Family-based Treatment For Childhood Obesity Research Articles

86185 Food Cost and Perceptions: through the lens of coaches providing family-based childhood obesity treatment

ABSTRACT IMPACT: This work will help to identify ways to adapt family-based obesity treatment based on families’ food purchasing behaviors and beliefs. OBJECTIVES/GOALS: Families in obesity treatment are encouraged to make dietary changes. Dietary changes are impacted by food choices, which can be influenced by food cost. The objective of this research is to explore families’ food purchase behaviors and beliefs from the perspective of their health coach, and to assess how health coaches adapt treatment to address these. METHODS/STUDY POPULATION: Semi- structured telephone interviews were conducted with 10 health coaches in the Effectiveness of Family-Based Weight Loss Treatment Implementation in Primary Care (PLAN) study across four geographic locations in MO, NY, and OH. Topics covered were professional background, perspectives on working with families, and discussions with families regarding cost perception and food choice. Conventional content analysis was used through ‘open-coding’ of transcribed text by reading the transcripts and assigning labels. Codes were then organized into themes. In addition to the interviews, coaches were asked to complete a FRAME checklist to identify adaptations or modifications that were made to the treatment. RESULTS/ANTICIPATED RESULTS: The coaches reported that cost is a barrier to making healthier food choices for some but not all of their FBT families. Themes for cost as a barrier include: fast food is cheaper; justification to choose old food choices; sales on foods high in calories and sugar; bulk buying; and fewer sales on healthier options. Themes for what families consider when purchasing healthier items include: perishable foods, increased waste, picky kids, lack of knowledge about healthy eating on a budget, afraid of including new foods, and no money for new foods. The final stage of content analysis for the FRAME schematic checklist is ongoing. DISCUSSION/SIGNIFICANCE OF FINDINGS: The results exemplify that families’ have different food purchasing behaviors and beliefs and consider a variety of factors when making food choices. The data gathered from the FRAME checklists will help in characterizing the adaptations or modifications made by coaches and allow for better understanding of the impact on the families.

Rationale and protocol for translating basic habituation research into family-based childhood obesity treatment: Families becoming healthy together study

This publication describes the rationale and protocol, including design, aims, intervention, and measures, of Families Becoming Healthy Together, a randomized clinical trial examining the effect of a limited RED (non-nutrient-dense, energy-dense) food variety prescription delivered within an 18-month family-based behavioral obesity treatment (FBT) on body mass index (BMI) and habituation rate to RED foods. One hundred fifty-six children (ages: 8–12 y; BMI: ≥ 85th percentile-for-age) and a caregiver (BMI: ≥ 25 kg/m2), both with overweight or obesity, will be randomized to one of two, interventions: FBT or FBT + Variety. All participants will receive 29 sessions of FBT and be prescribed the Traffic Light Diet (1000–1500 kcal/day, ≤ 2 RED food servings/day), and a physical activity goal (≥ 60 min/day [child] or 150 min/week [adult] of moderate-vigorous physical activity (MVPA)). FBT + Variety will also identify two RED foods, a dinner entrée and snack food, and develop meal plans that reduce variety of RED foods by regularly consuming these foods and limiting consumption of other RED foods. Measures of anthropometrics, dietary intake, habituation of salivary response to food cues, and physical activity will be assessed at 0, 6, 12, and 18-months. This study translates a line of basic behavioral research examining how dietary variety influences habituation into a dietary prescription that will be tested within an efficacy trial. It is hypothesized that a novel, limited dietary variety prescription within FBT should promote a faster food habituation rate, reducing energy intake and amplifying long-term weight loss in children.

A comparative effectiveness trial of two family-based childhood obesity treatment programs in a medically underserved region: Rationale, design & methods

While there is a large body of literature documenting the efficacy of family-based childhood obesity (FBCO) treatment interventions, there is little evidence that these interventions have been systematically translated into regular practice — particularly in health disparate regions. To address this research-practice gap, this project was guided by a community advisory board (CAB) and the RE-AIM planning and evaluation framework within a systems-based and community-based participatory research approach. Families with overweight or obese children between 5 and 12 years old, in the medically-underserved Dan River Region, were randomly assigned to one of two FBCO treatment programs (iChoose vs. Family Connections) delivered by local Parks & Recreation staff. Both programs have previously demonstrated clinically meaningful child BMI z-score reductions, but vary in intensity, structure, and implementation demands. Two clinical CAB partners embedded recruitment methods into their regional healthcare organization, using procedures representative to what could be used if either program was taken to scale. The primary effectiveness outcome is child BMI z-scores at 6-months, with additional assessments at 3-months and at 12-months. Secondary goals are to determine: (1) reach into the intended audience; (2) effectiveness on secondary child and parent outcomes; (3) intervention adoption by organizations and staff; (4) fidelity, cost, and capacity for intervention implementation; and (5) maintenance of individual-level changes and organizational-level sustainability. This research addresses literature gaps related to the features within clinical and community settings that could improve both child weight status and the translation of FBCO interventions into typical practice in medically-underserved communities. IdentifiersClincialtrials.gov: NCT03245775.

Assessment of Parents’ Preferences for Incentives to Promote Engagement in Family-Based Childhood Obesity Treatment

Family-based treatment (FBT) is recommended for childhood obesity, but even when sought, attrition is high. Extrinsic incentives, which have been effective for improving adult health, could improve FBT engagement. To assess parents' preferences for FBT incentives. Survey study of parents of children aged 6 to 17 years with obesity (body mass index in ≥95th percentile for age and sex). Parents' preferences for FBT incentive program attributes were assessed in a discrete choice experiment conducted using a nationally representative, web-based survey in March 2018. Attributes included (1) the monetary value of the incentive, (2) the payment structure, (3) the goal being incentivized, and (4) the person(s) being incentivized. A fractional factorial design was used to create a set of profiles representing hypothetical FBT incentives. Parents were presented with 10 pairs of profiles and asked which would most motivate them in FBT. Parents were also asked about preferences between a small, guaranteed incentive and a lottery for a large incentive. Analyses used a hierarchical Bayesian model and linear regressions. Parents' preference for different incentive program attributes and levels. The nationally representative survey had a 41.4% eligibility rate (n = 339) and a 89.7% completion rate (n = 304). A total of 53.3% of respondents (weighted percentage) were non-Hispanic white, 42.6% had an annual household income less than $50 000, and 28.3% had a bachelor's degree. Parents preferred higher incentives, although they were willing to accept lower-value incentives if both the parent and the child (vs the child alone) were required to meet the goal (mean difference [MD], -$108; 95% CI, -$132 to -$84), if the incentive used a gain-framed vs loss-framed payment structure (MD, -$72; 95% CI, -$85 to -$59), and if physical activity goals were incentivized over weight loss (MD, -$63; 95% CI, -$82 to -$44) or dietary monitoring (MD, -$5; 95% CI, -$1 to $28). Only 20.6% of parents preferred a lottery over a guaranteed payment. Preferences did not vary among demographic or health subgroups. In this study, parent-stated preferences did not align with FBT best practices or behavioral economic theory. A randomized clinical trial could examine whether aligning incentives with preferences or best practices would maximize FBT engagement and behavior change.

The relationship between executive functioning and weight loss and maintenance in children and parents participating in family-based treatment for childhood obesity

We examined the relationship between executive function and weight loss among children (8–12 years) and parents enrolled in a behavioral weight-loss program. 150 overweight/obese children and their parents participated in a 6-month family-based weight-loss intervention and completed baseline (month 0), post-treatment (month 6) and 18-month follow-up assessments (month 24), which included Digit Span (DS), Stop Signal Task (SST), and Wisconsin Card Sorting Test (WCST). Anthropometrics were additionally measured at mid-treatment (month 3) and 6-month follow-up (month 12). Children with more baseline WCST perseverative errors regained more weight (p = .002) at 18-month follow-up. Change in child BMIz was not associated with change in child executive function (p > .05) or parent executive function (p > .05). Among parents, baseline measure of DS-backward (p < .001) and post-treatment changes in WCST perseverative errors (p < .001) were associated with post-treatment changes in parent BMI. SST was not related to parent or child weight loss. Thus, children's baseline set-shifting was associated with weight regain during follow-up whereas changes in parent set-shifting was associated with changes in parent weight. Future research is needed to examine the relationship between executive function and weight loss and how this translates to intervention success for both overweight/obese children and participating parents.

Dose, Content, and Mediators of Family-Based Treatment for Childhood Obesity

Elucidation of optimal dosing and treatment content is critical for health care providers, payers, and policy makers, as well as mechanisms of change to inform intervention delivery and training initiatives for childhood obesity. To evaluate effects, following a 4-month family-based behavioral weight loss treatment (FBT), of 2 doses (HIGH or LOW) of a weight-control intervention (enhanced social facilitation maintenance [SFM+]) vs a weight-control education condition (CONTROL; matched for dose with LOW), on child anthropometrics, and to explore putative mediators of weight loss outcomes. For this parallel-group randomized clinical trial conducted at 2 US academic medical centers from December 2009 to March 2013, 172 parent-child dyads completed FBT and were then randomized to 8 months of SFM+ (HIGH, n = 59; LOW, n = 56) or CONTROL (n = 57). Children (aged 7-11 years) with overweight and obesity (body mass index [BMI; calculated as weight in kilograms divided by height in meters squared] ≥85th percentile) with at least 1 parent with overweight and obesity (BMI ≥25) were recruited. HIGH SFM+ vs LOW SFM+ (CONTROL matched the dose of LOW). Intention-to-treat analysis using mixed-effects models estimated change in child percentage overweight (percentage above the median BMI for a child's age and sex) for the FBT period (0-4 months) and the SFM+ period (4-12 months), and proportion of children achieving a clinically significant change in percentage overweight (≥9-unit decrease; months 0-12). Theory-based outcome mediators were also evaluated. This study recruited 172 parent-child dyads (mean [SD] age: parents 42.3 [6.4] years; children, 9.4 [1.3] years). The omnibus treatment × time interaction for child percentage overweight was significant (F8, 618.9 = 2.89; P = .004). Planned pairwise comparisons revealed that from months 4 to 12, LOW had better outcomes than CONTROL (difference, -3.34; 95% CI, -6.21 to -0.47; d = -0.40; P = .02). HIGH had better outcomes than LOW (difference, -3.37; 95% CI, -6.15 to -0.59; d = -0.38; P = .02) and CONTROL (difference, -6.71; 95% CI, -9.57 to -3.84; d = -0.77; P < .001). A greater proportion of children in HIGH (45 [82%]) vs LOW (34 [64%]) (difference, 18.00; 95% CI, 1.00-34.00; P = .03; number needed to treat = 5.56) and CONTROL (25 [48%]) (difference, 34.00; 95% CI, 16.00-51.00; P < .001; number needed to treat = 2.94) had clinically significant percentage overweight reductions. Food and activity monitoring and goal setting mediated the effect of LOW vs CONTROL (50%). Monitoring and goal setting, family and home environment, and healthy behaviors with peers mediated the effect of HIGH vs CONTROL (25%-42%). Following FBT, specialized intervention content (SFM+) enhanced children's weight outcomes and outperformed a credible control condition, with high dose delivery yielding the best outcomes. Sustained monitoring and goal setting, support from the family and home environment, and healthy peer interactions explained outcome differences, highlighting key treatment targets. clinicaltrials.gov Identifier: NCT00759746.

The Influence of Parental Health Literacy Status on Reach, Attendance, Retention, and Outcomes in a Family-Based Childhood Obesity Treatment Program, Virginia, 2013-2015.

IntroductionFew interventions have evaluated the influence of parent health literacy (HL) status on weight-related child outcomes. This study explores how parent HL affects the reach, attendance, and retention of and outcomes in a 3-month multicomponent family-based program to treat childhood obesity (iChoose).MethodsThis pre–post, quasiexperimental trial occurred in the Dan River Region, a federally designated medically underserved area. iChoose research protocol and intervention strategies were designed using an HL universal precautions approach. We used validated measures, standardized data collection techniques, and generalized linear mixed-effect parametric models to determine the moderation effect of parent HL on outcomes.ResultsNo significant difference in HL scores were found between parents who enrolled their child in the study and those who did not. Of 94 enrolled parents, 34% were low HL, 49% had an annual household income of less than $25,000, and 39% had a high school education or less. Of 101 enrolled children, 60% were black, and the mean age was 9.8 (standard deviation, 1.3) years. Children of parents with both low and high HL attended and were retained at similar rates. Likewise, parent HL status did not significantly influence improvements in effectiveness outcomes (eg, child body mass index [BMI] z scores, parent BMI, diet and physical activity behaviors, quality of life), with the exception of child video game/computer screen time; low HL decreased and high HL increased screen time (coefficient = 0.52, standard error, 0.11, P < .001).ConclusionBy incorporating design features that attended to the HL needs of parents, children of parents with low HL engaged in and benefited from a family-based childhood obesity treatment program similar to children of parents with high HL.

Randomised controlled trial evaluating the effectiveness and cost-effectiveness of 'Families for Health', a family-based childhood obesity treatment intervention delivered in a community setting for ages 6 to 11 years.

Effective programmes to help children manage their weight are required. 'Families for Health' focuses on a parenting approach, designed to help parents develop their parenting skills to support lifestyle change within the family. Families for Health version 1 showed sustained reductions in mean body mass index (BMI) z-score after 2 years in a pilot project. The aim was to evaluate its effectiveness and cost-effectiveness in a randomised controlled trial (RCT). The trial was a multicentre, investigator-blind RCT, with a parallel economic and process evaluation, with follow-up at 3 and 12 months. Randomisation was by family unit, using a 1 : 1 allocation by telephone registration, stratified by three sites, with a target of 120 families. Three sites in the West Midlands, England, UK. Children aged 6-11 years who were overweight (≥ 91st centile BMI) or obese (≥ 98th centile BMI), and their parents/carers. Recruitment was via referral or self-referral. Families for Health version 2 is a 10-week, family-based community programme with parallel groups for parents and children, addressing parenting, lifestyle, social and emotional development. Usual care was the treatment for childhood obesity provided within each locality. Joint primary outcome measures were change in children's BMI z-score and incremental cost per quality-adjusted life-year (QALY) gained at 12 months' follow-up (QALYs were calculated using the European Quality of Life-5 Dimensions Youth version). Secondary outcome measures included changes in children's waist circumference, percentage body fat, physical activity, fruit/vegetable consumption and quality of life. Parents' BMI and mental well-being, family eating/activity, parent-child relationships and parenting style were also assessed. The process evaluation documented recruitment, reach, dose delivered, dose received and fidelity, using mixed methods. The study recruited 115 families (128 children; 63 boys and 65 girls), with 56 families randomised to the Families for Health arm and 59 to the 'usual-care' control arm. There was 80% retention of families at 3 months (Families for Health, 46 families; usual care, 46 families) and 72% retention at 12 months (Families for Health, 44 families; usual care, 39 families). The change in BMI z-score at 12 months was not significantly different in the Families for Health arm and the usual-care arm [0.114, 95% confidence interval (CI) -0.001 to 0.229; p = 0.053]. However, within-group analysis showed that the BMI z-score was significantly reduced in the usual-care arm (-0.118, 95% CI -0.203 to -0.034; p = 0.007), but not in the Families for Health arm (-0.005, 95% CI -0.085 to 0.078; p = 0.907). There was only one significant difference between groups for secondary outcomes. The economic evaluation, taking a NHS and Personal Social Services perspective, showed that mean costs 12 months post randomisation were significantly higher for Families for Health than for usual care (£998 vs. £548; p < 0.001). The mean incremental cost-effectiveness of Families for Health was estimated at £552,175 per QALY gained. The probability that the Families for Health programme is cost-effective did not exceed 40% across a range of thresholds. The process evaluation demonstrated that the programme was implemented, as planned, to the intended population and any adjustments did not deviate widely from the handbook. Many families waited more than 3 months to receive the intervention. Facilitators', parents' and children's experiences of Families for Health were largely positive and there were no adverse events. Further analysis could explore why some children show a clinically significant benefit while others have a worse outcome. Families for Health was neither effective nor cost-effective for the management of obesity in children aged 6-11 years, in comparison with usual care. Further exploration of the wide range of responses in BMI z-score in children following the Families for Health and usual-care interventions is warranted, focusing on children who had a clinically significant benefit and those who showed a worse outcome with treatment. Further research could focus on the role of parents in the prevention of obesity, rather than treatment. Current Controlled Trials ISRCTN45032201. This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 21, No. 1. See the NIHR Journals Library website for further project information.

Design of the FRESH study: A randomized controlled trial of a parent-only and parent–child family-based treatment for childhood obesity

Approximately 1 out of 3 children in the United States is overweight or obese. Family-based treatment (FBT) is considered the gold-standard treatment for childhood obesity, but FBT is both staff and cost intensive. Therefore, we developed the FRESH (Family, Responsibility, Education, Support, & Health) study to evaluate the effectiveness of intervening with parents, without child involvement, to facilitate and improve the child's weight status. Targeting parents directly in the treatment of childhood obesity could be a promising approach that is developmentally appropriate for grade-school age children, highly scalable, and may be more cost effective to administer. The current paper describes the FRESH study which was designed to compare the effectiveness of parent-based therapy for pediatric obesity (PBT) to a parent and child (FBT) program for childhood obesity. We assessed weight, diet, physical activity, and parenting, as well as cost-effectiveness, at baseline, post-treatment, and at 6- and 18-month follow-ups. Currently, all participants have been recruited and completed assessment visits, and the initial stages of data analysis are underway. Ultimately, by evaluating a PBT model, we hope to optimize available child obesity treatments and improve their translation into clinical settings.

Parent binge eating and depressive symptoms as predictors of attrition in a family-based treatment for pediatric obesity.

Attrition is a significant problem in family-based treatment (FBT) for childhood obesity. Despite this, very few studies have examined factors associated with attrition. The current study examined parent symptoms of depression and binge eating as predictors of attrition in FBT. Participants included 77 parents of overweight children enrolled in FBT for childhood obesity. Data were collected at baseline and post-treatment. Binary logistic regression was used to assess associations between parent binge eating symptoms, depressive symptoms, and attrition. Results showed that parent binge eating symptoms (p=0.02), but not depressive symptoms (p=0.07), were significantly associated with attrition, after controlling for parent BMI, treatment group assignment, and family income. Higher reported parent binge eating symptoms were significantly related to attrition in FBT. Assessment of parent binge eating may be important in identifying families at risk for dropping out of FBT. Further, FBT may need to be adapted for families with parents who have a high level of psychopathology.

Service evaluation of the GOALS family-based childhood obesity treatment intervention during the first 3 years of implementation

ObjectivesTo evaluate the impact of the GOALS (Getting Our Active Lifestyles Started) family-based childhood obesity treatment intervention during the first 3 years of implementation.DesignSingle-group repeated measures with qualitative questionnaires.SettingCommunity venues...

Parent changes in diet, physical activity, and behavior in family-based treatment for childhood obesity.

Parent changes in diet, physical activity, and behavior in family-based treatment for childhood obesity.

The Built Environment Moderates Effects of Family-Based Childhood Obesity Treatment over 2 Years

Research suggests the neighborhood built environment is related to child physical activity and eating. The purpose of this study was to determine if characteristics of the neighborhood environment moderate the relationship between obesity treatment and weight loss, and if outcomes of particular treatments are moderated by built environment characteristics. The relationship between the built environment and standardized BMI (zBMI) changes for 191 8-12-year-old children who participated in one of four randomized, controlled trials of pediatric weight management was assessed using mixed models analysis of covariance. At 2-year follow-up, greater parkland, fewer convenience stores, and fewer supermarkets were associated with greater zBMI reduction across all interventions. No treatments interacted with characteristics of the built environment. Activity- and eating-related built neighborhood characteristics are associated with child success in behavioral obesity treatments. Efficacy may be improved by individualizing treatments based on built environment characteristics.

Moving forward in childhood obesity treatment: A call for translational research

Childhood obesity is one of the most serious challenges of the 21st century and it is vital that evidence-based treatment approaches can be translated into practice to meet public health needs. Yet policy-makers cannot afford to wait for the results of lengthy trials before ‘probably efficacious’ interventions are made available to the public, and the need for a continuous improvement methodology has been highlighted. In this discussion paper, we draw on our experiences of developing and evaluating a family-based childhood obesity treatment intervention to discuss the challenges of meeting research appraisal standards, public health needs and delivery practicalities. Recommendations are made for a shift towards a translational approach that brings together the strengths of hypothesis-driven research and high-quality service evaluation to create reciprocal links between evidence, policy and practice.

Family involvement in the treatment of childhood obesity: the Copenhagen approach

The objective of this study was to assess the impacts of a family-based childhood obesity treatment on anthropometry and predictors of dropout and successful weight loss. The 18-month treatment consisted of a intensive period (IP) including physical exercise, nutritional guidance, family psychotherapy, child group sessions and a 1-year follow-up (FU). One hundred children (10-12 years old, >140% of median weight-for-height) participated. The 81 children completing the IP decreased significantly from 2.9 to 2.6 body mass index (BMI) standard deviation score (SDS) units (p < 0.001). Furthermore, mean body fat percentage decreased significantly from 33.7 to 31.9 during IP. The 49 children completing the FU had a further decrease of 0.2 BMI SDS units (p = 0.003). Weight loss was less in children from immigrant families. Drop-out was higher if the mother had limited education and in immigrant families. This treatment with a psychological approach is feasible and results in significant weight loss during the programme. Future research should focus on how to improve the results of families with limited education and immigrants with non-European origin.

Ten-year outcomes of behavioral family-based treatment for childhood obesity.

Ten-year outcomes of behavioral family-based treatment for childhood obesity.

Long-term effects of family-based treatment for obesity on nontreated family members

We have previously shown that children in families in which both obese parents and children were targeted and reinforced for weight loss were more successful in weight loss after 5 years than children in a child alone target or nonspecific target control group. This effect was not observed in participating parents, with parent weight returning to baseline levels for all treatment groups (Epstein, Wing, Koeske and valoski, in press). The current study assessed the effect of the family-based treatment for childhood obesity on nontreated parents and siblings. Given the limitation that the majority of the nontreated parent and sibling data were based on participating parent report, the results showed overweight nonparticipating siblings of children in the parent plus child treatment group had significantly greater percent overweight change than overweight siblings in the child alone or nonspecific target groups. No significant group differences were observed for obese nonparticipating parents or for nonobese nonparticipating siblings or parents over the five-year period.

Effects of family-based behavioral treatment on obese 5-to-8-year-old children

The purpose of this study was to evaluate the effectiveness of family-based treatment for childhood obesity for 5-to-8-year-old children. Nineteen obese 5-to 8-year-old girls were randomly assigned to one of two treatments: a behaviorally oriented program which emphasized parent management, and a control group which provided equal education and attention, but not behavioral principles. The treatment group showed better weight loss and relative weight changes than the control group at the 8 and 12 month observations. These results show that the family-based treatment developed for 8-to-12-year-olds can be generalized to 5-to-8-year-old children.