The Effectiveness of Nutrition Specialists on Pediatric Weight Management Outcomes in Multicomponent Pediatric Weight Management Interventions: A Systematic Review and Exploratory Meta-Analysis.

BACKGROUND: Nutrition specialists are considered key members of multicomponent pediatric weight management intervention teams, but to date, their contribution has not been quantified. OBJECTIVE: The purpose of this systematic review was to estimate the effectiveness of interventions provided by treatment teams that include a nutrition specialist on pediatric weight management outcomes, including body mass index (BMI), BMI z score, and waist circumference when compared with treatment teams that do not include a nutrition specialist. METHODS: The results of a comprehensive literature search and a systematic and more targeted update of that search were included in the meta-analyses: a search of controlled trials published between July 2005 and April 2012, conducted during the 2015 Pediatric Weight Management Update Project of the Academy of Nutrition and Dietetics Evidence Analysis Library, and an update search of controlled trials published between May 2012 and December 2015 focusing on a more specific topic within the previous search. Studies included overweight and/or obese patients aged 6 to 18 years receiving outpatient weight management treatment. Data extraction of all studies identified was performed using a standardized tool. The resulting data from the search and the systematic update were merged. Ninety-nine studies and 209 study arms were included in the analysis. An exploratory meta-analysis using alternative meta-analytic methods designed for complex, heterogenous interventions was conducted to identify relative contributions by intervention provider category at selected time points. Meta-regression analyses were used to evaluate significant differences from the reference category for each provider category. RESULTS: The nutrition specialist-only condition resulted in increased reductions in BMI z score compared with behavioralist-only, combined nutrition specialist and behavioralist, and neither nutrition specialist or behavioralist category (reference) throughout the analysis. Meta-regression analysis indicated that the difference in BMI z score between the nutrition specialist-only category and the reference category was significant at 3 to <6 months, 6 months to <1 year, and 1-year to 2-year time points (P=0.01, P=0.05, and P=0.01, respectively). There were smaller increases in BMI over time for the nutrition specialist-only provider category compared with reference categories, and this difference was significant at the 3 to <6 months and 1-year to 2-years time points (P=0.001 and P=0.05, respectively). There were no significant differences among provider categories for waist circumference at any time point. CONCLUSIONS: Indirect evidence indicated that pediatric weight management outcomes for BMI z score and BMI at selected time points appeared to be better when a nutrition specialist was involved in delivering care.

Managing Complexity in Evidence Analysis: A Worked Example in Pediatric Weight Management.

Nutrition interventions are often complex and multicomponent. Typical approaches to meta-analyses that focus on individual causal relationships to provide guideline recommendations are not sufficient to capture this complexity. The objective of this study is to describe the method of meta-analysis used for the Pediatric Weight Management (PWM) Guidelines update and provide a worked example that can be applied in other areas of dietetics practice. The effects of PWM interventions were examined for body mass index (BMI), body mass index z-score (BMIZ), and waist circumference at four different time periods. For intervention-level effects, intervention types were identified empirically using multiple correspondence analysis paired with cluster analysis. Pooled effects of identified types were examined using random effects meta-analysis models. Differences in effects among types were examined using meta-regression. Context-level effects are examined using qualitative comparative analysis. Three distinct types (or families) of PWM interventions were identified: medical nutrition, behavioral, and missing components. Medical nutrition and behavioral types showed statistically significant improvements in BMIZ across all time points. Results were less consistent for BMI and waist circumference, although four distinct patterns of weight status change were identified. These varied by intervention type as well as outcome measure. Meta-regression indicated statistically significant differences between the medical nutrition and behavioral types vs the missing component type for both BMIZ and BMI, although the pattern varied by time period and intervention type. Qualitative comparative analysis identified distinct configurations of context characteristics at each time point that were consistent with positive outcomes among the intervention types. Although analysis of individual causal relationships is invaluable, this approach is inadequate to capture the complexity of dietetics practice. An alternative approach that integrates intervention-level with context-level meta-analyses may provide deeper understanding in the development of practice guidelines.