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Section V
Treatment and Prevention of Childhood Obesity
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29 | Family-Based Behavioral Treatment for Childhood Obesity |
| Dorothy J. Van Buren, Katherine N. Balantekin, Sara D. McMullin, and Denise E. Wilfley |
CONTENTS
Introduction
Current Treatment Recommendations for Childhood Obesity
Family-Based Behavioral Weight Loss
Dietary Modification
Energy Expenditure Modification
Behavior Modification
Parental Involvement
Socioenvironmental Contexts
Peer Level
Community Level
Treatment Duration, Modality, and Setting
Conclusions and Future Directions
References
INTRODUCTION
Childhood is an opportune time to address the serious disease of obesity. Since children are still growing, slowing their rate of weight gain or encouraging modest weight losses can help children normalize their weight [1]. However, it is this very fact that children are still growing that has often resulted in obesity in childhood not being treated seriously. The assumption has been that a child who is overweight or obese will “grow out of it,” but this is not the case. Without effective intervention, an estimated 82% of children who are obese, defined as having a body mass index (BMI) at or above the 95th percentile for sex and age [2], will track obesity into adulthood [3]. As reviewed in other chapters in this book, obesity at any age is associated with major physical (e.g., type 2 diabetes, cardiovascular disease) and psychological health burdens (e.g., depression) [4,5] that are costly to the individual as well as to society. For example, current health-care costs related to obesity are estimated to be $315.8 billion annually or 27.5% of health-care spending in the United States [6]. By successfully addressing obesity in childhood, not only do we help children lead healthier, happier lives but we may also be engaging in a form of indicated or targeted prevention of obesity and its costly comorbidities in adulthood [7]. Fortunately, effective treatments for childhood obesity have been developed, and in this chapter we will (1) provide a brief review of the literature in support of treatment of childhood obesity, (2) describe the components of family-based behavioral treatments for childhood obesity, (3) summarize the factors found to impact or predict the effectiveness of these treatments, and (4) explore future directions in the management of childhood obesity.
CURRENT TREATMENT RECOMMENDATIONS FOR CHILDHOOD OBESITY
The US Preventive Services Task Force (USPSTF) recommends that clinicians start tracking BMI percentiles at 2 years of age, that they screen children aged 6 years and older for obesity, and offer them or refer them to a comprehensive, behavioral intervention to promote improvement in weight status [3]. These recommendations are based on the results of a rigorous scientific review that demonstrated the efficacy of interventions of moderate (26–75 contact hours) to high (>75 contact hours) intensity that include dietary, physical activity, and behavioral counseling components [8]. Other organizations and professional groups have issued similar recommendations or treatment guidelines (i.e., the National Institute on Care and Excellence [NICE]; the Expert Committee on Childhood Obesity) [9–11].
Underpinning these recommendations and guidelines is a significant body of research pointing to the superiority of intensive, multicomponent lifestyle interventions in inducing weight loss in children and in reducing medical and psychological comorbidities associated with obesity compared with no-treatment controls, education only, or single-component conditions. The amount or duration of treatment contact has also been found to be a consistent predictor of long-term weight outcomes in children [12,13]. Furthermore, the inclusion of parents or caregivers in the treatment of childhood obesity improves weight loss outcomes in comparison with interventions that only target the child. In fact, interventions with a family-based component result in a 6% greater mean reduction in percentage overweight compared with those without [14]. A representative sample of these reviews and meta-analyses and their main findings are summarized in Table 29.1.
When obesity is addressed at an early age, weight loss outcomes are more robust and enduring [15–17]. These findings highlight the importance of catching obesity early in childhood and responding with a treatment of sufficient scope and intensity to help prevent children from tracking obesity into adolescence. Unfortunately, treatment for older children and adolescents with extreme obesity and severe medical comorbidities is somewhat more complicated. For this population, the use of pharmacotherapy (Chapter 30) and/or weight loss surgery (Chapter 31) in combination with evidence-based behavioral weight loss treatment may be considered [10]. However, there are few studies evaluating the long-term outcomes and safety of pharmacological and surgical treatments for pediatric obesity. Also, adherence to lifestyle behavior changes is still necessary following weight loss surgery and to potentiate the success of pharmacotherapy [18]. Therefore, even youth who meet the criteria for these more invasive interventions will benefit from participation in multi-component, behavioral weight control interventions.
FAMILY-BASED BEHAVIORAL WEIGHT LOSS
Family-based behavioral weight loss treatment (FBT) is a multicomponent behavioral weight control intervention developed and refined by Leonard Epstein, Denise Wilfley, and colleagues [19,20]. FBT targets both parents and children and is considered a first-line treatment for this population [1]. Not only does FBT have a positive impact on weight, but improvements in other health parameters such as reductions in blood pressure and cholesterol levels and psychological well-being are associated with FBT [21,22]. Although the majority of the research base for FBT rests on work done with children of elementary to middle school age [19], it has also been successfully adapted for use with preschoolers [23] and adolescents [24].
To improve a child’s weight status, FBT targets the modification of energy balance behaviors (i.e., decreasing caloric intake and increasing caloric expenditure) through the use of behavioral treatment techniques and the active involvement of a parent or caregiver. In FBT, the parent or caregiver, who is often also overweight or obese, is encouraged to change his or her own energy balance behaviors as well as support the child in these endeavors. Furthermore, the parent or caregiver is charged with the task of engineering the home environment so that it is conducive to healthy energy balance behaviors for the entire family. This focus on making changes throughout the household is an important tenet of FBT. Although significant weight change can occur within the first few months of FBT, weight losses are better maintained over the long term by extending treatment contact to allow for the focus on both the continued practice of behavioral change skills and the development of family and social networks in support of weight loss maintenance behaviors [25]. The components of FBT are described in the following sections and in Table 29.2.
TABLE 29.1
Relevant Reviews and Meta-analyses of Childhood Weight Loss Studies
Authors | Type of Review and Number of Studies | Target Population | Conclusions |
Altman et al., 2015 | Systematic review of 53 studies | Children (2–18 years) with overweight and obesity | This review found that multicomponent treatments that include a parent component are the most efficacious. |
Epstein et al., 2007 | Targeted systematic review of 8 studies | Children (5–12 years) with overweight and obesity | This review demonstrates a consistent pattern of weight loss results across efficacy studies across time, an important step in preparing interventions for translation to wider-spread clinical care. |
Hayes et al., 2015 | Systematic review of 22 studies | Children and adolescents (2–18 years) with overweight and obesity | This review found that behavioral interventions that include individual family sessions achieve a greater magnitude of weight loss than those with only group sessions. |
Ho et al., 2013 | Systematic review of 38 randomized control trials | Children and adolescents (≤18 years) with overweight and obesity | This review concluded that weight loss was greater when the duration of treatment was longer than 6 months. |
Janicke et al., 2014 | Meta-analysis of 20 randomized control trials | Children and adolescents (≤19 years) with overweight and obesity | This meta-analysis found that dose (duration, number of sessions, time in treatment) was positively related to effect size, and individual and in-person comprehensive family interventions were associated with larger effect sizes. |
Whitlock et al., 2010 | Targeted systematic review of 16 studies | Children (5–18 years) with overweight and obesity | This review confirmed that comprehensive moderate-to-high intensity behavioral interventions can be effective at producing significant weight loss in children. |
Wilfley et al., 2007 | Meta-analysis of 14 randomized control trials | Children (≤19 years) with overweight | This meta-analysis concluded that lifestyle interventions produce significant changes in weight status in the short term, with evidence suggesting results persist in the long term. |
Young et al., 2007 | Meta-analysis of 16 studies | Children (5–12 years) with overweight and obesity | This meta-analysis found that interventions with a family component achieve a greater magnitude of weight loss than those using an alternative treatment approach. |
TABLE 29.2
Family-Based Behavioral Treatment Components
Goal | Strategies |
Dietary Modification | |
Decrease caloric intake | • Define appropriate calorie range. • Increase intake of Green foods (i.e., highly nutritious, low-calorie-dense foods). • Decrease intake of Red foods (i.e., high-fat, high-sugar foods). |
Energy Expenditure Modification |
Increase energy expenditure | • Increase physical activity (goal: 60 min/day, 5 days/week). • Decrease sedentary activity (goal: <2 h/day outside of school time). |
Behavior Modification | |
Goal setting | • Dietary goals (e.g., <15 Red foods/week, calorie range 1200–1500). • Physical activity goals (e.g., >60 min activity/day, reduce sedentary activity by 50%). • Weight goals (e.g., weight loss of 0.5 lb/week). |
Self-monitoring | • Record daily food intake (e.g., calorie intake, number of Red foods, fruit and vegetable i... |
