Lifestyle Change Interventions for Children and Adolescents With Diabetes or Kidney Disease

Abstract

The purpose of this research letter is to report on the availability of evidence-based interventions for promoting lifestyle change in children and adolescents with diabetes or kidney disease. References for this review were obtained using several electronic databases, including Ebsco Host, PsychInfo, Medline, and CINAHL. Search topics included transplant adherence, diabetes adherence, kidney adherence, obesity and transplant, kidney disease, transplant noncompliance, renal failure, renal disease, chronic kidney failure, end-stage renal disease, obesity and diabetes, overweight and kidney disease, overweight and diabetes, overweight, treatment interventions and overweight, treatment interventions for obesity, children and obesity, growth chart, diabetes intervention, kidney disease intervention, obesity intervention, obesity and transplantation, obesity transplant intervention, motivational interviewing, physical activity level, physical activity, exercise intervention, body mass index measurement, body fat percentage, psychosocial issues of kidney disease, psychosocial issues of transplant, and coping with kidney disease. Search results included English language only and between the years 2000 and 2009. Very few lifestyle interventions have been shown to be effective for obese children or adolescents with diabetes and none for obese children and adolescents with kidney diseases. More research is needed to develop effective interventions for this vulnerable population.

Although the overall morbidity and mortality rates of children have declined in the past several decades, chronic disease in children has not. ¹ Kidney disease, diabetes, and obesity are among common childhood chronic diseases. Of these rates, Hispanic and African Americans are disproportionately affected with kidney disease, diabetes, and obesity.^2-4 Slightly more than 31% of 8165 children in one study had a body mass index (BMI) at or above the 85th percentile for age. ⁴ Without intervention beyond health education and counseling, these rates are likely to increase. Health education and counseling that encourages healthy lifestyle behaviors is a large portion of the current intervention requirements of most hospitals, yet patients continue to engage in unhealthy lifestyle behaviors. Education and counseling alone do not adequately motivate children and adolescents to lose weight and participate in cardiovascular activity.^5-7 Chronic disease intervention programs for obesity, kidney disease, or diabetes seek to improve adherence to medication and physical activity and to maintain a healthy weight. However, few intervention studies have been developed specifically for obese patients with kidney disease or diabetes.

Treatment adherence is a key issue in the management of chronic disease. Most transplant studies have evaluated adherence to medications versus lifestyle adherence to healthy eating and physical activity.^8-11 One study did evaluate metabolic syndrome in kidney transplant patients and found a prevalence of 60% after 6 years posttransplantation. ¹² It recommended a moderate protein intake, low lipid diet, and low calorie intake. ¹² Other kidney transplant studies suggested gastric bypass for obese patients,^13,14 but of these 2 studies, Alexander and Goodman ¹³ encouraged further study. DiCecco ¹⁵ recommended a team weight loss approach with pretransplant obese patients that uses education, support, medical nutrition therapy, physical therapy, and psychological support.

Heart Transplant Weight Loss Program

An intervention study by Park et al ¹⁶ used a weight loss program for post–heart transplant patients. Interventions consisted of a bibliotherapy weight loss program or a bibliotherapy plus telephone contact weight loss program. They found that those in the bibliotherapy plus phone contact group lost more weight and returned more 3-day food diaries and self-monitoring postcards. ¹⁶ They concluded that a minimal intervention program involving information plus limited professional contact may assist post–heart transplant patients with weight management. ¹⁶

A community intervention pilot study evaluated the effectiveness of weight management counseling or a 6-month scholarship to a weight loss program for heart transplant patients. ¹ The authors found significant differences for weight and cholesterol between weight management counseling and the weight loss program. ¹ They recommended more structured weight loss programs. ¹

Diabetes Treatment and Weight Loss Programs

Weight control is a large portion of treatment intervention for diabetes.^17-19 Poor management of diabetes may lead to further kidney damage, cardiovascular disease, and so on.^17-19 Because of the potential complications of the disease and the use of medications that may cause weight gain, diabetes and kidney disease often occur together.^17-19 Daley ²⁰ conducted a clinical trial that aimed to increase adherence levels of adolescents diagnosed with diabetes. Intervention consisted of mentoring by an insulin-dependent adult, but no significant differences were found. Another study evaluated the effects of a program that combined several weight loss strategies and diabetes control for overweight patients with type 2 diabetes. ²¹ Intervention consisted of either a 2-year combination therapy weight loss program (C therapy) or a 1-year standard therapy weight loss program, which was followed by a 1-year combination therapy weight loss program (S/C therapy). ²¹ C therapy consisted of meal replacement products, repetitive intermittent low-calorie diet weeks, and pharmacologic therapy. ²¹ The C therapy group and the S/C therapy group had significant weight loss (P < .001). ²¹

General Physical Activity and Obesity Intervention Studies

Wiegel et al ²² conducted an outpatient program aimed to help obese children establish a healthy lifestyle and lose weight. Intervention included physical activity, nutritional education, and coping strategies. They found that the active treatment group reduced total BMI and showed beneficial effects for BMI, fat mass, and systolic blood pressure (P < .05). ²² This study illustrates the potential effectiveness of a comprehensive weight loss program for obese children, but it does not specifically address children with diabetes or kidney disease. ²²

Some review studies have examined obesity in children and adolescents.^7,23 One review study evaluated weight loss interventions for obese adolescents. ⁷ The authors examined the amount of physical activity participation versus describing effective studies for weight loss. ⁷ Another study found that school-based physical activity programs had a positive effect on physical activity levels. ²³ The authors recommended a combination of printed educational materials and school curriculum changes that promote physical activity. ²³

A review study by Oude Luttikhuis et al ²⁴ examined 54 lifestyle treatment studies that focused on diet, physical activity, or behavior change and 10 studies that used drug treatment. They found that lifestyle programs can reduce the level of obesity in children. ²⁴ They also found that the combination of orlistat or sibutramine combined with a lifestyle program was also effective in reducing obesity, although with adverse effects. ²⁴

Conclusions

Lifestyle behavioral intervention for children with kidney disease or diabetes may help them to increase and avoid further shortening their life span. More effective programs are needed that focus on increasing physical activity and healthy eating. Some studies have tested interventions to increase treatment adherence within areas of inactivity and unhealthy eating, but few have discussed how to increase physical activity and healthy eating specific to this population. The ability to offer programs that produce significant improvements in adherence to dietary and exercise recommendations, let alone long-term lifestyle change, is limited. ²⁵ An important knowledge gap exists about how best to organize effective and comprehensive weight loss treatment programs for obese and overweight children with these illnesses. Additional research is needed to aid in the development of more effective interventions.