population, particularly with regard to the effect of severe caloric restriction on linear growth and development.

Behavior Modification

Behavior modification facilitates weight-loss efforts by helping patients develop appropriate eating and exercise behaviors and cope with disturbing weight-related thoughts and emotions (Stunkard, 1987). The effectiveness and importance of this treatment component has been documented in more than 100 controlled clinical trials (Brownell and Kramer, 1994). Standard behavioral programs include self-monitoring, positive reinforcement, stimulus control, cognitive restructuring, and nutrition education. The details of the standard behavior modification program have been reviewed extensively by Epstein (1986) and Kramer et al. (1989).

Long-Term Outcome

The true effectiveness of treatment can be measured only by examining data on long-term outcome. While few studies have attempted to follow patients beyond the initial treatment, results reported to date have been promising, especially compared with 5- and 10-year outcomes in adults (Kramer et al., 1989). Epstein et al. (1990b) evaluated the 5-year outcome results of four prospective, randomized, controlled, multidisciplinary treatment programs that differed with respect to how family-based treatment or exercise was implemented. Subjects were 6–12 years of age at the start of the studies and were randomized to alternative treatments that lasted 8–12 weeks, with monthly meetings continuing for another 6–12 months. One subgroup within each of two of the studies achieved a 10 percent reduction in relative weight at the end of 5 years. The best results were achieved by reciprocal reinforcement of the children and their parents compared with a program that reinforced only the child for success.

Ten-year follow-up data have been reported for a three-arm study of multidisciplinary treatment (Epstein et al., 1990c). The groups differed only in the method of reinforcement for weight and behavior change. Children in the group that reinforced both parents and children showed significantly greater reductions in percentage of overweight after 5 and 10 years (11.2 and 7.5 percent, respectively). In addition, a greater percentage of children in the parent-plus-child treatment group achieved or approached normal weight for height (33 percent) than of the children treated without their parents (5 percent).

Nuutinen and Knip (1992) conducted a 5-year follow-up study of 48



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