Providers' involvement of blended families in pediatric weight management programs

INTRODUCTION

Family based interventions are the standard for pediatric weight management programs (PWMPs), yet the details of how to involve additional family members, when youth are part of blended families (i.e., step families) or reside in multiple households is not well understood. The objective of this study is to describe how providers involve blended families and multiple households in PWMPs.

METHOD

A cross-sectional exploratory survey was conducted of providers at PWMPs in the United States and Canada. The survey questions included had both multiple choice and open-ended responses. Univariate analyses were conducted.

RESULTS

71 providers participated, representing 47 centers/clinics. The majority (96%) reported assessing multiple households, most often during the medical history. Providers reported including the primary caretakers at all known residences (59%), but not immediate family members beyond the primary caretakers. Providers reported adapting dietary (88%) and physical activity (77%) recommendations to accommodate multiple households. The most frequent adaptations included the goals at each family/household, adjustments on a per family basis or based on family resources, and making materials available to all family members. The most frequent challenges in extending treatment plans to multiple households included one caretaker/household not willing to participate or being present at visits, and inconsistency between households. Despite providers reporting that they assess multiple households, they did not have a formal interview template or form to use in assessments (27%).

DISCUSSION

Providers recognize the challenges and complexity that blended families present with in obesity treatment. Further research is need to increase provider assessment and involvement of blended families and the extension of goals and treatment plans to multiple homes. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Adult weight management patients' perceptions of family dynamics and weight status

Our overall objective was to describe the parent-child, romantic, and family dynamics of adult weight management program (WMP) patients, and associations with children's and partners' weight status. First, we determined if family functioning mediated the effect between parent-child feeding practices and perceived child weight status, and romantic relationship anxiety and avoidance and perceived partner weight status. Second, we assessed if perceived child and partner weight status moderated the associations between family functioning and parent-child feeding practices and romantic relationship anxiety and avoidance, respectively. Patients (N=203) who resided with a child and partner from two WMPs completed assessments of parent-child feeding practices (Child Feeding Questionnaire), romantic relationship anxiety and avoidance (Relationship Structures Questionnaire), family functioning (Family Assessment Device General Functioning Scale), and perceived child and partner weight status. Bivariate analyses determined differences in weight status and relationship dynamics and family functioning, and mediation and moderation analyses were conducted to answer the two research questions. Family functioning was not a mediator between romantic relationship dynamics and partner weight status or parent-child dynamics and child weight status. Lower family functioning was associated with higher parent-child restrictive feeding practices, only among children with overweight/obesity. Similarly, lower family functioning was associated with higher anxiety and avoidance in romantic relationships, only for partners with overweight/obesity. Patients with children and/or partners with overweight/obesity reported more impaired family dynamics and functioning, compared to patients with children and/or partners with a healthy weight status.

Youth weight status and family functioning in paediatric primary care

The purpose of this study is to examine the associations between family functioning and youth overweight and obesity in a sample of primary care paediatric patients. Specially, we hypothesize that caregivers of youth with an overweight/obese weight status will report more impaired family functioning. A cross-sectional descriptive study was conducted with 329 caregivers of youth ages 2 to 18 seen in paediatric primary care. Caregivers completed the Family Assessment Device General Functioning Scale and clinical demographics, including parent-reported youth height and weight to calculate body mass index (BMI). Family functioning was used as a continuous total variable, and as a dichotomous variable based on clinically impaired or healthy family functioning. Analyses included descriptive statistics, Pearson's correlations, and independent t tests. Caregivers who reported impaired family functioning based on the clinical cutoff score were more likely to report that their youth had a higher BMI and BMI z-score. Caregivers with impaired family functioning and who identified as being in two-parent families, with at least a Bachelor's degree, and a moderate to high family income were more likely to report their youth was a higher weight status. Further screening and assessment of family functioning in combination with youth weight status among a larger diverse sample of primary care paediatric patients over time will provide insight into what aspects of family functioning may contribute to maintaining a healthy lifestyle or adopting new health behaviours to prevent and/or treat obesity in youth.

Providers' Involvement of Parents, Families, and Family Dynamics in Youth Weight Management Programs

Family-based interventions are the current standard for the treatment of pediatric obesity, yet the details of how providers are involving family members, and the barriers to family involvement, are largely unknown. The objective of this study is to describe how providers in pediatric weight management (PWM) involve family members, identify barriers to family involvement, and how they address challenging family dynamics. A cross-sectional survey was administered to PWM centers/clinics and their providers in the United States and Canada. Analyses included descriptive statistics at the participant (N = 71) and clinic/center (N = 47) levels. Providers indicated that they assessed patients and parents’ perspectives, not other family members, motivation, weight/medical history, dietary and activity behaviors, goals, and barriers. Providers also reported that they asked patients’ perspectives about their parents’ aforementioned behaviors, and siblings’ dietary, activity, and sedentary/screen time behaviors, and weight/medical history. Providers reported that the balance between the patient and parent changed as children aged, with more focus given to the child, and less to the parent, as the child grew older. The most frequent barrier to involving family members in treatment included challenging family dynamics. The most challenging family dynamics were divorce/separation and parent-child conflicts. Providers often refer to and rely on mental/behavioral health providers to address barriers to family involvement and challenging family dynamics. Further research is needed to determine adequate provider training and comfort in dealing with family dynamics in treatment, and ways to mitigate barriers to involving families in PWM.

Family Functioning in Pediatric Primary Care Patients

INTRODUCTION

The purpose of this study was to pilot a brief measure of family functioning (Family Assessment Device-General Functioning [FAD_GF]) with caregivers of children aged 2 to 18 years, seen for routine pediatric primary care visits.

METHODS

This study evaluated the psychometric properties of the FAD_GF in a pediatric primary care sample of 400 families. Confirmatory factor analysis was used to validate the FAD_GF using R, and WLSMV was used to estimate missing variables.

RESULTS

The FAD_GF was found to be reliable with this sample, α = .90. The model fit was χ²(54) = 56.44, P = .38, with root mean square error of approximation = .01 and comparative fit index = .99. The 12 items were significantly predicted by family functioning, and family functioning explained more than 20% of the variance in the items, R² > .25. Overall, 12.6% (n = 46) of families were identified as having clinically impaired family functioning.

DISCUSSION

The FAD_GF provides clinicians the ability to make evidence-informed decisions regarding referrals to family therapists.

Postoperative outcomes based on patient participation in a presurgery education and weight management program

BACKGROUND

The benefits of presurgery weight management programs (WMPs) for bariatric patients are mixed; some show a positive impact on percent excess weight loss (%EWL) at 12 months postsurgery, while others show no effect.

OBJECTIVES

The purpose of this study was to compare pre- and postoperative 6- and 12-month outcomes between patients who attended a 12-week presurgery WMP and patients who did not participate.

SETTING

Ohio State Wexner Medical Center, University Hospital, United States.

METHODS

A retrospective medical record analysis was conducted to compare preoperative and 6- and 12-month postoperative outcomes for patients who attend the presurgery WMP (n = 56) and patients who did not (n = 441) within a 2-year time period (N = 497). Descriptive statistics and independent t tests were conducted to determine mean differences between groups, while controlling for surgery type, for weight status outcomes (%EWL, change in body mass index) preoperatively and 6 and 12 months postsurgery, and length of stay and readmission rate.

RESULTS

Patients who attended the preoperative WMP had significantly higher %EWL at 12 months postsurgery compared with patients who did not attend the WMP. Additional findings indicated a positive, but nonsignificant effect, from the WMP on presurgery body mass index, and postsurgery %EWL at 6 months and body mass index change at 6 and 12 months postsurgery.

CONCLUSIONS

Patients attending the WMP had better 12-month %EWL and outcomes compared with those who did not attend the WMP, though this was not true for 6-month outcomes and differed based on surgery type.

Family Functioning and Childhood Obesity Treatment: A Family Systems Theory-Informed Approach

Childhood obesity recommendations advise providers to use family-based care for the treatment of youth and adolescent obesity. Family-based care, defined as the inclusion of a caregiver and a youth, is commonly conducted through behavioral interventions that target the dietary and physical activity behaviors of the attending parent-youth dyads. However, focusing on behaviors isolated to the parent and youth neglects the rest of the family members, and the larger rules, routines, communication, and dynamics in the family. Family-based interventions grounded in family systems theory (FST) target family dynamics to influence weight-related behaviors through higher-level changes in the family. The utility of using FST in childhood obesity treatment has not been extensively conceptualized or applied. Few outcome studies have reported on variables representative of FST, and even fewer FST interventions have been conducted. Because of the lack of detail on the application of FST to childhood obesity treatment, providers are left with little clarity on how to use FST in clinical encounters. We provide the background and evidence for use of FST, detail how families organize around weight-related behaviors that contribute to obesity, and on the basis of their organization, what type of treatment might be beneficial, FST-informed or family-based behavioral interventions. Finally, a suggested family-based clinical algorithm is provided detailing the use of FST through assessment, intervention, and follow-up that can be refined over time by providers and researchers committed to viewing obesity in the context of the family and family dynamics.

The relationship between trauma and weight status among adolescents in eating disorder treatment

A relationship between trauma and eating disorders in adolescence is well established, though less is known about how different types of trauma, apart from childhood sexual abuse, associate with eating disorders. The purpose of this study is to describe the prevalence of various trauma types in a clinical sample of adolescents presenting at an outpatient eating disorder treatment facility (N = 182). Thirty-five percent of the sample reported experiencing one or more traumatic events during their lifetime. Bullying was the most prevalent type of trauma (10%), followed by significant death/loss (9%), and sexual abuse (8%). Adolescents with any trauma exposure had higher body mass index (BMI), BMI percentile, and percent expected body weight (%EBW) compared to those without any trauma exposure. Specifically, patients who were exposed to bullying and domestic violence reported a significantly higher %EBW than those who were not exposed. On average, adolescents exposed to bullying had a %EBW that was 7 percentage points higher than their non-exposed peers. Patients with bulimia nervosa were more likely to report trauma exposure than those with other eating disorder diagnosis. Providers working with adolescents diagnosed with eating disorders of all weight statuses should consider assessing for past and current trauma, including bullying and exposure to domestic violence. Trauma informed approaches to eating disorder treatment are needed to avoid potentially activating or exacerbating trauma related distress for adolescents in eating disorder treatment.

Bariatric Surgery Candidates' Peer and Romantic Relationships and Associations with Health Behaviors

BACKGROUND

The aim was to assess the romantic and peer relationships of bariatric surgery candidates and associations with health behaviors.

METHOD

Adults seeking bariatric surgery (N = 120) completed surveys addressing health behaviors and social relationships at information sessions. Analysis was done to compare male/female differences in peer and romantic relationships and associations with health behaviors. Previously published reference (REF) data on the Relationship Structures questionnaire was used for comparison, and to split our sample into those ≤ or > REF mean for relationship anxiety and avoidance.

RESULTS

Our sample reported higher avoidance and lower anxiety in their close friendships and romantic relationships compared to the REF sample. Men in our sample had higher peer and romantic relationships avoidance compared to the REF sample and had significantly higher close friendship avoidance than women in our sample. Participants with lower anxiety in their romantic relationships (≤ REF) had higher uncontrolled eating and physical activity; those with more anxiety in their romantic relationships (> REF) had a higher BMI.

CONCLUSIONS

Our findings highlight the potential influence that social relationships may have on health behaviors within the bariatric surgery population. Further investigation is warranted to explore male bariatric surgery candidates' relationships to inform understanding and intervention development.

Mothers' Perspectives on the Development of Their Preschoolers' Dietary and Physical Activity Behaviors and Parent-Child Relationship: Implications for Pediatric Primary Care Physicians

The study explores female caregivers' reflections on their relationship with their child (2-5 years old) and the development of their child's dietary and physical activity behaviors. Five, 90-minute semistructured focus groups were conducted to inquire about children's growth, eating behaviors and routines, physical activity, personality, and the parent-child relationship. Nineteen female caregivers diverse in race/ethnicity, age, and educational attainment participated. Participants reported that they maintained a schedule, but needed to be flexible to accommodate daily responsibilities. Family, social factors, and day care routines were influences on their children's behaviors. The main physical activity barriers were safety and time constraints. Guidance from pediatric primary care providers aimed at supporting female caregivers to build a positive foundation in their parent-child relationship, and to adopt and model healthy diet and physical activity behaviors that are respectful of schedules and barriers should be a priority for childhood obesity prevention.

Methods and design of a 10-week multi-component family meals intervention: a two group quasi-experimental effectiveness trial

Background

Given the ongoing childhood obesity public health crisis and potential protective effect of family meals, there is need for additional family meals research, specifically experimental studies with expanded health outcomes that focus on the at-risk populations in highest need of intervention. Future research, specifically intervention work, would also benefit from an expansion of the target age range to include younger children, who are laying the foundation of their eating patterns and capable of participating in family meal preparations. The purpose of this paper is to address this research gap by presenting the objectives and research methods of a 10-week multi-component family meals intervention study aimed at eliciting positive changes in child diet and weight status.

Methods

This will be a group quasi-experimental trial with staggered cohort design. Data will be collected via direct measure and questionnaires at baseline, intervention completion (or waiting period for controls), and 10-weeks post-intervention. Setting will be faith-based community center. Participants will be 60 underserved families with at least 1, 4–10 year old child will be recruited and enrolled in the intervention (n = 30) or waitlist control group (n = 30). The intervention (Simple Suppers) is a 10-week family meals program designed for underserved families from racial/ethnic diverse backgrounds. The 10, 90-min program lessons will be delivered weekly over the dinner hour. Session components include: a) interactive group discussion of strategies to overcome family meal barriers, plus weekly goal setting for caregivers; b) engagement in age-appropriate food preparation activities for children; and c) group family meal for caregivers and children. Main outcome measures are change in: child diet quality; child standardized body mass index; and frequency of family meals. Regression models will be used to compare response variables results of intervention to control group, controlling for confounders. Analyses will account for clustering by family and cohort. Significance will be set at p < 0.05.

Discussion

This is the first experimentally designed family meals intervention that targets underserved families with elementary school age children and includes an examination of health outcomes beyond weight status. Results will provide researchers and practitioners with insight on evidence-based programming to aid in childhood obesity prevention.

Trial registration

NCT02923050. Registered 03 October 2016. Retrospectively registered.

Marriage and Family Therapy Trainees' Reports of Explicit Weight Bias

Discrimination based on an individual's weight has been observed in health care, education, retail, and other public sectors (Puhl & Huer, Obesity, 17, 941, 2007). Such inequity, known as "weight bias," generates negative short-term and long-term consequences for the individuals that experience it (Puhl & Brownell, Weight bias in health care settings, 2007). Past research has shown that healthcare trainees exhibit weight bias (Phelan et al., Obesity, 22, 1201, 2014; Wigton & McGaghie, Journal of General Internal Medicine, 16, 262, 2001), yet little focus is given to weight bias in marriage and family therapy (MFT) education. The purpose of this study was to survey MFT students (N = 162) to explore weight bias and how contextual factors associate with weight bias. Participants in MFT programs reported explicit weight bias, with specific contextual factors associating with more bias. Female participants reported more fear of gaining weight, and individuals who identified as overweight had higher rates of explicit weight bias. Contextual differences and implications for training programs are discussed.

Predictors of follow-up for overweight youth and parents

Attrition is a significant problem for health care providers working with youth and parents involved in childhood obesity treatment. Barriers for families in childhood obesity treatment have been explored, but less is known about factors that may be associated with follow-up attendance. The purpose of this study is to explore youth and parent variables, pediatrician's evaluations of youth and parents' likelihood to change (LTC), and their association with attendance at follow-up. One hundred ninety-three youth and parent dyads were included in the sample; slightly more than half of the sample did not return for a follow up visit. Descriptive statistics, paired and independent t tests, and correlations were used to determine associations between youth and parent demographic factors, attendance at follow-up, and pediatricians' evaluation of likelihood to change. Evaluations of LTC and demographic factors did not significantly associate with follow-up appointment attendance. Single parents were more likely to be rated by pediatricians as likely to make changes. Implications for future research and clinical practice are discussed.

Camp-based immersion treatment for obese, low socioeconomic status, multi-ethnic adolescents

BACKGROUND

Immersion treatment (IT) provided in a camp setting has been shown to promote short-term improvements in weight and health status in obese adolescents. However, evidence of IT's long-term efficacy and efficacy for multi-ethnic and lower socioeconomic status (SES) adolescents is limited.

METHODS

This was a cohort study with a pre/post design and longitudinal follow-up. The intervention was a 19-day camp-based IT program comprising (1) a nutrition curriculum and ad-lib access to a nutritious diet, (2) several hours of physical activity daily, (3) group therapy, and (4) cognitive-behavioral therapy (CBT). This analysis included 52 low-SES adolescents that participated in 2009 and 2010. A subgroup of 33 campers and their families was offered follow-up monthly for 10 months. Primary outcome measures were change in weight-related parameters immediately postcamp and after 10 months of follow-up.

RESULTS

Campers had significant short-term improvements in mean waist circumference (mean [M], 2.6; standard deviation [SD], 3.2 cm), weight (M, 2.6; SD, 1.9 kg), BMI (M, 1.1; SD, 0.9 kg/m2), BMI z-score (M, 0.06; SD, 0.07), and percent overweight (M, 6.1; SD, 4.7). Campers offered follow-up had a modest increase in mean percent overweight (M, 2.0; SD, 8.4) during 10 months of follow-up. However, 33% experienced continuing decline in percent overweight during follow-up, and long-term follow-up was associated with significant overall (precamp vs. end of follow-up) improvements in percent overweight (M, 4.9; SD, 7.2).

CONCLUSIONS

Camp-based IT with CBT is a promising intervention for improving short- and long-term weight status of low-SES adolescents. Additional research is needed to increase long-term efficacy.

Quality of life and BMI changes in youth participating in an integrated pediatric obesity treatment program

BACKGROUND

Changes in Quality of Life (QOL) measures over time with treatment of obesity have not previously been described for youth. We describe the changes from baseline through two follow up visits in youth QOL (assessed by the Pediatric Quality Life Inventory, PedsQL4.0), teen depression (assessed by the Patient Health Questionnaire, PHQ9A), Body Mass Index (BMI) and BMI z-score. We also report caregiver proxy ratings of youth QOL.

METHODS

A sample of 267 pairs of youth and caregiver participants were recruited at their first visit to an outpatient weight-treatment clinic that provides care integrated between a physician, dietician, and mental health provider; of the 267, 113 attended a visit two (V2) follow-up appointment, and 48 attended visit three (V3). We investigated multiple factors longitudinally experienced by youth who are overweight and their caregivers across up to three different integrated care visits. We determined relationships at baseline in QOL, PHQ9A, and BMI z-score, as well as changes in variables over time using linear mixed models with time as a covariate.

RESULTS

Overall across three visits the results indicate that youth had slight declines in relative BMI, significant increases in their QOL and improvements in depression.

CONCLUSIONS

We encourage clinicians and researchers to track youth longitudinally throughout treatment to investigate not only youth's BMI changes, but also psychosocial changes including QOL.

Promising insights into the health related quality of life for children with severe obesity

BACKGROUND

Childhood obesity is a growing health concern known to adversely affect quality of life in children and adolescents. The Patient Reported Outcomes Measurement Information System (PROMIS) pediatric measures were developed to capture child self-reports across a variety of health conditions experienced by children and adolescents. The purpose of this study is to begin the process of validation of the PROMIS pediatric measures in children and adolescents affected by obesity.

METHODS

The pediatric PROMIS instruments were administered to 138 children and adolescents in a cross-sectional study of patient reported outcomes in children aged 8-17 years with age-adjusted body mass index (BMI) greater than the 85th percentile in a design to establish known-group validity. The children completed the depressive symptoms, anxiety, anger, peer relationships, pain interference, fatigue, upper extremity, and mobility PROMIS domains utilizing a computer interface. PROMIS domains and individual items were administered in random order and included a total of 95 items. Patient responses were compared between patients with BMI 85 to<99th percentile versus ≥99th percentile.

RESULTS

136 participants were recruited and had all necessary clinical data for analysis. Of the 136 participants, 5% ended the survey early resulting in missing domain scores at the end of survey administration. In multivariate analysis, patients with BMI ≥ 99th percentile had worse scores for depressive symptoms, anger, fatigue, and mobility (p<0.05). Parent-reported exercise was associated with better scores for depressive symptoms, anxiety, and fatigue (p<0.05).

CONCLUSIONS

Children and adolescents ranging from overweight to severely obese can complete multiple PROMIS pediatric measures using a computer interface in the outpatient setting. In the 5% with missing domain scores, the missing scores were consistently found in the domains administered last, suggesting the length of the assessment is important. The differences in domain scores found in this study are consistent with previous reports investigating the quality of life in children and adolescents with obesity. We show that the PROMIS instrument represents a feasible and potentially valuable instrument for the future study of the effect of pediatric obesity on quality of life.

A biopsychosocial pilot study of overweight youth and care providers' perceptions of quality of life

This pilot study examined the relationship between youth and care provider self-reports of depressive symptoms assessed through the Patient Health Questionnaire and reports of youth physical and psychosocial functioning assessed by PedsQL4.0 in a rural outpatient overweight pediatric population (N = 66 child and care provider pairs). The relationship between youth body mass index (BMI), youth and care provider depression, youth quality of life (QOL), care provider perception of youth QOL, and youth and care provider congruence of QOL perceptions was examined. Paired t tests were completed to assess the differences between QOL scores for youth and care providers for subgroups based on age, age and gender, and age and race. The mean age of youth participants was 11.9 years; youth BMI ranged from 26.76 to 54.10 (M = 37.20). Our results showed that there are significant differences in youth and care providers' perceptions of QOL when specific demographic categories are assessed by age, gender, and race.

Camp Golden Treasures: a multidisciplinary weight-loss and a healthy lifestyle camp for adolescent girls

Camp Golden Treasures, (CGT) the first non-profit weight loss camp for overweight adolescent girls in the nation, was held for six weeks from June 24 to August 3, 2007 at the East Carolina University campus in Greenville, NC. The primary goal was to support campers to lose weight, raise self esteem, and to learn the tools necessary to lead a healthy lifestyle while reducing risks for developing chronic disease or mitigating the effects of existing obesity-related conditions (sleep apnea, insulin resistance, hypertension, lower extremity dysfunction, etc.). While at CGT, campers learned about the importance of physical activity and proper nutrition through workshops, discussion groups and hands-on activities. Additionally campers were taught the necessary tools and strategies needed to make concrete, positive lifestyle changes so they can achieve a healthy weight. Due to the nature of a chronic disease such as obesity, multidisciplinary collaborators including physical therapy, nutrition, health education, management, family therapy, risk management, fundraising, public relations, medical, nursing, and physician coverage were involved in designing, planning, and implementing CGT.