,31 The diets were designed in accordance with the proportions of macronutrients recommended by the Food and Nutrition Board of the National Research Council: carbohydrates 50-55% of total daily energy intake (EI) (sugars < 10%); fats 30-35% of EI (10-20% monounsaturated, < 10% saturated, 7-10% polyunsaturated); cholesterol < 300 mg /day, and proteins 10-15% of EI.32

The initial objective of the intervention was to join both adolescents and their families in the nutritional treatment; therefore, they received an energy-adjusted full-day menu for three weeks, to achieve the established calorie and nutrient objectives. The meal plan specified all daily meals, the type of foods to include with serving sizes (expressed in grams or individual portions), the garnishes, tips for healthy cooking, and daily bread and oil servings (table I).

 

 

The second meal plan used in EVASYON programme consisted of full-day menus with food choices structured similarly to the diets used before, but specifying the main food group and the serving size, and with the possibility to choose from a list of specific foods. In this context, the meal plans became an easy tool for the family to acquire a degree of self-sufficiency selecting healthy foods and to develop healthy habits for making good decisions for the family´s wellbeing (table II).

The next step in the extensive body-weight maintenance programme was the full-day meal plan with exchanges. The exchange lists system used in the EVASYON study was based on the unification of nutrients (carbohydrates, proteins and lipids) and calories taking into account normal Spanish foods and serving sizes.33 The serving sizes of listed food items corresponded to an average of the amount of calories, carbohydrates, proteins and fats supplied, thus, any selection within a food group covered the same energy and macronutrient content.34 Based on the daily established energy requirements per person, the number of exchanges for each food group was quantified, following the dietary guidelines of food consumption in Spain.35 This method helped professionals generate uniformity in exchange conversions for recipes and food labels, in order to adapt family and personal food habits. On this basis, meals described the main food groups to be included, and each group was broken down into a list of foods with appropriately exchangeable food-portions (servings expressed in grams and home measures). This system gave flexibility and diversity to the diet and the family became responsible for programming the weekly menu by applying the acquired knowledge36 (table III).

Assessing nutritional knowledge

The understanding of the environmental influences, parents´ habits, health concerns and the association within nutritional knowledge and food choices, is relevant to develop effective youth obesity prevention strategies.36,37,38 At baseline, the EVASYON adolescents were requested to complete information about basic nutrition concepts, healthy eating and the relationship between several foods items and the corresponding food group to analyse their nutritional knowledge and food preferences (Additional file 5).

Nutritional assessment and educational materials

The intensive programme included weekly in-person visits with the RD to control the understanding and the fulfillment of the dietetic patterns and lifestyles, to answer possible doubts and to motivate the participants with the previously one-week established objectives. After this, group sessions took place, where the RD emphasized dietary knowledge, teaching of behavioural-change techniques and motivational, life and time management strategies, as well as the importance of the compliance with healthy habits and family support.

Educational materials were developed for EVASYON study to support the dietary treatment targets, such as the childhood food guide pyramid, pictures of portionsizes, cooking techniques, basic concepts for planning healthy menus, etc., which were available on the EVASYON webpage.39 Similarly, all the incidences and changes related to lifestyle were recorded in a notebook of guidance to be reviewed by the RD in the next interview. A practical guide with recommendations for controlling body weight was handed out to families.

During the extensive body-weight maintenance period, adolescents attended monthly in person follow-up visits with the RD. They and their families received group sessions on different aspects such as diet, physical activity, healthy habits and weight maintenance skills, how to engage in healthy weight control behaviors and relapse prevention. Objectives were planned to be accomplished on a one-month basis. Other studies have reported successful results following these strategies.40

 

Discussion

The EVASYON study is a multidisciplinary and multicentre programme for overweight/obese adolescents that involved the management of dietary habits, physical activity and psychological profiles, in order to lower adiposity and prevent the development of chronic adult disease related to obesity such as diabetes, hypertension, and metabolic syndrome.

The EVASYON nutritional programme was monitored by RDs as practitioners qualified to implement and evaluate nutritional assistance programmes targeted at improving the nutritional status of the population. 41 These professionals were previously trained according to the work plan of the project with specific workshops and seminars, in order to reduce inter-individual (inter-centre) variations. Moreover, the teaching material and protocols for the different worksheets of the project were available for all centers through a continuously updated website.39

Many different approaches and therapies have been proposed for weight loss treatment in obese and overweight children.15,42,43,44 Unbalanced hypocaloric diets or very low calorie diets probably lack essential vitamins and minerals and should not be recommended during the period of growth.

Programmes including moderate calorie restriction and physical exercise have achieved better results than diet only, showing decreases in total body fat mass, and cardiovascular risk factors, maintaining total body fatfree mass, as well as improving insulin sensitivity and lipid profile, such as an increase of high density lipoprotein cholesterol fraction (HDL-c) levels.16,43,45,46,47,48 The magnitude of the energy restriction together with the duration of the trial are always a challenge, but more especially in this population group. In adolescents, energy requirement and micronutrient intake are critical issues for appropriate growth and development. 33 Our strategy consisted of a moderate calorie restriction for a limited period of time (9 weeks) followed by a maintenance period with a balanced non calorie-restricted diet. In the literature, trials with obese adolescents used different calorie restriction ranges varying from 600 kcal/day to 1,800 kcal/day.15,43,49,50 In the current study, a supply of total energy between 1,300 kcal/day and 2,200 kcal/day for participants was indicated according to the degree of obesity.

It is important to mention that breakfast apparently provides considerable protection for future obesity in adulthood.51 We strongly recommended three food groups (dairy products, cereals and fruit) to be included in menus.33,52 Semi-skimmed milk, low fat yoghurts and fresh cheese were also recommended as healthy choices to cover the daily needs of calcium, and contribute to the protein content of the diet.20

Moreover, over the last few years, the type of dietary fat has been receiving more attention regarding its association with obesity and its co-morbidities. Participants were advised by RDs to remove meat fat before cooking, reduce cold meats, and margarines, shortenings, pastries and industrial cakes which contain saturated and hydrogenated fats.20,33

Due to the large evidence on the protective effect of olive oil on body weight and lipid control,53,54 olive oil was recommended as the principal fat source for cooking and dressing meals. To complete the daily nutrient requirements with healthy foods, common choices presented in menus for dinner were vegetables and salads, soups, cereals, eggs, fish and lean meats while for dessert fresh fruit or yoghurt were encouraged.

Furthermore, observational data support that consuming large portions of energy-dense foods could play a role in the etiology of obesity.6,55 A reduction in the consumption of canned juices and soft drinks containing excess sugar and additives, meat servings, eating away from home, and portion size33,56 should be encouraged together with increased consumption of moisture-rich foods such as fruits and vegetables, legumes, fish and cereals. These messages seem to be effective in preventing weight gain and promoting weight loss.6,44,55,57

In conclusion, the dietary intervention of the EVASYON programme was developed to improve nutritional education in order to achieve food behavior modification. A moderate calorie restriction for a limited period of time seems to be a good strategy in treating overweight/obese adolescent since it is crucial to maintain their appropriate growth and development. Moreover, combining fixed plan with free-choice menus helps adolescent and their families make the right decisions for every day meals.

 

Competing interests

The author(s) declare that they have no competing interests.

 

Authors´ contributions

MM and AdM contributed equally to this work. AsM, AmM and CC designed the study and obtained funding. The RDs MM, TR, BZ, PR and PM intensively participated in the dietary intervention study. All authors provided insight into the study design and contributed to the drafts and approved the final version.

 

Acknowledgements and Funding

Our research work received the award from AESAN (Spanish Agency for Food Security and Nutrition) from the Spanish Ministry of Health and Consumption for the best applied research project in 2009.

We gratefully acknowledge all adolescent participants and their families who participated in the study. The careful reading of the final English version of the manuscript by Edwards M. (University of Malaga) is sincerely appreciated.

 

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Correspondence:
Amelia Marti.
Department of Nutrition and Food Sciencies,
Physiology, and Toxicology.
University of Navarra.
Pamplona. Spain.
E-mail: amarti@unav.es

Recibido: 14-VIII-2011.
Aceptado: 17-VIII-2011.

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