Family-based models for childhood-obesity intervention: a systematic review of randomized controlled trials

Understanding parent perspectives on engagement with online youth-focused mental health programs

OBJECTIVE

Online youth-focused health programs often include parent modules-that equip parents with skills to assist their child in improving their health-alongside youth-specific content. BRAVE Self-Help, an evidence-based program designed for children and teenagers with early signs of anxiety, is a popular Australian program that includes six parent modules. Despite its popularity and proven efficacy, BRAVE Self-Help shares the same challenge as many online self-help programs-that of low participant engagement. Using parents registered in BRAVE Self-Help as 'information rich' participants, we explored (a) factors that influenced parent engagement in online health programs, and (b) their recommendations for enhancing parent engagement.

DESIGN AND OUTCOME MEASURE

We conducted semi-structured interviews with 14 parents registered in BRAVE Self-Help. Data were analysed through reflexive thematic analysis.

RESULTS

Social-, family- and program-related factors drove parents' program engagement and recommendations. Social sub-themes related to the benefits of professional and community support in promoting more engagement. Family sub-themes included difficulties with program engagement due to competing priorities, perceptions that condition severity influenced engagement, and feelings that previously-acquired health knowledge reduced motivation to engage. Program sub-themes included perceived usefulness and ease-of-use.

CONCLUSION

Program designers could target support systems, include flexible delivery options, and use iterative design processes to enhance parent engagement.

Building Healthy Families: Outcomes of an Adapted Family Healthy Weight Program Among Children in a Rural Mid-Western Community

Background: This study aimed to evaluate the effectiveness of implementing an adapted, evidence-based 12-week Family Healthy Weight Program (FHWP), Building Healthy Families, on reducing BMI metrics and clinical health indicators in a real-world community setting. Methods: Ninety child participants with a BMI percentile greater or equal to the 95th percentile for gender and age and their parents/guardians (n = 137) enrolled in the program. Families attended 12 weekly group-based sessions of nutrition education, family lifestyle physical activity, and behavior modification. A pre-post study design with a 6-month follow-up was used. Results: Nine cohorts of families between 2009 and 2016 completed the program with 82.1% retention at 12 weeks and 53.6% at 6 months. Participants had statistically significant improvements at 12 weeks in BMI z-score, %BMIp95, body mass, body fat, fat mass, fat-free mass, and systolic blood pressure with greater improvement at 6 months in body mass, BMI metrics, body fat, fat mass, fat-free mass, and systolic blood pressure. Parents/guardians of the participants had similar statistically significant body composition and blood pressure improvements (p < 0.05). In addition, children had significant improvements in high-density lipoprotein (HDL) cholesterol and aspartate aminotransferase (AST) liver enzymes at 6 months. Conclusions: Overall, this study demonstrated that an evidence-based FHWP can result in statistically meaningful declines in BMI z-score and accompanied clinically meaningful changes in health risk. Participants lost ∼4% of their body mass in 12 weeks, while their parents/guardians lost closer to 7% of their body mass, which supports previous literature suggesting body mass changes influence health.

Family systems approaches in pediatric obesity management: a scoping review

Family-based obesity management interventions targeting child, adolescent and parental lifestyle behaviour modifications have shown promising results. Further intervening on the family system may lead to greater improvements in obesity management outcomes due to the broader focus on family patterns and dynamics that shape behaviours and health. This review aimed to summarize the scope of pediatric obesity management interventions informed by family systems theory (FST). Medline, Embase, CINAHL and PsycInfo were searched for articles where FST was used to inform pediatric obesity management interventions published from January 1980 to October 2023. After removal of duplicates, 6053 records were screened to determine eligibility. Data were extracted from 50 articles which met inclusion criteria; these described 27 unique FST-informed interventions. Most interventions targeted adolescents (44%), were delivered in outpatient hospital settings (37%), and were delivered in person (81%) using group session modalities (44%). Professionals most often involved were dieticians and nutritionists (48%). We identified 11 FST-related concepts that guided intervention components, including parenting skills, family communication, and social/family support. Among included studies, 33 reported intervention effects on at least one outcome, including body mass index (BMI) (n = 24), lifestyle behaviours (physical activity, diet, and sedentary behaviours) (n = 18), mental health (n = 12), FST-related outcomes (n = 10), and other outcomes (e.g., adiposity, cardiometabolic health) (n = 18). BMI generally improved following interventions, however studies relied on a variety of comparison groups to evaluate intervention effects. This scoping review synthesises the characteristics and breadth of existing FST-informed pediatric obesity management interventions and provides considerations for future practice and research.

Changes in weight status of caregivers of children and adolescents enrolled in a community-based healthy lifestyle programme: Five-year follow-up

Whānau Pakari is a family-centred healthy lifestyle programme for children/adolescents with overweight/obesity in New Zealand. This secondary analysis from our randomised trial within the clinical service assessed 5-year BMI changes in accompanying caregivers (n = 23), mostly mothers. Overall, baseline and 5-year caregivers' BMI were similar (32.50 vs 31.42 kg/m2, respectively; p = 0.31) but two-thirds (65%) experienced BMI reductions. Five-year BMI change was similar in High-intensity and Low-intensity randomisation groups [-1.37 kg/m2 (-4.95, 2.21); p = 0.44]. Caregiver's BMI change was not associated with child's BMI change. Despite no overall BMI reduction, our findings contrast with upward BMI trajectories predicted for NZ adults with overweight/obesity.

Rethinking family-based obesity treatment

Emerging research in paediatric obesity has demonstrated that parental involvement in the weight management process can improve weight outcomes in children. Recent guidelines by the American Academy of Pediatrics note the importance of parent and family involvement in treatment. However, it is currently unknown if including the entire family in obesity treatment can supersede outcomes associated with participation of only one parent. Family Systems Theory (FST) provides the theoretical foundation for examining one's healthy behaviours as they exist within the context of their family, defined by family dynamics. This narrative review aims to reconsider prior definitions of paediatric family-based management using the FST framework to be inclusive of family and household diversity and in doing so, inform research not only within weight management but also other domains of clinical care requiring family support or change. Applying FST to paediatric weight management highlights the link between family dynamics and paediatric obesity, demonstrating the association of dysfunctional family dynamics with more severe obesity. While family-based weight management remains the gold standard for treatment of paediatric obesity, more investigation is needed in expanding family-based interventions to impact entire families and potentially improve outcomes more broadly for overall family health and wellbeing.

Challenges encountered by parents from urban, lower social economic class in changing lifestyle behaviors of their children who are overweight or obese

BACKGROUND

Parents from urban, lower social economic classes often encounter unique challenges in their lives, which shape how they work with their children who are overweight or obese to change their exercise and eating behaviors at home. The present study took an initial step to address a gap in the literature by describing the challenges that parents from lower social economic classes in an urban city encountered in changing exercise and eating behaviors of their children who are overweight or obese.

METHODS

A conversational style semi-structured interview with prompts and probes was conducted to 44 parents whose child is overweight or obese. Inductive content analysis and constant comparison was used to analyze the data. Data trustworthiness was established by using a variety of strategies.

RESULTS

Two major themes with eight sub-themes emerged from the data: Challenges to promote a healthy active lifestyle, and challenges from their child's development and lifestyle behavior. Eight sub-themes were: (1) Need for effective strategies for a lifestyle behavior change, (2) monitor and promote healthy choices, (3) money, time, and dangerous neighborhood, (4) scientific knowledge to promote a healthy active lifestyle, (5) developmental changes of adolescence, (6) unmotivated and lack of persistence, (7) sneaking eating, and (8) peer pressure.

CONCLUSION

The challenges, from economic to parenting, are certainly of importance, and understanding these challenges will be crucial to help school-based professionals develop interventions. Those identified challenges should be clearly placed within family-school collaboration practices.

Relationships examined: Parent and child readiness to change and sociodemographic characteristics in family based weight loss treatment

BACKGROUND

Family based treatment is an effective, multipronged approach to address obesity as it plagues families.

OBJECTIVE

To investigate the relationships among sociodemographic characteristics (e.g., education and income), body mass index (BMI) and race/ethnicity with readiness to change for parents enrolled in the Primary care pediatrics, Learning, Activity and Nutrition (PLAN) study.

METHODS

Multivariate linear regressions tested two hypotheses: (1) White parents will have higher levels of baseline readiness to change, when compared to Black parents; (2) parents with higher income and education will have higher levels of readiness to change at baseline.

RESULTS

A positive relationship exists between baseline parent BMI and readiness to change (Pearson correlation, 0.09, p < 0.05); statistically significant relationships exist between parent education level (-0.14, p < 0.05), income (0.04, p < 0.05) and readiness to change. Additionally, a statistically significant relationship exists, with both White (β, -0.10, p < 0.05), and Other, non-Hispanic (-0.10, p < 0.05) parents exhibiting lower readiness to change than Black, non-Hispanic parents. Child data did not indicate significant relationships between race/ethnicity and readiness to change.

CONCLUSIONS

Results demonstrate that investigators should consider sociodemographic characteristic factors and different levels of readiness to change in participants enrolling in obesity interventions.

A Hybrid Mobile Phone Feasibility Study Focusing on Latino Mothers, Fathers, and Grandmothers to Prevent Obesity in Preschoolers

OBJECTIVE

To pilot the feasibility of a mobile phone childhood obesity intervention for family caregivers of Latino preschool-aged children.

METHODS

An evidence-based early childhood obesity intervention was adapted to have cultural relevance and a shorter-length curriculum for mothers, fathers, and grandmothers of 2- to 5-year-old Latino children. Traditional in-person group sessions (four weeks) were combined with eight weeks of mobile phone content to support parenting skills and evidence-based and age-appropriate nutritional practices in either English or Spanish. A convenience sample of Latino families were recruited from WIC and Early Education Centers in East Los Angeles. Feasibility measures were collected. Child and caregiver height and weight were measured, and caregiver surveys of child dietary intake were collected at baseline, 1- and 6-month post-baseline. Changes in child's dietary intake and BMI, as well as caregiver BMI, were examined using a mixed effects linear regression model with family random intercept and nested random slope for time period of measurement.

RESULTS

The program was delivered to 64 low-income Latino families (46 mothers, 34 fathers, 16 grandmothers, and 48 children). Children had a reduction in raw BMI, BMI percentile, and BMI z-scores at 6-months post-baseline compared to baseline measurements. The study also demonstrated stable BMI outcomes among all caregivers.

CONCLUSION

The pilot study shows promise in preventing childhood obesity, and having a multi-generational impact on weight outcomes. Leveraging the high-use of mobile phones has the potential to shorten in-person interventions, and engage fathers and grandmothers who play an important role in shaping healthy weight practices in young children.

'It's been a lifelong thing for me': parents' experiences of facilitating a healthy lifestyle for their children with severe obesity

OBJECTIVE

For parents and guardians, assisting children/adolescents with severe obesity to lose weight is often a key objective but a complex and difficult challenge. Our aim in this study was to explore parents' (and guardians') perspectives on the challenges they have faced in assisting their children/adolescents with severe obesity to lead a healthy lifestyle.

METHODS

Thirteen parents/guardians were interviewed from a pool of families who had been referred but did not engage between 2016 and 2018 (N = 103), with the Perth Children's Hospital Healthy Weight Service, a clinical obesity program for children/adolescents (parent age M = 43.2 years, children age M = 10.3 years). Using semi-structured interviews and thematic analysis, we identified 3 broad themes.

RESULTS

Parental weight-related factors reflected parents' own lifelong obesity narrative and its effect on their own and their families' ability to live a healthy lifestyle. Perceived inevitability of obesity in their child reflected parents' feelings that the obesity weight status of their children/adolescent was a persistent and overwhelming problem that felt 'out of control'. Lastly, parents reported challenges getting medical help stemming from co-morbid medical diagnosis in their child/adolescent, and difficulties with medical professionals.

CONCLUSION

This study demonstrates that parents face challenges in supporting healthy lifestyle for children/adolescents with severe obesity due to parents own internal weight biases and their negative experiences within the healthcare system when seeking help.

Quantifying the childhood and adolescent overnutrition attributable to specific risk factors: The Young Lives Study in Peru

OBJECTIVE

Launching priority actions demand a comprehensive appraisal of the size effect that risk factors have on the burden of overweight and obesity. This study aimed to estimate the incidence of overweight and obesity among children and adolescents, with special emphasis on the role of specific risk factors.

MATERIALS AND METHODS

Secondary analysis of data from the younger cohort of the Young Lives Study in Peru (2002-2017). The outcomes were: overweight and obesity, defined by the World Health Organization standards; whereas the exposures included caesarean birth, physical activity levels, sodas and sugar-sweetened beverages consumption, snacks consumption, and maternal body mass index (BMI). We used multilevel Poisson regression models, considering the repetitive nature of data, to estimate incidence rate ratios (IRRs) and population attributable fractions (PAFs).

RESULTS

A total of 2052 children, mean age 1 (SD 0.4) year, and 50% girls, were enrolled at baseline. After 14 (SD 0.5) years of follow-up, the incidence of overweight and obesity were 7.9 (95% CI 7.6-8.2) and 2.2 (95% CI 2.0-2.4) per 100 person-year, respectively. Maternal BMI (IRRs 3.51; PAF 31.8%), low physical activity (IRR 1.64; PAF 27.4%), caesarean birth (IRR 1.63; PAF 11.4%), almost daily snack consumption (IRR 1.60; PAF 32.1%), and almost daily consumption of sweetened beverages (IRR 1.47; PAF 26.0%) increased the risk of developing obesity.

CONCLUSIONS

This study provides evidence on the risk of overweight and obesity attributable to diet habits, physical activity and the obesogenic niche among children and adolescents in Peru, which may guide the implementation of evidence-based interventions.

Clinician and healthcare managers' perspectives on the delivery of secondary and tertiary pediatric weight management services

Clinician and healthcare managers' (HCMs) views on weight management service delivery are imperative for informing the nature of future services to treat children with obesity. This qualitative study used semi-structured focus groups and one-on-one semi-structured interviews. Participants were 27 clinicians (medical, nursing, or allied health) and nine HCMs (senior executives in the hospital) who worked in six secondary or tertiary pediatric weight management clinics across five public hospitals in New South Wales, Australia. Clinicians reported that using a combination of group and individual sessions improved engagement with families and reduced attrition rates. Clinicians and HCMs recommended integrating clinics into community centers and providing specific programs for sub-groups, such as children from culturally and linguistically diverse communities or children with developmental delay. Many clinicians and HCMs stressed the importance of pediatric weight clinics using a holistic approach to treatment. To improve the likelihood of future funding for pediatric weight management clinics and to optimize models of care, centers must embed research into their practice. Addressing common barriers to current pediatric weight management services and designing future models of care based on key stakeholders' preferences is critical to achieving optimal care provision for this high-risk population.

Perceptions of a family-based lifestyle intervention for children with overweight and obesity: a qualitative study on sustainability, self-regulation, and program optimization

BACKGROUND

Family-based lifestyle interventions (FBLIs) are an important method for treating childhood weight problems. Despite being recognized as an effective intervention method, the optimal structure of these interventions for children's overweight and obesity has yet to be determined. Our aim was to better understand participants' (a) implementation of behaviour strategies and long-term outcomes, (b) perceptions regarding the optimal structure of FBLIs, and (c) insights into psychological concepts that may explain the success of these programs.

METHODS

Purposive sampling was used to recruit participants. We conducted focus groups as well as one-to-one interviews with parents (n = 53) and children (n = 50; aged 7-13, M = 9.4 yr, SD = 3.1) three months following their involvement in a 10-week, multi-component, FBLI involving education and activities relating to healthy nutrition, physical activity, and behavior modification. Using an interpretivist approach, a qualitative study design was employed to examine participant experiences.

RESULTS

We identified three higher-order categories: (a) participants' program experiences and perceptions (b) lifestyle changes post-program, and (c) recommendations for optimizing family-based programs. Themes identified within these categories included (a) support and structure & content, (b) diet and physical activity, and (c) in-program recommendations and post-program recommendations.

CONCLUSIONS

We identified several challenges that can impair lasting behavior change (e.g., physical activity participation) following involvement in a FBLI. On optimizing these programs, participants emphasized fun, interactive content, interpersonal support, appropriate educational content, and behavior change techniques. Concepts rooted in motivational theory could help address calls for greater theoretical and mechanistic insight in FBLIs. Findings may support research advancement and assist health professionals to more consistently realize the potential of these interventions.

ENTREN-F family-system based intervention for managing childhood obesity: Study protocol for a randomized controlled trial at primary care

BACKGROUND

Pediatric obesity is a primary public health concern, and designing effective programs for managing it is of the utmost importance. The objective of this study was to describe the protocol study of a three-arm, parallel, randomized controlled trial aimed at assessing the efficacy of a family-system-based intervention ("ENTREN-F" program) for managing childhood obesity, compared to the "ENTREN" program (no "F" - without specific family-system-based workshop) and a control group (behavioral monitoring).

METHODS/DESIGN

The ENTREN-F program was a multicomponent family-system-based intervention carried out by a multidisciplinary team in the primary health care setting. The program targeted children between 8 and 12 years with overweight and obesity (P ≥ 85th). Parents were actively involved in the process. The contents were designed using the Cognitive Behavioral Therapy (CBT) principles. The program comprised individual behavioral monitoring, a healthy habits workshop for children and their parents, a CBT workshop for children, and a family-system-based workshop for parents, enhancing parental management skills plus family functioning. The trial's primary outcomes included changes in child body mass index (BMI) z-scores, child's psychological well-being, and family functioning over six months. Secondary outcomes included changes in eating behavior, physical activity, self-esteem, parental distress, parental feeding practices, and parental modeling.

DISCUSSION

To our knowledge, this is one of the few randomized controlled trials to assess the efficacy of a multicomponent program that considers health from a comprehensive perspective, trying to improve children's psychological well-being and family functioning besides weight loss. This study, therefore, addresses a gap in the literature. If found to be efficacious, it suggests a new potential health service for translation into National Primary Health Care services in Spain, one of the ten countries with the highest prevalence of obesity in Europe.

Community-Based Interventions to Reduce Fat Intake in Healthy Populations: A Systematic Review and Meta-Analysis

Background:

Reducing fat intake is a major focus of most dietary recommendations aiming to prevent chronic diseases. Thus, this study aimed to summarize community-based interventions for reducing fat consumption among healthy people.

Methods:

According to PRISMA guidelines, in this systematic review and meta-analysis databases including PubMed/MEDLINE, Scopus, EMBASE, Cochrane Library, Web of Science, ProQuest, and Google Scholar were searched up to January 2021. Randomized clinical trials (RCTs) or quasi-experimental studies reporting the effect of community-based interventions to reduce fat intake in a healthy populations were included. The quality of studies was assessed using the Cochrane Collaboration tool and The Joanna Briggs Institute Critical Appraisal Checklist. Meta-analysis was performed using CMA2 software.

Results:

Our search strategy resulted in a total of 1,621 articles, 43 of which were included in the study after screening. Of the 43 included studies, 35 studies reported a significant decrease in fat intake using educational and multiple intervention methods. About 82% of studies using the technology were effective (significant decrease in fat intake) in reducing fat intake. Moreover, studies specifically designed to change fat intake were more effective than multicomponent interventions. The meta-analysis of high-quality studies showed that the differences in total fat (-0.262 g/d) and saturated fat (-0.350 g/d) intake between the intervention and control groups were statistically significant (P<0.05).

Conclusion:

Based on the high-quality studies, educational and multiple interventions are suggested in the community settings to decrease fat intake. For a concise conclusions, long-term and high frequency interventions focusing on reducing fat intake are desirable.

Effectiveness of national multicentric school-based health lifestyles intervention among chinese children and adolescents on knowledge, belief, and practice toward obesity at individual, family and schools' levels

BACKGROUND

This study aims to evaluate the effectiveness of the trial of national multicentric school-based health lifestyles intervention toward childhood obesity on the KBP at individual, family and schools' levels.

METHODS

The national trial was a multi-centered, cluster-controlled trial, which was conducted in seven provinces from September 2013 to February 2014, aiming at preventing childhood overweight and obesity. Integrated intervention strategies focused on changing specific practice related to energy intake and expenditure, such as decreasing the consumption of sweetened fizzy drinks, increasing the consumption of vegetables, ensuring proper protein intake, reducing sedentary practice including screen time, and maintaining at least 1 h of moderate to vigorous physical activity. A total of 27,477 children and adolescents in the control group and 30,997 in the intervention group were recruited with a mean follow-up period of 6.7 months. The binomial response mixed-effects model was used for assessing the effects of the national school-based health lifestyles intervention on obesity-related KBP at students individual, parents' and schools' levels.

RESULTS

Children and adolescents in the intervention group mastered better obesity-related knowledge, and they had higher correct response rates to all questions about obesity-related knowledge compared to the control group (P < 0.05). In terms of obesity-related belief, individuals in the intervention group was more motivated than the control group, participants in the intervention group had higher correctness of 71.18, 52.94, and 56.60% than the control group of 68.61, 49.86, and 54.43%, (P < 0.05). In addition, healthier habits of eating breakfast and drinking milk every day were observed in the intervention group. For the beliefs toward obesity, parents of the intervention group had higher correctness than the control group. At the same time except for the fruit consumption, other obesity-related practice in the intervention group were healthier than the control group (P < 0.05). Except for some beliefs and practice, the intervention effect at the parent level was not significant in other aspects.

CONCLUSION

The obesity-related knowledge and beliefs of children and adolescents got improved significantly. However, the effects on the knowledge, beliefs and certain practices of their parents and school administrators failed to reach significance.

Global relationship between parent and child obesity: a systematic review and meta-analysis

BACKGROUND

The growing prevalence of overweight and/or obese children is an important public health problem in both developed and developing countries. Although the association of obesity between parents and their children is well known, its underlying mechanisms are not well established.

PURPOSE

This meta-analysis examined parent-child (PC) relationships in obesity and identified factors such as world region and country income level that may influence this relationship.

METHODS

We identified all related studies published between January 1, 2015 and May 31, 2020 by conducting a literature search using the MeSH terms "obesity," "overweight," "body mass index," "parent," "child," "associate," and "relate" in the PubMed database in English.

RESULTS

The meta-analysis of 23 studies that reported an odds ratio (OR) for parent and child obesity associations found a significant association between parents and children who were overweight or obese (pooled OR, 1.97; 95% confidence interval, 1.85-2.10). A meta-regression analysis was used to examine the sources of interstudy heterogeneity. The association between parent and child obesity was higher in Asia than in Europe and the Middle East and higher in high-income countries than in middle-or low-income countries. In addition, a higher association between parent and child obesity was found when both parents were obese than when only the father or mother was obese. This study from multiple countries indicates a significant PC relationship in weight status that varies according to PC pair type, parent and child weight statuses, world region, and country income level.

CONCLUSION

These results demonstrate that the risk of childhood obesity is greatly influenced by parental weight status and indicate that parents could play an important role in preventing child obesity.

Unique Features of a Web-Based Nutrition Website for Childhood Cancer Populations: Descriptive Study

Background

Children with cancer experience a myriad of nutritional challenges that impact their nutrition status during treatment and into survivorship. Growing evidence suggests that weight at diagnosis impacts cancer outcomes, but provider guidance on nutrition and diet during treatment varies. Nutrition literacy and culinary resources may help mitigate some common nutritional problems; however, many patients may face barriers to accessing in-person classes. Along with dietitian-led clinical interventions, web-based resources such as the newly updated electronic cookbook (e-cookbook) created by The University of Texas MD Anderson Cancer Center, @TheTable, may facilitate access to nutrition and culinary education during treatment and into survivorship.

Objective

We sought to define and describe the features and content of the @TheTable e-cookbook and compare it with analogous resources for a lay audience of patients with childhood cancer and childhood cancer survivors as well as their families.

Methods

We evaluated freely available web-based resources via a popular online search engine (ie, Google). These searches yielded three web-based resources analogous to @TheTable: the American Institute for Cancer Research’s Healthy Recipes, The Children’s Hospital of San Antonio’s Culinary Health Education for Families Recipe for Life, and Ann Ogden Gaffney and Fred Hutchinson Cancer Research Center’s Cook for Your Life. These sites were analyzed for the following: number of recipes, search functionality, child or family focus, cancer focus, specific dietary guidance, videos or other media, and miscellaneous unique features.

Results

Cook for Your Life and Culinary Health Education for Families Recipe for Life were the most comparable to @TheTable with respect to cancer focus and family focus, respectively. Healthy Recipes is the least user-friendly, with few search options and no didactic videos.

Conclusions

The @TheTable e-cookbook is unique in its offering of child- and family-focused content centered on the cancer and survivorship experience.

A Type III Hybrid Effectiveness-Implementation Pilot Trial Testing Dissemination and Implementation Strategies for a Pediatric Weight Management Intervention: The Nebraska Childhood Obesity Research Demonstration Project

Background: Several family-based efficacious pediatric weight management interventions (PWMIs) have been developed to reduce child weight status. These programs are typically based in larger cities delivered by an interdisciplinary team in a hospital or medical center. The degree to which these efficacious PWMIs have been translated to, and are feasible in, rural or micropolitan areas is unclear. This study protocol describes a pilot Type III hybrid effectiveness-implementation (T3HEI) trial testing a multilevel strategy that focuses on the adoption, implementation, and sustainability of a PWMI online training program and resource package designed for implementation in micropolitan and rural areas. Methods: The trial design employed the Reach, Effectiveness, Adoption, Implementation and Maintenance (RE-AIM) framework to evaluate outcomes and the Promoting Action on Research Implementation in Health Services framework to specify potential mechanisms of adoption, implementation, and sustainability. The study will test the feasibility of a fund and contract dissemination strategy in the adoption of a PWMI in four to eight rural communities, compare a learning collaborative implementation strategy including embedded training and sustainability action planning with communities who receive the PWMI online program and resources alone, and determine whether the PWMI reach, effectiveness, and maintenance are of magnitude similar to previous effectiveness trials. The dissemination and implementation process focused on an integrated research-practice partnership process model that includes a systems-based approach with multiple sectors and vertical decision-making representation. Conclusions: Our pilot T3HEI study has the potential to inform how best to move and sustain evidence-based PWMIs into practice. The findings will inform larger scale dissemination, implementation, and sustainability efforts in medically underserved areas across the country. Trial registration: This protocol is registered with clinicaltrials.gov (NCT04719442).

Health behaviour outcomes of a family based intervention for paediatric obesity in primary care: A randomized type II hybrid effectiveness-implementation trial

BACKGROUND

Paediatric obesity is a multifaceted public health problem. Family based behavioural interventions are the recommended approach for the prevention of excess weight gain in children and adolescents, yet few have been tested under "real-world" conditions.

OBJECTIVES

To evaluate the effectiveness of a family based intervention, delivered in coordination with paediatric primary care, on child and family health outcomes.

METHODS

A sample of 240 families with racially and ethnically diverse (86% non-White) and predominantly low-income children (49% female) ages 6 to 12 years (M = 9.5 years) with body mass index (BMI) ≥85th percentile for age and gender were identified in paediatric primary care. Participants were randomized to either the Family Check-Up 4 Health (FCU4Health) program (N = 141) or usual care plus information (N = 99). FCU4Health, an assessment-driven individually tailored intervention designed to preempt excess weight gain by improving parenting skills was delivered for 6 months in clinic, at home and in the community. Child BMI and body fat were assessed using a bioelectrical impedance scale and caregiver-reported health behaviours (eg, diet, physical activity and family health routines) were obtained at baseline, 3, 6 and 12 months.

RESULTS

Change in child BMI and percent body fat did not differ by group assignment. Path analysis indicated significant group differences in child health behaviours at 12 months, mediated by improved family health routines at 6 months.

CONCLUSION

The FCU4Health, delivered in coordination with paediatric primary care, significantly impacted child and family health behaviours that are associated with the development and maintenance of paediatric obesity. BMI did not significantly differ.

Improved Motor Proficiency and Quality of Life in Youth With Prader-Willi Syndrome and Obesity 6 Months After Completing a Parent-Led, Game-Based Intervention

PURPOSE

To determine changes and potential differences in physical activity (PA), gross motor proficiency (MP), and health parameters after a 6-month follow-up (FU) period following participation in a parent-led PA intervention in youth with or without Prader-Willi syndrome (PWS).

METHODS

About 42 youth with PWS and 65 youth without PWS but with obesity (body fat percentage >95th percentile for age and sex), aged 8-16 years, participated. The intervention included preplanned PA sessions containing playground and console-based video games scheduled 4 days per week for 24 weeks. Families received training and curriculum materials. PA (accelerometry), MP (Bruininks-Oseretsky Test of MP), and health-related quality of life were obtained before (PRE), after completing the intervention (POST), and at FU.

RESULTS

There were no significant changes in PA at any time point. At FU and POST, participants showed higher bilateral coordination (PRE = 9.3 [0.4], POST = 11.7 [0.5], and FU = 11.1 [0.6]); speed and agility (PRE = 9.2 [0.4], POST = 10.8 [0.4], and FU = 11.5 [0.5]); and strength (PRE = 8.0 [0.3], POST = 9.2 [0.3], and FU = 9.2 [0.3]) than at PRE. At FU (80.3 [2.1]) and POST (79.8 [1.7]), youth without PWS showed higher health-related quality of life than PRE (75.0 [1.8]).

CONCLUSION

The improvements in MP and health-related quality of life at FU suggest long-term durability of intervention outcomes.

Family-Based Obesity Prevention Interventions among Hispanic Children and Families: A Scoping Review

This scoping review examined intervention and sample characteristics of family-based obesity prevention interventions among Hispanic youth. This review also examined the degree to which existing interventions were culturally-adapted, acknowledged social determinants of health (SDoH), and collaborated with community stakeholders. A comprehensive search across Medline Ovid, Embase, Scopus, PsycInfo, and Pubmed was used to identify 13 studies primarily based in the U.S. (92.3%). Data was extracted by two independent reviewers. Most used a randomized control trial design (69.2%), a behavior change theory (84.6%), and reported moderate to high (≥70%) retention (69.2%). Studies targeted improvements in physical activity (69.2%) and fruit and vegetable intake (92.3%) through nutrition education, cooking demonstrations, and tastings. Younger children from low socioeconomic backgrounds (61.5%) were well represented. Most interventions were culturally-adapted (69.2%), all studies reported collaboration with stakeholders, yet only half used strategies that acknowledged SDoH (46.2%). To increase our understanding of the underlying mechanisms by which family-based approaches can reach and engage Hispanic youth and families, future studies should rigorously evaluate theoretical constructs, family processes, and SDoH that influence program participation and health behaviors. This information will guide the design and development of future interventions aimed at reducing obesity disparities among Hispanic youth.

Interaction and influence of child and family characteristics upon success of weight management treatment

PURPOSE

Interventions to address childhood obesity demonstrate moderate effects at best. Previous research has focused on factors of the intervention that influence success. Yet, effective overweight and obesity interventions require an interaction between family and individual factors. It is vital to characterize those who are successful vs. those who are not within treatment based on these factors.

METHODS

This study utilized data from an existing multidisciplinary (i.e., nutrition, physical therapy, psychology, and medicine) group treatment for children with overweight and obesity. Children (N = 113) were given the Behavior Assessment System for Children, the Pediatric Quality of Life Inventory, and completed an interview at baseline, then height and weight were measured at 6 months and 12 months post-intervention. Latent class analysis was used to determine how family and individual characteristics and behavior interact and group together to characterize individuals who lose weight vs. do not lose weight during treatment.

RESULTS

The four-cluster model was the best fit for the data. The four identified groups delineated one for whom treatment was successful, and three for whom treatment was not successful. Those three were differentiated by families who appeared to have inconsistent engagement with treatment, families who appeared to not be engaged with treatment, and families who had baseline risk factors that likely require a significantly higher level of treatment.

CONCLUSION

Characterizing the differences between those who successfully respond to this treatment from those who were unsuccessful can help identify those most likely to benefit from treatment. Future research and treatment considerations should include treatment modifications for nonresponders.

LEVEL OF EVIDENCE

Level III, longitudinal cohort study.

Understanding children and young people's experiences pursuing weight loss maintenance using the Socio-ecological Model: A qualitative systematic literature review

Developing a broader understanding of children and young people's experiences of long-term attempts of weight management may provide insight into both enablers and barriers to successful weight loss maintenance. This review aims to explore children and young people's perceptions of long-term attempts of weight management. Six databases were searched for qualitative studies describing young participants (<25 years, previously or currently above a healthy weight) experiences of weight management for >6 months following intentional weight loss. A thematic synthesis was undertaken. Themes were interpreted using the Socio-ecological Model. Factors supporting attempts to maintain weight loss included having clear motivation for change; developing personal skills to manage the challenges of change; family support/dynamics that encourage healthy lifestyles; and health-promoting cultures in schools/workplaces, communities, and the broader living environment. Conversely, ambivalence, difficulty coping with changes, peer pressure, challenging family dynamics, limited professional support, and unhealthy living environments were barriers to maintaining behavior change. These facilitators and barriers at each level of the Socio-ecological Model informed a model of weight loss maintenance for children and young people. Supporting children, young people, and families to develop the skills to manage the individual, social, and environmental challenges that shape attempts of long-term weight management will help to support their ability to manage their weight long term.

Healthier together: a pilot study on the implementation of a novel family centered pediatric obesity prevention program

CONTEXT

With pediatric obesity rates reaching epidemic scales across the United States, innovative research to identify key factors for successful implementation of obesity intervention programs is increasingly paramount. Project Healthy Attitudes Produces Positive Youth (HAPPY) is a family centered pediatric obesity prevention program targeting elementary age children and their families.

OBJECTIVES

To determine whether Project HAPPY interventions emphasizing social networks were successful.

METHODS

This was a small scale evaluation of the Project HAPPY pilot program, conducted after school at a public elementary campus in Solano County, California. From April 2018 to May 2018, first year medical students from Touro University California College of Osteopathic Medicine served as "family navigators," guiding participants through a 5 week curriculum of didactic lessons, cooking demonstrations, and physical exercises. Eligibility requirements for Project HAPPY included basic English proficiency, confirmed enrollment of at least one child at the elementary school, and willingness to attend all study sessions. The primary outcome evaluated was a shift in attitude toward individual health. Changes in body mass index (BMI) and health behaviors were assessed as secondary outcomes. Outcomes were assessed through surveys and measurements of BMI completed during Session 1, Session 10, and 4, 6, and 8 month follow up sessions.

RESULTS

Initial study participants included seven families, consisting of elementary school students with their siblings and parents (n=27). Only four families (n=13) completed the entire 5 week intervention. Over the course of the study, survey results of participants' attitudes regarding health suggested a positive trend toward self efficacy, while BMI appeared stable or increased. Participants demonstrated retention of successful health behaviors up to 8 months after the end of the intervention through qualitative reports of being "more conscious of meals and what (they) are eating," "valu[ing their] nutrition on a daily basis," "play[ing] a lot outside and inside on the weekends," "carry[ing] a water bottle," and "cook(ing) a lot." A higher percentage of respondents in the final session compared selected the option "strongly agree" to each of the following statements: "I can be healthier if my family works together" (87.5% final session vs. 84.6% first session), "Drinking water makes me healthy" (87.5% final session vs. 84.6% first session), "Moving my body makes me healthy" (87.5% final session vs. 76.9% first session), "I reach my goals even when things get in my way" (62.5% final session vs. 46.2% first session), "Eating fruits and veggies make me healthy" (100% final session vs. 92.3% first session), "I can be healthy and enjoy my favorite foods" (87.5% final session vs. 66.7% first session), and "I can create a healthy balanced meal" (87.0% final session vs. 75.0% first session). Concrete data analysis was severely complicated by loss of study participants to follow up and incomplete data collection.

CONCLUSIONS

Project HAPPY showed promising indications that should be further evaluated in studies of larger scale and longer duration.

Children's perceptions of their parent's parenting strategies and child influence on purchases in a supermarket

This field study identified, through observation, child influence on food and beverage purchases within a supermarket, as well as the influence of the children's perceptions of their parents' parenting strategies related to eating behaviors on these purchases. Four supermarkets were recruited to participate and agreed to allow recruitment of parent-child dyads and implementation of data collection protocols within their stores. Parent-child (7-14 yo) dyads were recruited to wear eye-tracking glasses during the supermarket visit, complete separate individual interviews, and have their store receipts scanned. The receipt data provided evidence of what was purchased, including overall purchases, as well as purchases of energy-dense, nutrient-poor foods and beverages. The eye-tracking data, together with the receipt data, identified which items were requested by the child and purchased. The child interviews provided the child's perceptions of parenting strategies (i.e., parental monitoring, control). Seventy-six dyads agreed to participate and completed the study protocols. During most of the shopping trips, items were purchased as a result of child-initiated request interactions. Children's perceptions of their parent's use of monitoring was consistently associated with fewer purchases overall and of energy-dense, nutrient-poor items, and with reduced child influence on what was purchased.

Diet Quality and Eating Practices among Hispanic/Latino Men and Women: NHANES 2011-2016

Dietary quality of Hispanic/Latino adults residing in homes with children may differ by gender, that in turn, may impact youth through role modeling and food availability. Using a nationally representative sample (n = 1039) from the National Health and Nutrition Examination Survey (2011-2016), adjusted regression analyses were used to examine food-related practices, food group intake, and dietary quality among Hispanic/Latino men and women in homes with children (6-17 years). Compared to women, men had lower total 2015 Healthy Eating Index (HEI) scores and component HEI scores for healthy food groups. Men also ate more meals that were not home prepared/week and purchased more foods from non-grocery stores than women. Negative food-related practices and working more hours/week may explain in part the lower dietary quality observed among Hispanic/Latino men than women. Interventions may be improved by targeting gender-specific food-related behaviors that could positively impact dietary quality of youth residing with them.

The Effectiveness of a Blended In-Person and Online Family-Based Childhood Obesity Management Program

Background: The purpose of this study was to evaluate the effectiveness of a 10-week blended family-based childhood obesity management program, relative to a wait-list control, in improving child body mass index (BMI) z-scores, child lifestyle behaviors, parental support for healthy eating and physical activity, and self-regulation for healthy eating and physical activity support. Methods: This study was registered as a randomized wait-listed controlled trial; however, due to low recruitment and program delivery logistics, this study transitioned into a quasi-experimental design. Families with children 8-12 years of age with a BMI ≥85th percentile for age and sex were recruited (October 2018 to March 2019) in British Columbia, Canada. The intervention provided families 10 weeks of in-person and online support on improving lifestyle behaviors. Results: Children's BMI z-scores were not significantly changed. Intervention group significantly improved their days of moderate-to-vigorous physical activity relative to control (0.75 ± 1.5; p < 0.01; ηp² = 0.15); however, child dietary behaviors were not significantly changed. Relative to control, intervention group showed significant improvements in parental support for healthy eating (0.13 ± 0.36; p < 0.05; ηp² = 0.06) and physical activity (1.0 ± 1.6; p < 0.05; ηp² = 0.09) and self-regulation for healthy eating (2.0 ± 3.5; p < 0.01; ηp² = 0.11) and physical activity support (2.0 ± 3.2; p < 0.05; ηp² = 0.28). Conclusions: Preliminary evidence showed that the intervention was not effective in improving child BMI z-scores, but it was effective in promoting children's physical activity and parents' support behaviors. A longer study period may be required to change BMI z-scores. Clinical Trial Registration number: NCT03643341.

Examining the interdependence of parent-child dyads: Effects on weight loss and maintenance

BACKGROUND

This study aimed to further elucidate correlated weight changes in parent-child dyads enrolled in family-based treatment (FBT) by modeling the interdependence of weight changes during treatment.

METHODS

Parent-child dyads (n = 172) with overweight/obesity (child mean zBMI = 2.16 ± 0.39; parent mean BMI = 37.9 ± 9.4 kg/m2 ) completed 4 months of FBT and were randomized to one of three 8-month maintenance interventions (Social Facilitation Maintenance [SFM]-high dose, SFM-low dose or control). Weight/height was measured at 0, 4 and 12 months. Structural equation models simultaneously estimated the effect that an individual had on their own (actor effect) and on one another's (partner effect) weight-status across time using the actor-partner interdependence model.

RESULTS

Actor paths were significant over time for parent and child. Partner paths were significant for child zBMI predicting parent BMI at 4 and 12 months. Maintenance condition moderated actor/partner paths in the model.

CONCLUSIONS

Child weight change may motivate parents to make environmental and behavioural changes that impact their own weight.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT00759746.

Family Dynamics and Pediatric Weight Management: Putting the Family into Family-Based Treatment

PURPOSE OF REVIEW

The treatment of pediatric obesity entails working with entire families. However, aside from parenting and family health behaviors, family dynamics and relationships are not often incorporated in clinical treatment of obesity.

RECENT FINDINGS

Evidence across several studies suggest a relationship between family dynamics and child weight, with impaired family dynamics associated with higher weight status in children. Evidence is mixed if child age and family function are associated. Unfortunately, there is little evidence that addressing family dynamics (i.e., relationships and overall family system) will improve weight in children with obesity. Notably, few studies target family dynamics specifically. There are several validated measures of family dynamics available for researchers to explore the family system as it relates to child health and behaviors. A deeper understanding of family dynamics and relationships may provide new avenues to address issues of weight in children; accounting for the family, and their underlying functioning, may benefit the clinician and child engaged in weight management.

Effectiveness of family-based weight management interventions for children with overweight and obesity: an umbrella review

OBJECTIVES

The objective of the review was to synthesize the effectiveness and strategies used in family-based behavioral childhood obesity interventions in improving child weight-related outcomes.

INTRODUCTION

Family-based interventions are common practice in the treatment of childhood obesity. Research suggests that direct parental involvement can improve child weight-related outcomes. However, challenges remain in assessing the effects of family-based interventions on child weight and weight-related behavior due to the lack of quality programs and diversity of treatment strategies.

INCLUSION CRITERIA

The review included systematic reviews and/or meta-analyses of family-based behavioral interventions in children aged ≤18 who were classified as overweight and/or obese, and which reported child weight related outcomes, such as body mass index (BMI), body fat percentage and waist circumferences.

METHODS

Seven databases were searched from 1990 to May 2016 to identify English language publications. Reference lists of included reviews and relevant registers were also searched for additional reviews. All included systematic reviews were critically appraised by two reviewers independently. Data extracted included characteristics of included systematic reviews and weight-related outcomes reported. Data synthesis involved categorizing the interventions into seven categories and presented findings in narrative and tabular format. Quality of evidence was assessed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach.

RESULTS

The umbrella review included 14 systematic reviews (low to moderate methodological quality), published between 2004 and 2015, including 47 independent trials ranging from one month to seven years follow-up conducted in more than 16 countries. The majority of reviews (93%) reported weight outcomes of children aged six to 13 years. All reviews except one indicated that family-based interventions were successful in improving child weight and/or weight-related behavior. Five reviews highlighted that parent-only interventions had similar (n = 4) or greater (n = 1) effectiveness compared to parent-child interventions. Effective interventions employed parent-targeted strategies, including nutrition and physical activity education sessions, positive parenting skills, role modelling and child behavior management to encourage positive healthy eating/exercise behaviors in children and/or whole family.

CONCLUSIONS

Family-based interventions targeting parents, alone or with their child, are effective for child weight management. Due to the lack of high quality evidence, especially in emerging parent-only interventions, further research is warranted. Health practitioners can work with parents as agents of change and focus on fostering positive parenting skills, such as monitoring, reinforcement, role modelling, and providing a nurturing environment, in order to support health behaviors in their children. Future research needs to explore whether parent-only interventions are more cost-effective compared to parent-child interventions, and to include larger populations, longer intervention duration and follow-up.

Parents lose less weight than nonparents in an intensive lifestyle intervention

OBJECTIVE

Understand whether parents lose less weight than nonparents in behavioural weight interventions.

METHODS

The Look AHEAD (Action for Health in Diabetes) trial randomized adults with Type 2 diabetes and overweight to an intensive lifestyle intervention (ILI) or control (diabetes support and education [DSE]). Participants who reported living with a child under age 18 were designated as 'parents' for this analysis. Intention to treat analysis was performed of the effect of the ILI on change in weight at 1 year by parental status. Adherence to attending intervention visits was compared between parents and nonparents. Subgroup analyses were done based on previous subgroup findings in the Look AHEAD study.

RESULTS

Among 4,547 participants, 15% were parents. Parents were younger and more likely to have self-identified as African American or Hispanic/Latino. Comparing ILI with DSE, parents lost less weight than nonparents (-7.1% vs. -8.3%, p = 0.021). African American female parents lost 4% body weight compared with 7% in African American female nonparents (p = 0.01).

CONCLUSIONS

In a randomized trial, parents lost less weight than nonparents, and this difference was largest for African American women. These findings suggest parents face unique challenges achieving weight loss; more research is needed to understand and optimize interventions for parents.

Assessing Parents' Communication of Weight and Weight Management from Clinic to Home

Background: Family-oriented therapies are the gold standard of childhood obesity treatment, yet little is known about if or how information gathered by one parent from a health care provider is translated to the home. We assessed how families of children and adolescents with overweight and obesity communicate weight-related information received from their provider to family members not present at the visit. Methods: Parents and children (9-18 years old, N = 112) completed the McMaster's Family Assessment Device Communication Subscale (FADc) and investigator-derived questions describing weight-related communication practices with family members. We used descriptive statistics to describe communication practices and separate logistic regression models to assess associations of communication practices with parent-reported FADc, child BMI z-score, child sex, parent BMI, household income, and site. Results: Most parents discuss with other family members: their child's weight (60.4%) or weight management discussions with the child's provider (57.9%). Median parent FADc score was 2.0 (IQR 0.5). The most common facilitator to weight-related conversations was understanding what the provider said (95.1%). Higher FADc score (worse communication) was associated with whether parents ask other family members' opinions about weight information received from their child's provider [odds ratio 0.22 (95% confidence interval 0.05-0.99)]. Higher income was associated with many healthy communication practices. Conclusions: Slightly more than half of parents discuss with family members what their provider said regarding their child's weight. More effort must be placed on aiding parents in relaying information from the provider to other family members in the home to encourage family lifestyle changes and alleviate childhood obesity.

Perspectives and Impact of a Parent-Child Intervention on Dietary Intake and Physical Activity Behaviours, Parental Motivation, and Parental Body Composition: A Randomized Controlled Trial

Adults and children in Canada are not meeting physical activity guidelines nor consuming sufficient nutrient-rich foods. High engagement in these unhealthy behaviours can lead to obesity and its associated diseases. Parent-child interventions aimed at obesity prevention/treatment have assisted families with making positive changes to their nutrition and physical activity behaviours. Given that the home environment shapes early health behaviours, it is important to target both parents and children when addressing diet and physical activity. One method that has been shown to improve health outcomes is co-active coaching. The current study explored the impact of a three-month co-active coaching and/or health education intervention on the dietary intake and physical activity behaviours of parents with overweight/obesity and their children (ages 2.5-10; of any weight). Body composition (i.e., body mass index [BMI] and waist circumference), changes in parental motivation with respect to physical activity and dietary behaviours, and parental perceptions of program improvements were collected. A concurrent mixed methods study comprised of a randomized controlled trial and a descriptive qualitative design was utilized. Fifty parent-child dyads were recruited and randomly assigned to the control (n = 25) or intervention (n = 25) group. Assessments were completed at baseline, mid-intervention (six weeks), post-intervention (three months), and six-month follow-up. A linear mixed effects model was utilized for quantitative analysis. Inductive content analysis was used to extract themes from parent interviews. No significant results were observed over time for the dependent measures. Parents in both control and intervention groups reported varied program experiences, including developing changes in perspective, increased awareness of habits, and heightened accountability for making positive changes in themselves, and consequently, their families. Parents also shared barriers they faced when implementing changes (e.g., time, weather, stress). Qualitatively, both groups reported benefitting from this program, with the intervention group describing salient benefits from engaging in coaching. This research expands on the utility of coaching as a method for behaviour change, when compared to education only, in parents with overweight/obesity and their children.

Attachment, Parenting, and Obesogenic Behavior: A Dyadic Perspective

Pediatric obesity is a growing health concern afflicting the United States. The treatment for pediatric obesity, as a health epidemic, costs billions of dollars to our nation, leaving providers and researchers searching for effective and sustainable ways to better manage the biological, psychological, and social health of individuals and families. While many assessments and interventions continue to emerge, researchers have predominately focused on intra-individual concerns among white non-Hispanic populations. This quantitative study was grounded in a relational theory (attachment theory), with a dyadic and primarily Hispanic sample. Evidence from our study supported that child attachment predicted child obesogenic behavior and that this relationship was mediated by child self-regulation. Children with insecure attachments had more obesogenic behaviors and lower self-regulation of eating than those with secure attachments. Family therapists should be on the frontlines of relational research and clinical interventions that interface with biopsychosocial health across diverse cultures and families.

Evaluation of dyadic changes of parent-child weight loss patterns during a family-based behavioral treatment for obesity

BACKGROUND

Family-based treatment (FBT) for children with overweight and obesity is a package that includes nutrition and physical activity education, as well as parenting and behavior therapy skills. To date, the majority of research suggests that one of the best predictors of child weight loss is parent weight loss. However, the bidirectional processes facilitating parent-child weight loss are not well understood.

OBJECTIVE

To evaluate the strength and direction of parent-child weight-change patterns during a 6-month intervention with FBT for childhood obesity.

METHODS

Parent-child weight change dynamics were evaluated using a bivariate multilevel approach.

RESULTS

Significant positive weight reductions throughout treatment were observed among both parents and children (P's < .01 for both parent and child). In the model adjusting for the conditional influence of attendance over time, parents' initial weight loss was associated with subsequent weight loss by their child (B = 0.102, P < .05; d = 0.352) across the first 10 sessions. Child's weight loss also was associated with subsequent weight loss by their parent (B = 0.105, P < .01; d = 0.412) across the first 10 sessions. A small and negative effects of parents' weight loss on children and children's weight loss on parents from sessions 10 to 20 may have been reflective of slowed rates of weight loss as treatment progressed.

CONCLUSIONS

Together these data suggest that parent-child dyads mutually influence weight loss in FBT. Future studies should leverage how to make best clinical use of these dynamic effects in the context of family-based interventions.

Prevention and Management of Childhood Obesity and Its Psychological and Health Comorbidities

Childhood obesity has become a global pandemic in developed countries, leading to a host of medical conditions that contribute to increased morbidity and premature death. The causes of obesity in childhood and adolescence are complex and multifaceted, presenting researchers and clinicians with myriad challenges in preventing and managing the problem. This article reviews the state of the science for understanding the etiology of childhood obesity, the preventive interventions and treatment options for overweight and obesity, and the medical complications and co-occurring psychological conditions that result from excess adiposity, such as hypertension, nonalcoholic fatty liver disease, and depression. Interventions across the developmental span, varying risk levels, and service contexts (e.g.,community, school, home, health care systems) are reviewed. Future directions for research are offered with an emphasis on translational issues for taking evidence-based interventions to scale in a manner that will reduce the public health burden of the childhood obesity pandemic.

One Size Does Not Fit All: Sociodemographic Factors Affecting Weight Loss in Adolescents

Successful lifestyle changes for weight reduction are heavily dependent on recognizing the importance of societal and cultural factors. Patients 13-19 years of age with a BMI ≥95th percentile are eligible for our multidisciplinary adolescent weight loss clinic. A behavioral questionnaire was administered at the initial visit. Patients were seen every 4-6 weeks. Bivariate analysis was used to identify sociodemographic factors associated with differences in weight loss. Overall, receiving reduced cost meals was associated with a lower likelihood of losing weight (kg) (p < 0.01). When stratified by race, White adolescents were more likely to lose weight if caretakers reported having enough money to buy healthy food (p < 0.05); in contrast, Black adolescents were less likely to lose weight (p < 0.05). However, Black patients were more likely to lose weight if they reported eating fruits and vegetables (p < 0.05). Female adolescents were more likely to lose weight if they felt unhappy about their appearance (p < 0.05). Interestingly, male adolescents were less likely to lose weight if they felt unhappy about their appearance (p < 0.05). Social and cultural norms influence weight loss in adolescents in unique and differing ways. Culturally competent individualized interventions could increase weight loss in diverse groups of adolescents with obesity.

Investigating the relationship between parental weight stigma and feeding practices

Promoting a healthy diet in children remains a prominent public health priority. Parents have been shown to be a major influence on their children's eating behaviors, but limited research has been devoted to exploring the factors that lead parents to select certain feeding practices over others. Past research has demonstrated a link between weight stigma (i.e., prejudicial attitudes or discriminatory behavior targeted at individuals who carry excess weight) and an individual's own weight-related behaviors and outcomes, but no study has examined how parental levels of weight stigma maybe associated with a parent's preferred feeding practices. The primary objective of this study was to examine the cross-sectional associations between parental levels of weight-based stigmatization with parental feeding practices. Responses were collected on Amazon's Mechanical Turk website for n = 406 parents who 1) had at least one child aged 5-10 and 2) perceived themselves to be overweight or obese. After adjusting for relevant covariates, parental weight stigma was shown to be significantly associated with restrictive feeding practices, and verbal modeling of eating behaviors (all ps < .05). A priori exploratory mediation analysis identified concern about child weight as a significant mediator between weight stigma and parental feeding practices. A discussion of the potential limitations of this study, future directions of research, and implications of these findings are included.

Effects of Exercise in Addition to a Family-Based Lifestyle Intervention Program on Hepatic Fat in Children With Overweight

OBJECTIVE

Pediatric hepatic steatosis is highly prevalent and closely related to type 2 diabetes. This study aimed to determine whether the addition of supervised exercise to a family-based lifestyle and psycho-educational intervention results in greater reduction of percentage of hepatic fat (HF), adiposity, and cardiometabolic risk factors in children with overweight/obesity.

RESEARCH DESIGN AND METHODS

The study subjects of this nonrandomized, two-arm, parallel design clinical trial were 116 overweight/obese children (10.6 ± 1.1 years of age, 53.4% girls) living in Vitoria-Gasteiz (Spain). For 22 weeks, they followed either a lifestyle and psycho-education program (control intervention [CInt], N = 57), consisting of two family-based education sessions/month, or the same plus supervised exercise (intensive intervention [II], N = 59) focused mainly on high-intensity aerobic workouts (3 sessions/week, 90 min/session). The primary outcome was the change in percentage of HF (as measured by MRI) between baseline and the end of the intervention period. Secondary outcomes included changes in BMI, fat mass index (FMI), abdominal fat (measured by DEXA), blood pressure, triglycerides, HDL, LDL, γ-glutamyl transferase, glucose, and insulin concentrations.

RESULTS

A total of 102 children completed the trial (N = 53 and N = 49 in the CInt and II groups, respectively). Percentage of HF decreased only in the II group (-1.20 ± 0.31% vs. 0.04 ± 0.30%, II and CInt groups, respectively), regardless of baseline value and any change in adiposity (P < 0.01). BMI, FMI, abdominal fat (P ≤ 0.001), and insulin (P < 0.05) were reduced in both groups.

CONCLUSIONS

Multicomponent intervention programs that include exercise training may help to reduce adiposity, insulin resistance, and hepatic steatosis in overweight/obese children.

Rethinking the association between overweight/obesity and ADHD in children: a longitudinal and psychosocial perspective

OBJECTIVE

This study examines the association between attention-deficit/hyperactivity disorder (ADHD) and overweight/obesity in a large-scale longitudinal study of children, while controlling for a range of psychosocial factors.

METHOD

Data were obtained from Growing Up in Ireland, a nationally representative and longitudinal study of approximately 6500 children who were assessed at 9 and 13 years of age. Body mass index (BMI) was determined using measured height and weight, ADHD status was determined by parent reports of professional diagnoses and ADHD symptoms were measured using the Strengths and Difficulties Questionnaire (SDQ).

RESULTS

The associations between ADHD status, ADHD symptoms (SDQ) and BMI category at age 9 and 13 years were evaluated using logistic regression. Adjustments were made for child factors (sex, developmental coordination disorder, emotional symptoms, conduct problems, birth weight and exercise) and parental factors (socio-economic status, parental BMI, parental depression, and maternal smoking and alcohol use during pregnancy). Logistic regression indicated that ADHD status was not associated with BMI category at 9 or at 13 years of age, but children with ADHD at 9 years were significantly more likely to be overweight/obese at 13 years than those without ADHD. However, when other child and parental factors were adjusted for, ADHD status was no longer significantly associated with weight status. Female sex, low levels of exercise, overweight/obese parents and prenatal smoking during pregnancy consistently increased the odds of childhood overweight/obesity.

CONCLUSIONS

While ADHD and overweight/obesity co-occur in general populations, this relationship is largely explained by a variety of psychosocial factors.

Family-based, healthy living intervention for children with overweight and obesity and their families: a 'real world' trial protocol using a randomised wait list control design

INTRODUCTION

Family-based behavioural weight management interventions are efficacious and widely used to address childhood obesity. Curriculum and strategies vary extensively and scale-up often depends on ensuring that the intervention fits the adoption context.

AIMS AND OBJECTIVES

To evaluate the impact and implementation of a 'made in British Columbia' (BC) family-based early intervention programme (EIP) for 8-12 years old with overweight and obesity and their families.

METHODS AND ANALYSIS

A randomised waitlist-control trial will assess a 10-week interactive, family-based lifestyle intervention followed by four maintenance sessions, in BC, Canada. We aim to enrol 186 families. The blended intervention includes at least 26 contact hours between participants and programme providers, including interactive activities and educational materials through weekly 90-min group sessions, an online family portal, and self-directed family activities. Curricular content includes information and activities related to healthy eating, physical activity (PA), positive mental health, parenting practices and sleep hygiene. The waitlist control group will receive a modified programme with the same 10-week sessions in the family portal, and four group sessions. Families participate in data collection at baseline, postintervention (week 10) and follow-up (week 18). The primary outcome is to assess changes in child body mass index z-score at 10 weeks between the groups. Secondary outcomes include changes at 10 weeks between the groups in child and parent PA behaviour and skills, healthy eating behaviour, and mental health. Process evaluation will address reach, implementation and maintenance (baseline, 10-week and 18-week) using recruitment tracking forms, parent questionnaire, programme attendance tracking forms, leader feedback surveys, parents and children satisfaction surveys and postprogramme interviews with facilitators, stakeholders and parents. Intention-to-treat analyses will be conducted. Process evaluation will be analysed thematically.

ETHICS AND DISSEMINATION

Study procedures were designed to address research and community needs and will follow ethical standards.

TRIAL REGISTRATION NUMBER

NCT03643341.

A Cross-Sectional Study on the Relationship between the Family Nutrition Climate and Children's Nutrition Behavior

Background: Parents influence their children’s nutrition behavior. The relationship between parental influences and children’s nutrition behavior is often studied with a focus on the dyadic interaction between the parent and the child. However, parents and children are part of a broader system: the family. We investigated the relationship between the family nutrition climate (FNC), a family-level concept, and children’s nutrition behavior. Methods: Parents of primary school-aged children (N = 229) filled in the validated family nutrition climate (FNC) scale. This scale measures the families’ view on the consumption of healthy nutrition, consisting of four different concepts: value, communication, cohesion, and consensus. Parents also reported their children’s nutrition behavior (i.e., fruit, vegetable, water, candy, savory snack, and soda consumption). Multivariate linear regression analyses, correcting for potential confounders, were used to assess the relationship between the FNC scale (FNC-Total; model 1) and the different FNC subscales (model 2) and the child’s nutrition behavior. Results: FNC-Total was positively related to fruit and vegetable intake and negatively related to soda consumption. FNC-value was a significant predictor of vegetable (positive) and candy intake (negative), and FNC-communication was a significant predictor of soda consumption (negative). FNC-communication, FNC-cohesion, and FNC-consensus were significant predictors (positive, positive, and negative, respectively) of water consumption. Conclusions: The FNC is related to children’s nutrition behavior and especially to the consumption of healthy nutrition. These results imply the importance of taking the family-level influence into account when studying the influence of parents on children’s nutrition behavior. Trial registration: Dutch Trial Register NTR6716 (registration date 27 June 2017, retrospectively registered), METC163027, NL58554.068.16, Fonds NutsOhra project number 101.253.

Outcomes From a Sequential Multiple Assignment Randomized Trial of Weight Loss Strategies for African American Adolescents With Obesity

BACKGROUND

Minority adolescents are at highest risk for obesity and extreme obesity; yet, there are few clinical trials targeting African American adolescents with obesity.

PURPOSE

The purpose of the study was to develop an adaptive family-based behavioral obesity treatment for African American adolescents using a sequential multiple assignment randomized trial (SMART) design.

METHODS

Fit Families was a SMART where 181 African American adolescents (67% female) aged 12-17 were first randomized to office-based versus home-based behavioral skills treatment delivered from a Motivational Interviewing foundation. After 3 months, nonresponders to first phase treatment were rerandomized to continued home-based behavioral skills treatment or contingency management with voucher-based reinforcement for adolescent weight loss and for caregiver adherence to the program. All interventions were delivered by community health workers. The primary outcome was treatment retention and percent overweight.

RESULTS

All adolescents reduced percent overweight by -3.20%; there were no significant differences in percent overweight based on treatment sequence. Adolescents receiving home-based delivery in Phase 1 and contingency management in Phase 2 completed significantly more sessions than those receiving office-based treatment and continued skills without CM (M = 8.03, SD = 3.24 and M = 6.62, SD = 2.95, respectively). The effect of contingency management was strongest among older and those with lower baseline confidence. Younger adolescents experienced greater weight reductions when receiving continued skills (-4.90% compared with -.02%).

CONCLUSIONS

Behavioral skills training can be successfully delivered to African American adolescents with obesity and their caregivers by community health workers when using a home-based service model with incentives. More potent interventions are needed to increase reductions in percent overweight and may need to be developmentally tailored for younger and older adolescents.

Adapting family-based treatment for paediatric obesity: A randomized controlled pilot trial

OBJECTIVE

This pilot study aimed to refine and test an adaption of family-based treatment (FBT) for eating disorders that addressed the distinct clinical needs of adolescents with overweight or obesity in the absence of eating disorder pathology. Our hypothesis was that FBT for paediatric obesity (FBT-PO) would be feasible to implement and superior to a nutrition education counselling (NEC) condition delivered to both parents and patients, thereby controlling for key information dissemination across groups while manipulating active therapeutic content and strategy.

METHOD

Seventy-seven adolescents were randomized to FBT-PO or NEC across two sites.

RESULTS

Results supported our core prediction, in that weight status among adolescent study participants receiving FBT-PO remained stable while increasing among participants randomized to NEC. Attrition was high in both conditions.

CONCLUSIONS

FBT-PO, while not seeming to yield a marked decrease in body mass index z-score, may arrest an otherwise-occurring weight-gain trajectory for these adolescents. This efficacy finding is consistent with the overall PO literature supporting parental involvement in the treatment of PO. Future research efforts should address retention in FBT-PO.

Dose response relationship between program attendance and children's outcomes in a community based weight management program for children and their families

INTRODUCTION

The Go4Fun program in New South Wales, Australia is a community based weight management program for overweight and obese children aged 7-13 years and their families. This study assessed the impact of the number and type of sessions attended on body mass index (BMI) z-score, fruit and vegetable intake and physical activity and sedentary behaviours to determine the number of sessions required to achieve optimal program outcomes.

METHODS

Secondary analysis was conducted on pre and post participant program data collected over 3.5 years. Relationships between session attendance and program outcomes were assessed using Spearman's correlation and multivariate analyses of variance and multivariate regression. Number of sessions required to achieve optimal program outcomes was determined using piecewise linear regression.

RESULTS

For 3090 participants (48.5% of registrants) who attended at least five sessions, outcome measures improved significantly at post program compared with pre (p < 0.01). No relationships were seen between number and type of sessions attended and outcome measures. Children of mothers without a post-school qualification (university degree or vocational qualification) were more likely to achieve lower levels of improvements in BMI z-score (p = 0.02) and vegetable intake (P < 0.01) than those children with post-school qualified mothers (F = 3.68, p = 0.03). Children of mothers without post-school education that attended seven sessions or more achieved significantly better BMI z-score outcomes (p < 0.01) than those who attended fewer sessions.

CONCLUSIONS

Maternal educational attainment influences program attendance and health and behavioural outcomes in a family based obesity treatment program.

Health Care Providers' Perspectives on Family Compliance and Behavior Change in a Childhood Obesity Program

Background. Evidence suggests that children and adolescents growing up in low-income families and those with underrepresented ethnocultural backgrounds tend to have high prevalence rates of obesity and more difficulty adhering to childhood obesity interventions. However, less is known about how intergenerational, family-based approaches to lifestyle interventions for childhood obesity support sustained behavior change. Aims. The aim of this study was to explore the perspectives of health care providers regarding family adherence and behavior change in a childhood obesity program that served ethnoculturally diverse and low-income families. Method. Semistructured in-person interviews were conducted with 18 providers at one of three hospitals participating in a Canadian family-based childhood obesity program. Data were thematically analyzed using a constant comparative approach. Results. The following key themes emerged as challenges from the provider's perspective for family adherence and behavior modification in the childhood obesity program: divergent views about obesity, complicated lives and logistical priorities, parental role modeling, and intergenerational tensions. Discussion and Conclusion. This examination of providers' perspectives on family adherence and behavior modification relevant to the management of childhood obesity highlight the importance of tailoring childhood obesity programs to the complex and diverse needs of families from diverse backgrounds. Recommendations include methods of service delivery that address logistical challenges and are better suited to extended families, particularly grandparents.

An Internet-Based Childhood Obesity Prevention Program (Time2bHealthy) for Parents of Preschool-Aged Children: Randomized Controlled Trial

Background

Electronic health (eHealth) obesity programs offer benefits to traditionally delivered programs and have shown promise in improving obesity-related behaviors in children.

Objective

This study aimed to assess the efficacy of a parent-focused, internet-based healthy lifestyle program for preschool-aged children, who are overweight or at or above the fiftieth percentile for body mass index (BMI) for their age and sex, on child BMI, obesity-related behaviors, parent modeling, and parent self-efficacy.

Methods

The Time2bHealthy randomized controlled trial was conducted in Australia, during 2016 to 2017. Participants were recruited both online and through more traditional means within the community. Parent or carer, and child (aged 2-5 years) dyads were randomized into an intervention or comparison group. Intervention participants received an 11-week internet-based healthy lifestyle program, underpinned by social cognitive theory, followed by fortnightly emails for 3 months thereafter. Intervention participants set goals and received individual feedback from a dietitian. They were also encouraged to access and contribute to a closed Facebook group to communicate with other participants and the dietitian. Comparison participants received email communication only. Objectively measured child BMI was the primary outcome. Secondary outcomes included objectively measured physical activity, parent-measured and objectively measured sleep habits, and parent-reported dietary intake, screen time, child feeding, parent modeling, and parent self-efficacy. All data were collected at face-to-face appointments at baseline, 3 months, and 6 months by blinded data collectors. Randomization was conducted using a computerized random number generator post baseline data collection.

Results

A total of 86 dyads were recruited, with 42 randomized to the intervention group and 44 to the comparison group. Moreover, 78 dyads attended the 3- and 6-month follow-ups, with 7 lost to follow-up and 1 withdrawing. Mean child age was 3.46 years and 91% (78/86) were in the healthy weight range. Overall, 69% (29/42) of participants completed at least 5 of the 6 modules. Intention-to-treat analyses found no significant outcomes for change in BMI between groups. Compared with children in the comparison group, those in the intervention group showed a reduced frequency of discretionary food intake (estimate −1.36, 95% CI −2.27 to −0.45; P=.004), and parents showed improvement in child feeding pressure to eat practices (−0.30, 95% CI 0.06 to −0.00; P=.048) and nutrition self-efficacy (0.43, 95% CI 0.10 to 0.76; P=.01). No significant time by group interaction was found for other outcomes.

Conclusions

The trial demonstrated that a parent-focused eHealth childhood obesity prevention program can provide support to improve dietary-related practices and self-efficacy but was not successful in reducing BMI. The target sample size was not achieved, which would have affected statistical power.

Trial Registration

Australian New Zealand Clinical Trials Registry ANZCTR12616000119493; https://www.anzctr.org.au/ Trial/Registration/TrialReview.aspx?id=370030 (Archived by WebCite at http://www.webcitation.org/74Se4S7ZZ).