Systematic Review and Meta-Analysis of Comprehensive BehavioralFamily Lifestyle Interventions Addressing Pediatric Obesity

David M Janicke1 PHD Ric G Steele2 PHD Laurie A Gayes2 MS Crystal S Lim1 PHD Lisa

M Clifford1 PHD Elizabeth M Schneider1 PHD Julia K Carmody1 MS and Sarah Westen1 MS1Department of Clinical and Health Psychology University of Florida and 2Clinical Child Psychology Program

University of Kansas

All correspondence concerning this article should be addressed to David M Janicke PHD Department of

Clinical and Health Psychology University of Florida PO Box 100165 Gainesville FL 32610 USA

E-mail djanickephhpufledu

Received January 16 2014 revisions received March 29 2014 accepted April 7 2014

Purpose To conduct a meta-analysis of randomized controlled trials examining the efficacy of comprehen-

sive behavioral family lifestyle interventions (CBFLI) for pediatric obesity Method Common research

databases were searched for articles through April 1 2013 20 different studies (42 effect sizes and 1671

participants) met inclusion criteria Risk of bias assessment and rating of quality of the evidence were

conducted Results The overall effect size for CBFLIs as compared with passive control groups over all

time points was statistically significant (Hedgersquos gfrac14 0473 95 confidence interval [362 584]) and sugges-

tive of a small effect size Duration of treatment number of treatment sessions the amount of time in treat-

ment child age format of therapy (individual vs group) form of contact and study use of intent to treat

analysis were all statistically significant moderators of effect size Conclusion CBFLIs demonstrated effi-

cacy for improving weight outcomes in youths who are overweight or obese

Key words children intervention outcome meta-analysis obesity

Childhood obesity is a significant public health concern

with roughly 32 of children considered overweight or

obese (Ogden Carroll Kit amp Flegal 2012) The sequelae

of pediatric obesity include comorbid medical complica-

tions such as high blood pressure abnormal lipid pro-

teins liver disease sleep disordered breathing and type

2 diabetes (Daniels 2006) Overweight and obese children

face increased risks for poor self-esteem and body image

peer victimization weight stigmatization depressive symp-

toms and other psychological difficulties (Daniels 2006

Puhl Luedicke amp Heuer 2011) Obesity in childhood also

leads to increased risks of being obese in adulthood (Singh

Mulder Twisk van Mechelen amp Chinapaw 2008)

Pediatric interventions that lead to weight reductions

have been associated with improvements in metabolic fac-

tors (Ebbeling Leidig Sinclair Hangen amp Ludwig 2003)

and self-esteem (Janicke et al 2008) There is a need for

evidence-based pediatric obesity interventions to treat in-

creased weight status in children and adolescents

Research to elucidate factors contributing to the con-

tinual rise in rates of pediatric obesity provides evidence of

environment by gene interactions contributing to child and

adolescent weight status Studies have also shown that en-

vironmental factors can alter genetic factors associated with

weight (Koletzko Brands Poston Godfrey amp

Demmelmair 2012) Potential environmental factors in-

clude consuming large portions of high-calorie nutrient-

poor foods decreased engagement in physical activity

and increased time spent in sedentary behaviors (Lioret

Volatier Lafay Touvier amp Maire 2009 Spear et al

2007) One of the strongest predictors of child weight is

parent weight status (Whitaker Wright Pepe Seidel amp

Dietz 1997) Given that parents play a significant role in

establishing patterns of eating and physical activity

Journal of Pediatric Psychology 39(8) pp 809ndash825 2014

doi101093jpepsyjsu023

Advance Access publication May 13 2014

Journal of Pediatric Psychology vol 39 no 8 The Author 2014 Published by Oxford University Press on behalf of the Society of Pediatric PsychologyAll rights reserved For permissions please e-mail journalspermissionsoupcom

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throughout childhood (Spear et al 2007) behavioral

family lifestyle interventions have been developed that

focus on modifying the obesogenic family environment to

address weight management in children and adolescents

Generally behavioral family lifestyle interventions

focus on encouraging overweight and obese children and

their parents to modify the familyrsquos dietary intake physical

activity habits or both Dietary modifications generally

target reducing the consumption of high-fathigh-calorie

foods and increasing consumption of fruits and vegetables

as well as dietary monitoring through classifications

systems such as the Stoplight diet (Epstein 1993)

Activity targets commonly include increasing the intensity

and duration of physical activity (ie play family activities

organized sports or structured exercise program) and

reducing time spent in sedentary activities (eg television

viewing) Behavioral strategies to support the adoption of

healthier lifestyle behaviors are central to these programs

Specific strategies may include the following parent model-

ing monitoring of dietary intake and physical activity goal

setting problem solving gradual shaping child behavior

management strategies including differential attention and

contingency management and stimulus control

Parents are often considered a critical agent of change

in behavioral lifestyle interventions as they exercise signif-

icant control over childrenrsquos eating and physical environ-

ment and ultimately behaviors As such one or both

parents are typically included in treatment Parents are

often encouraged if not specifically targeted to also

follow healthy lifestyle treatment recommendations The

format of behavioral family lifestyle interventions varies

from group based (multiple families participate at one

time) and individual family based (family meets one-

on-one with interventionist) to a combination of these

formats The extent to which children and adolescents

are directly involved in treatment also varies across

interventions While the vast majority of interventions

require children or adolescents to regularly attend interven-

tion sessions with their parents some recent interventions

have adopted a lsquoparent-onlyrsquo model in which only the

participating parent(s) attend intervention sessions during

which they are taught strategies to support their child or

adolescent in modifying weight-related lifestyle behaviors

(Golan Kaufman amp Shahar 2006 Janicke et al 2008)

The number of content components also varies across

lifestyle interventions Some interventions may include

only two components For example an intervention may

address dietary intake using behavior strategies but not

address physical activity Others may address physical

activity and dietary intake but not use behavior strategies

Finally there are those interventions that are

comprehensive in that they address all three intervention

components For the purposes of this review interventions

that included content addressing all three areas (ie die-

tary intake physical activity and behavior strategies) are

referred to hereafter as comprehensive behavioral family

lifestyle interventions (CBFLIs) Owing to the increase in

outcome research examining treatments for pediatric obe-

sity there is a need to understand the current efficacy of

these interventions as well as to identify moderators of

treatment success to inform future clinical practice and

treatment outcome research

Jelalian and Saelens (1999) conducted a review of pe-

diatric obesity treatments in the empirically supported

treatment series published in the Journal of Pediatric

Psychology over a decade ago They concluded that be-

havioral lifestyle interventions could be considered well-

established treatments and that there was strong evidence

for their short- and long-term efficacy (eg 5 and 10 years

posttreatment) in reducing weight in school-age children

The evidence of behavioral lifestyle interventions for ado-

lescents was only considered lsquolsquopromisingrsquorsquo owing to the

limited number of treatment outcome studies in adoles-

cents at that time However there was no requirement

that the treatments reviewed by Jelalian and Saelens

(1999) be CBFLIs

Not surprisingly since the Jelalian and Saelens review

a number of systemic reviews and meta-analyses of pediat-

ric obesity interventions have been published (Kitzmann

et al 2010 McGovern et al 2008 Oude-Luttikhuis

et al 2009 Seo et al 2010 Whitlock OrsquoConnor

Williams Beil amp Lutz 2010 Wilfley et al 2007) The

general consensus from these published reports is that pe-

diatric obesity interventions result in small to moderate

short-term improvements in adiposity in children and ad-

olescents However a thorough examination of this litera-

ture finds mixed methodology and results across meta-

analyses with great variety in the number of studies in-

cluded in different meta-analyses largely owing to differing

foci and study inclusion and exclusion criteria (ie intent-

to-treat [ITT] analysis different intervention components

duration of treatment or follow-up analysis randomization

of treatment participants minimum sample size require-

ments adequate control condition) Moreover a number

of meta-analyses use broad inclusion criteria that allow for

lifestyle interventions with diverse treatment components

(two or three component programs) or interventions deliv-

ered in different settings (eg community clinic research

and school Kitzmann et al 2010) While informative one

disadvantage to this lsquobroader approachrsquo is that such clinical

heterogeneity precludes a meaningful answer as to the

810 Janicke et al

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ber 13 2014httpjpepsyoxfordjournalsorg

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nloaded from

intervention type to which an effect can be generalized

(Cohen Thombs amp Hagedoorn 2010)

Although a number of meta-analyses include interven-

tion studies with behavioral family components many do

not provide explicit examination of interventions with a

behavioral family component or adequately define behav-

ioral components (Kitzmann et al 2010 McGovern et al

2008 Seo et al 2010 Wilfley et al 2007) To our knowl-

edge only three meta-analyses have explicitly examined the

efficacy of pediatric lifestyle interventions that require the

inclusion of a behavioral family component (Oude-

Luttikhuis et al 2009 Whitlock et al 2010 Young

Northern Lister Drummond amp OrsquoBrien 2007)

However even these three reviews do not require the use

of all three common lifestyle intervention components (ie

dietary intake physical activity and behavioral strategies)

for study inclusion in the meta-analytic reviews

Whitlock and colleagues identified 11 fair- or good-

quality behavioral family lifestyle intervention trials pub-

lished between 2005 and 2008 addressing weight loss in

overweight and obese children and adolescents 19 years

of age (Whitlock et al 2010) Results revealed that behav-

ioral family lifestyle interventions of medium to high inten-

sity (ie 26 hr of treatment contact) had moderate to

large effects on weight outcomes compared with very low

intensity interventions (eg lt10 hr) in the short term

with intervention effectiveness tending to increase with

more intensive interventions The authors also concluded

that there was insufficient evidence to draw conclusions on

outcomes gt12 months after treatment

The Cochrane Collaborative published a review that

included 54 randomized controlled trials (RCTs) published

through May 2008 and focused on lifestyle interventions

(ie dietary physical activity andor behavioral oriented

treatment) for children and adolescents (mean age lt18

years at posttreatment) (Oude-Luttikhus et al 2009)

However they only identified eight behavioral family life-

style interventions that qualified for a separate meta-anal-

ysis examining both short- and long-term outcomes in

elementary-age and adolescent youth While noting many

limitations in the literature and the lack of quality data to

adequately ascertain treatment efficacy the authors con-

cluded that behavioral family lifestyle interventions result

in significant and clinically meaningful changes in weight

status for children and adolescents compared with stan-

dard care and self-help both in the short and long term

Finally Young and colleagues (2007) identified 44

pediatric obesity interventions across 16 studies for chil-

dren aged 5ndash12 years Of these 44 interventions 31 were

behavioral lifestyle interventions Results indicated that rel-

ative to alternative treatment interventions behavioral

lifestyle interventions produce larger effects at posttreat-

ment Relative to Oude-Luttikhus et al (2009) who re-

quired intent-to-treatment analysis for study inclusion

Young and colleagues did not include intent-to-treatment

analysis as an inclusion criteria This may in part account

for the larger number of interventions included and the

large effect size reported by Young et al

While these three meta-analyses provide essential

information on the relative efficacy of behavioral family

lifestyle interventions the most recent review was of inter-

ventions published only through May 2008 Additionally

the target of past meta-analyses of behavioral family life-

style interventions has been on change in weight status

and therefore more information is needed on the impact of

these interventions on key secondary outcomes such as

dietary intake and physical activity as well as potential

moderators of treatment effects Finally none of these

past reviews explicitly required that interventions were

CBFLIs meaning they did not require interventions to

include all three treatment components to be included

(ie dietary intake physical activity and behavioral

strategies) Thus the primary objective of this review is

to evaluate the efficacy of CBFLIs in reducing or stabilizing

child adiposity in overweight and obese youth A secondary

objective of this review is to evaluate the impact of CBFLIs

on key secondary outcomes including child caloric intake

physical activity sedentary behavior and parent use of

behavior management strategies A final secondary objec-

tive of this meta-analysis is to evaluate potential modera-

tors of treatment outcome including (1) child age (2) child

sex (3) duration and intensity of treatment (4) length of

time from baseline to outcome assessment (5) whether the

parent(s) is targeted for health behavior or weight change

(6) type of comparison control condition (7) methodolog-

ical rigor of studies and (8) other study characteristics

(ie ITT analysis used manualized intervention exclusion

of children over the 99th percentile for body mass index

(BMI) form of therapy [individual vs group vs both] and

form of contact [in-person in-person plus internet

phone]) These moderating variables were selected based

on findings from previous published studies as well as

reviews and recommendations for treating pediatric obesity

(Faith et al 2012 Jelalian amp Saelens 1999 Spear et al

2007 Wilfley et al 2007) and represent potential

important directions for future intervention research

The proposed methods will draw heavily from the

Cochrane Collaboration and represent current best practice

in systematic review methodology This review will add to

the literature by examining only those studies that include

behavioral lifestyle interventions that are comprehensive in

nature (intervention explicitly addresses dietary intake and

Meta-Analysis of Family Interventions for Obesity 811

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physical activity and uses behavioral change strategies)

examining a greater variety of possible moderators of treat-

ment outcomes including studies published up to April

2013 and by including standardized methods to evaluate

trial quality of included studies and rate the level of evi-

dence for our findings

MethodsCriteria for Considering Studies for This Review

Types of Studies

RCTs comparing an active CBFLI for overweight or obesity

in children or adolescents with an attentioneducational

control other active treatment or wait list control were

considered for this review Studies meeting the following

criteria were included

RCTs published in full in peer-reviewed journalsunpublished dissertations and brief reports that in-clude sufficient methodological details to allow (1) crit-ical appraisal of study quality and (2) calculation ofeffect sizes

Primary aim of the trial was to evaluate the efficacy oreffectiveness of an active CBFLI for overweight or obe-sity in children or adolescents with change in weight asthe primary outcome

Both the treatment and the control arms of the studymust have a minimum sample size of 10 at theposttreatment assessment

Types of Participants

Children and adolescents 19 years of age at baseline

who are classified as overweight or obese based on age

and gender norms (Kuczmarski et al 2000) were in-

cluded in this review Studies were excluded if (1) partic-

ipants were from special populations such as children or

adolescents with developmental disabilities developmental

delays or cognitive impairment (2) child or adolescent

participants were diagnosed with a chronic illness that in-

hibits typical growth and development (eg cystic fibrosis)

or bulimia nervosa (3) any of the child participants were

classified as normal weight in any of the treatment arms at

baseline assessment or (4) children or adolescents with an

underlying diagnosis that predisposes children to obesity

or greater than normal weight gain (eg Prader-Willi

Syndrome Thyroid disease)

Types of Interventions

Interventions were included if (1) the active treatment

included dietary physical activity and behavioral compo-

nents that focused on change in weight and weight-related

health behaviors (for explicit criteria see below) (2) the

primary objectives of the intervention were to produce

weight loss or prevent further weight gain in children or

adolescents who were already obese or overweight at base-

line and (3) interventions were conducted in outpatient or

community settings Studies were excluded if the active

intervention being evaluated (1) involved a curriculum-

based school weight management program and (2) child

weight was based on subjective methods of measurement

(eg self-reported parent-reported interviewer estimated)

Active interventions in which only parents attended treat-

ment sessions but child weight or adiposity was the pri-

mary outcome were eligible for inclusion in this analysis

Studies reporting only previously reported data and studies

in which medication was part of treatment were also

excluded

Interventions that were considered to include a dietary

component must have included education presentation

or discussion of healthy eating dietary guidelines or

food preparation strategies Interventions that were consid-

ered to address physical activity must have included one of

the following (1) education on the importance of adequate

physical activity (2) encouragement to increase physical

activity (3) guidelines for recommended levels of physical

activity for children or (4) structured physical activity time

for children during intervention sessions Finally for an

intervention to have been considered lsquolsquobehavioralrsquorsquo the de-

scription of the active treatment must have included one of

the following terms self-monitoring stimulus control goal

setting positive reinforcement differential or contingency

management behavioral parent training or problem solv-

ing Moreover these terms must have described efforts to

help families makes changes to child dietary intake or phys-

ical activity Only studies that included sufficient informa-

tion to determine whether they met these inclusion criteria

were eligible for review

Type of Outcome Measures

Change in child weight at posttreatment was the primary

outcome targeted in this meta-analysis For inclusion mea-

sures of child weight must have been objective adjusted

for child age and sex and reported as one of the following

BMI BMI z-score BMI percentile percent overweight or

adiposity Data were analyzed at pretreatment and

posttreatment When available data were also analyzed at

the first follow-up visit that occurred at least 6 months

postbaseline Change in child weight must have been re-

ported or was able to be calculated from the inclusion of

pretreatment and posttreatment weight values In addition

child weight must have been assessed at the same time

points across all randomized conditions

812 Janicke et al

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ber 13 2014httpjpepsyoxfordjournalsorg

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Search Methods for Identification of Studies

A two-phase search strategy was used to identify studies for

this review First five electronic databases (the Cochrane

Central Register of Controlled Trials [CENTRAL] ProQuest

Dissertations and Theses Full Text PsycINFO via EBSCO

PubMed and Web of Science) were systematically searched

by one member of the research team using the following

truncated key terms to identify studies for review (child

OR adolescent OR family OR parent) AND (intervention

OR treatment) AND (overweight OR obesity) While the

integrity of the search terms was not significantly altered

some changes in search strategies were necessary based on

the requirements of the particular database used (ie use

of MeSH terms for PubMed) Systematic searches of these

databases occurred in February 2013 and again in April

2013 to allow for identification of studies published up

through April 1 2013 The search was limited to articles

that were available in English

A total of 7734 articles were identified through the

initial searches across databases while an additional 12

articles were identified from examination of published

meta-analyses and systematic reviews reporting on inter-

ventions addressing pediatric obesity (see Figure 1 for the

PRISMA Flow diagram) Of these 7746 studies 192 were

removed as they represented duplicates across one or more

databases 9 studies were removed as no full-text article of

the study was available and 7149 were excluded based on

an initial screening of the title and abstract Study exclu-

sion criteria for the abstract review were as follows

1 Participants

a Youth gt19 years of age

b Less than 10 participants in any condition at

posttreatment

2 Intervention

a At least one arm of the intervention is not a

primarily behavioral intervention

b Nonrandomized controlled trial

c Child weight was not a primary outcome of the

intervention

3 Comparison groups

a Study did not include at least one of the fol-

lowing control conditions (i) no treatment con-

trol (ii) waitlist control (iii) education control

or (iv) treatment as usual control

During the second phase of the search the remaining

298 articles were assigned to one of three teams composed

of two reviewers who each independently assessed the full

text of the remaining articles to determine eligibility for

inclusion in the analysis When an inclusion or exclusion

decision could not be reached by the two reviewers the full

team of reviewers discussed the concerns to yield a con-

sensus The reviewers were not blind to the names of study

authors institutions or journals Of the 298 full-text arti-

cles reviewed 278 were excluded (see Figure 1 for reasons

for exclusions) The two-phase process resulted in 20 stud-

ies eligible for inclusion in the current meta-analysis

Data Extraction

A coding document was developed for data extraction pro-

cedures This included critical study information such as

references details of participants and their demographics

aspects of the intervention or therapy characteristics of the

treatment team the setting of the intervention outcome

measures and statistical outcomes Both members from

each review team carried out data extraction from studies

that were identified for inclusion All intervention and out-

come data were compared for consistency and resolved to

100 agreement with the assistance of the first author as

needed

Assessment of Study Rigor

Study rigor was assessed on an 18-point scale developed by

Lundahl et al (2010) and based on criteria from existing

assessment instruments and approaches such as the

Cochrane system Each study was rated by the first

author based on criteria such as number of participants

attrition quality control inclusion of the assessment of

treatment fidelity objectivity of measurements and report-

ing of follow-up data Higher scores indicate higher study

quality

Assessment of Risk of Bias

Available information about the included trials was used to

assess risk of bias in five domains random sequence gener-

ation (failure to use a specified randomization process)

allocation concealment (failure to blind investigators for

future randomization assignments) blinding of outcome as-

sessment (failure to conceal outcome assessors from partic-

ipant intervention group assignment) incomplete outcome

data (failure to report complete outcome data from all ran-

domized participants) and selective reporting (failure to

report results for all planned outcome data) Guidelines

from the Cochrane Handbook were followed for this as-

sessment (Higgins amp Green 2011)

Meta-Analysis of Family Interventions for Obesity 813

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Rating the Quality of Evidence and Strength ofRecommendations

The Grading of Recommendations Assessment

Development and Evaluation (GRADE) system was used

to evaluate the quality of evidence in this review With

the GRADE system evidence for specific outcomes is

rated across studies rather than within individual studies

In this approach RCTs are initially considered to provide

high-quality evidence and observational studies are

considered to provide low-quality evidence for estimates

of intervention effects Five factors may lead to rating

down the quality of evidence (risk of bias inconsistency

indirectness imprecision and publication bias) and three

factors may lead to rating up (large effect size dosendash

response relationship exists and consideration of all plau-

sible confounding variables) The quality of evidence for

each outcome across studies falls into one of four catego-

ries ranging from lsquolsquohighrsquorsquo to lsquolsquovery lowrsquorsquo

Data Analysis

The primary objective of this meta-analysis was to evaluate

the efficacy of CBFLIs on adiposity in children and adoles-

cents To control for change in weight status due to the

intervention the effect size calculated was constructed as a

comparison of the change in weight status in the control

condition as compared with the intervention condition

Independent effect sizes were calculated for the primary

outcome variable (adiposity) in each identified study To

minimize the distortion of standard error estimates

resulting from nonindependent effect size estimates

(Card 2012) multiple outcomes derived from the same

sample were aggregated such that each study (or group

Studies identified through initial database searches

(n = 8025)

Scre

enin

g In

clud

ed

Elig

ibili

ty

Iden

tifi

cati

on

Studies identified through other sources

(n = 12)

Study Abstracts Screened for Eligibility (n = 8037)

Studies Excluded based on Abstract Review

(n = 6067)

Duplicate StudiesRecords Removed (n = 1672)

Studies excluded after full text review (n = 278)

a) All participants 19 years and above = 2 b) Not all children overweightobese = 52 c) Curriculum-based school program = 23 d) Lack of appropriate control = 54 e) Medication intervention = 1 f) Lack of data to calculate effect size = 11 g) Follow-up data from another paper = 2 h) Duplicate data from another paper = 10 i) Methods paper only = 5 j) Not a randomized controlled trial = 45 k) Intervention does not include dietary

physical amp behavioral components = 36 l) Primary outcome is not objectively

adiposity-based variable = 10 m) Sample size lt 10 in one condition = 15 n) Child-only intervention = 12

Studies eligible and included in qualitative

synthesis (n = 20)

Full Text Manuscript Assessed for Eligibility

(n = 298)

Figure 1 PRISMA participant flow diagram

814 Janicke et al

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nloaded from

of studies using the same sample) contributed only one

overall effect size at each assessment point for the primary

outcome variable For studies reporting multiple outcome

measures assessing the same general construct (eg BMI

zBMI percent overweight) an overall effect size was

created by averaging the individual effect sizes If studies

reported multiple analyses using subsets of the same

sample the analysis most directly assessing change in

childrenrsquos weight or adiposity was used

Effect sizes were calculated following the aforemen-

tioned rules (eg one effect size per variable per study

etc)

Hedgesrsquo g (Hedges amp Olkin 1985) was used as the

index of standard mean difference between treatment con-

ditions in the current meta-analysis Hedgesrsquo g is preferred

as an index of mean difference when the preponderance of

studies in the sample use relatively small sample sizes with

correspondingly greater standard errors (Card 2012) In

studies where efficacy of treatment is represented via

other statistics (eg F t X) these values were converted

into Hedgersquos g using standard conversion procedures

Cohen (1969) provided guidelines for interpreting the d

effect size small 020ndash049 medium 050ndash079 and

large 080 Mean effect sizes based on Hedgersquos g follow

these same conventions All effect sizes were expressed in

terms of 95 confidence intervals (CIs) Confidence bands

that did not include zero were considered statistically sig-

nificant while those with confidence bands including zero

were considered nonsignificant

Before calculating mean effect sizes individual effect

sizes were weighted to reflect the degree to which the stan-

dard error approximates population parameters (Card

2012) Specifically a weighted mean effect size was calcu-

lated by computing the product of each studyrsquos effect size

by its weight calculating the sum of each individual

weighted effect size and dividing this sum by the sum of

weights

To examine the homogeneity of effect sizes for the

primary outcome variable the Q statistic was used A sig-

nificant Q statistic indicates that within-group variability

among effect sizes is greater than sampling error alone

would predict This is presumed to signal systematic dif-

ferences between studies in the sample perhaps suggesting

the presence of moderator variables (Card 2012) To pre-

serve statistical power for the planned moderation analyses

described below a fixed effect model was used when esti-

mating heterogeneity among the sample of studies (Card

2012)

Continuous and categorical moderators were assessed

using differing methodologies Continuous variables (eg

age duration) modeled separately were analyzed using

weighted regression analyses with studies with lower stan-

dard error contributing more weight in the regression equa-

tion Categorical variables (eg gender setting) were

analyzed using analysis of variance techniques to assess

differences between groups of interest It is recommended

that 20 studies per group be included to achieve optimal

power to detect group differences (Card 2012) Therefore

lack of significant differences between groups found in

these analyses may be due to insufficient power as this

study only contained 20 studies in total For this reason

secondary analyses of interactions between moderating var-

iables were not assessed

To evaluate the degree to which publication bias (ie

file-drawer problem Rosenthal 1979) inflated the result-

ing effect sizes of this meta-analysis an effect size fail-safe N

was calculated (Card 2012) An effect size fail-safe N in-

dicates the number of unidentified studies with an average

effect size that would be necessary to reduce the obtained

mean effect size to the smallest meaningful effect size

(ESmin) Following Rosenthal (1979) the smallest meaning-

ful effect size was set to 01

ResultsDescription of Studies

The literature search returned 20 studies that were eligible

for inclusion based on the inclusion and exclusion criteria

(see PRISMA diagram) Across these studies 42 effect sizes

were calculated to account for multiple time points and

multiple outcomes To prevent violations of independence

effect sizes from a single study were averaged to create an

overall average effect size for each study which was then

used to calculate the overall effect size across all studies

Descriptions of study characteristics are presented in

Table I

The majority of the studies were published in the past

10 years although one study was published in 1985 Of

the 20 studies presented here eight did not provide zBMI

data In these cases BMI body fat or overweight data

were used and averaged to yield a single estimate of weight

change for the study For length of study period studies

ranged from no data after measurements to follow-up 2

years after baseline Study rigor was measured using an

18-point scale assessing methodological quality derived

from Lundahl et al (2010) This scale was used because

it yielded the most comprehensive assessment of study

rigor identified The average total score on this scale was

123 and scores ranged from 9 to 16 The average num-

ber of participants per study was 8628 with a range of

22ndash108 The total number of child participants across

studies was 1671

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Overall Weight Outcome Effect Size

The overall effect size for change in zBMI in CBFLIs as

compared with that in passive control groups over all

time points was statistically significant (gfrac14 0473 95

CI [362 584]) This finding is consistent with Cohenrsquos

classification of a lsquolsquosmall effect sizersquorsquo (Cohen 1969)

Only one study yielded a negative effect size (Kalarchian

et al 2009) indicating that the rest of the studies yielded

improved outcomes as compared with the control group

The effect size of each individual study as well as each

studyrsquos contribution to the overall effect size is depicted

in Figure 2

Table I Study Characteristics

Study authors

Type of

study

Sample

size

Child

age

range

Percent

female

Country where

study conducted

Race

ethnicity

Duration

of Tx

(month)

Parent

targeted for

lifestyle

change

Outcome

assessment

time point(s)

Outcome

assessment

Boudreau Kurowski

Gonzalez Dimond amp

Oreskovic (2013)

2-arm RCT 26 9ndash12 512 United States Lfrac14 100 6 No 6 BMI z-score

Bocca Corpeleijn Stolk

amp Sauer (2012)

2-arm RCT 75 3ndash5 720 The Netherlands NR 4 Yes 4 12 BMI z-score

Debar et al (2012) 2-arm RCT 208 12ndash17 100 United States Wfrac14 72 5 No 6 12 BMI z-score

Diaz Esparza-Romero

Moya-Camarena

Robles-Sardin amp

Valencia (2010)

2-arm RCT 43 9ndash17 512 Mexico NR 6 No 6 12 BMI z-score

Golley et al (2007) 2-arm RCT 74 6ndash9 6352 Australia Wfrac14 98 5 Yes 12 BMI z-score

Janicke et al (2008) 3-arm RCT 71 8ndash14 606 United States Wfrac14 73 4 Yes 4 10 BMI z-score

AAfrac14 10

Hfrac14 9

Ofrac14 8

Jiang et al (2005) 2-arm RCT 68 12ndash15 397 China NR 24 Yes 24 BMI

Kalarchian et al (2009) 2-arm RCT 192 8ndash12 570 United States Wfrac14 74 12 No 6 12 18 overweight

AAfrac14 26

Kalavainen Korppi amp

Nuutinen (2007)

2-arm RCT 70 7ndash9 657 Finland Ffrac14 985 6 Yes 6 12 BMI z-score

Nemet et al (2005) 2-arm RCT 46 6ndash16 435 Isreal NR 3 No 3 12 BMI BMI

body fat

Nemet Barzilay-Teeni amp

Eliakim (2008)

2-arm RCT 22 8ndash11 636 Isreal NR 3 No 3 BMI body

fat

Reinehr et al (2010) 2-arm RCT 66 8ndash16 606 Germany NR 6 NR 6 BMI z-score

Sacher et al (2008) 2-arm RCT 116 8ndash12 543 United Kingdom Wfrac14 50 12 No 6 BMI z-score

Savoye et al (2007) 2-arm RCT 174 8ndash16 603 United States Wfrac14 37 12 No 6 12 24 Body fat

AAfrac14 39

Hfrac14 24

Senediak amp Spence

(1985)

3-arm RCT 33 6ndash13 NR United States NR 1 No 1 overweight

Shelton et al (2007) 2-arm RCT 43 3ndash10 535 Australia NR 1 Yes 3 BMI and WC

Vos Huisman Houdijk

Pijl amp Wit (2012)

2-arm RCT 79 8ndash17 532 The Netherlands NR 3 No 3 12 BMI z-score

Wafa et al (2011) 2-arm RCT 107 7ndash11 535 Malaysia NR 6 No 6 BMI z-score

West Sanders Cleghorn

amp Davies (2010)

2-arm RCT 101 4ndash11 673 Australia Wfrac14 87 3 No 6 BMI z-score

Mfrac14 6

Afrac14 4

Ifrac14 3

Williamson et al (2005) 2-arm RCT 57 11ndash15 100 United States AAfrac14 100 6 Yes 6 24 BMI body fat

Note AAfrac14African American Afrac14Asian Ffrac14 Finnish Hfrac14Hispanic Ifrac14 Indigenous Lfrac14 Latina Mfrac14Mediterranean Ofrac14 other Wfrac14White WCfrac14waist circumference

NRfrac14 not reported RCTfrac14 randomized controlled trial

816 Janicke et al

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Dow

nloaded from

Overall Effect Sizes for Secondary Outcomes

Eight studies provided useable information on child caloric

intake The overall effect size for change in caloric intake in

CBFLIs as compared with that in passive control groups

over all time points was not statistically significant

(gfrac14 0086 95 CI [090 263])

There was an insufficient number of studies (eg less

than two) meeting inclusion and exclusion criteria for this

review that reported on physical activity sedentary behav-

ior and parent use of behavioral management strategies to

allow for the calculation of an effect size based on the

Cochrane review guidelines

Posttreatment and Follow-up Assessment WeightOutcome Effect Size

Secondary analysis separately examined weight outcomes

directly following completion of the intervention

(posttreatment) and outcomes at later follow-up assess-

ments Based on 20 studies the effect size for CBFLIs at

posttreatment as compared with control groups was statis-

tically significant (gfrac14 0416 95 CI [307 526])

Furthermore based on 11 studies the effect size for

CBFLIs at follow-up assessment as compared with control

groups was also statistically significant (gfrac14 0386 95 CI

[248 524] Both of these meet criteria for a lsquolsquosmall effect

sizersquorsquo (Cohen 1969) The difference between the effect size

for posttreatment assessments and follow-up assessments

was not statistically significant

Moderator Analyses

A test of heterogeneity was then conducted to determine

the appropriateness of testing for moderating variables The

Q test of heterogeneity was statistically significant (84446

p lt 001) indicating that these studies are heterogeneous

Figure 2 Forest plot depicting overall effect size of each study included in the meta-analysis The overall effect size is delineated as a dotted

vertical line The size of the dot represents the weight of the study in contributing to the overall effect size The error bars represent the 95

confidence interval

Meta-Analysis of Family Interventions for Obesity 817

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Dow

nloaded from

and that study variables are significantly moderating the

study effect sizes Therefore analyses with each moderator

variable modeled separately were conducted to assess

study characteristics that may be influencing effect size

outcomes Moderating variables were included based on

reviews and recommendations for treating pediatric obe-

sity previous research and their potential of representing

important directions for future intervention research (Faith

et al 2012 Jelalian amp Saelens 1999 Spear et al 2007

Wilfley et al 2007) Continuous moderator variables ex-

amined in this meta-analysis included time between base-

line and posttreatment assessment duration of treatment

number of sessions child age child sex (ie female)

methodological rigor of study and amount of time in treat-

ment for both child and parent Duration of treatment

number of sessions child age and the amount of time

that the child spent in treatment were all statistically sig-

nificant moderators Specifically larger effect sizes were

associated with longer treatment (duration in weeks)

more treatment sessions a greater total amount of time

(over the course of treatment) that the child spent in treat-

ment and greater child age The results of continuous

moderating analyses are presented in Table II

Categorical moderators analyzed in this meta-analysis

included whether the study sample used ITT analysis type

of control group use of a manualized treatment BMI

greater than the 99th percentile as an exclusionary criteria

if the parents were targeted for their own health behavior

change format for therapy and form of contact with par-

ticipants Results from these analyses are presented in

Table III Use of ITT analysis format of therapy and

form of contact were significant moderating variables

such that individual and in-person CBFLIs were associated

with larger effect sizes

Effect Size Fail-Safe N Calculation

A fail-safe N was calculated to help evaluate the likelihood

of our overall effect size being an overly positive represen-

tation of the true effect size This calculation assesses the

number of studies with an effect size of zero that would

have to be included before the overall effect size would

shrink to the smallest meaningful effect size Our calcula-

tions indicated that 75 studies with an effect size of zero

would have to be added to this meta-analysis to bring

down the overall effect size to 01

Risk of Bias

Each study was assessed on five dimensions for risk of bias

The summary risk of bias findings across all studies are

presented in Figure 3 Overall the 20 studies included in

this review exhibit relatively low risk of bias for random

sequence generation and selective reporting Over half of

the studies examined were judged to exhibit unclear or

high risk of bias for blinding of outcome assessment In ad-

dition over half to the studies reviewed reported insuffi-

cient methodological details and outcome data to

determine if there was low or high risk of bias for incom-

plete outcome data and thus were classified as unclear risk

of bias Finally over half of the studies examined exhibited

high risk of bias for allocation concealment

GRADE Rating

A rating of lsquolsquomoderatersquorsquo (3 on a scale of 1ndash4) was assigned

to the quality of evidence for improvements in BMI Z-score

based on the GRADE system As all trials were RCTs our

review assumed a starting point of high-quality evidence (a

rating of 4) However the quality of evidence was incon-

sistent and there are some potential concerns with risk for

bias (see previous section) which lowered the overall rating

from high quality to moderate quality A rating of lsquolsquolow

qualityrsquorsquo (2 on a scale of 1ndash4) was assigned to the quality

of evidence for changes in caloric intake based on the

GRADE system As all trials were RCTs our review as-

sumed a starting point of high-quality evidence (a rating

of 4) However owing to the potential concerns for risk of

bias and the fact that the measurement of dietary intake

was viewed as imprecise the GRADE rating was reduced

from high quality to low quality See Table IV for a display

of the Summary of Findings Table

Discussion

Previous reviews examining studies published before 2008

have reported that lifestyle interventions addressing pedi-

atric obesity are associated with improvements in weight

Table II Continuous Moderator Analyses

Moderator variables R2 value p value Beta

Time between baseline and

assessment

043 198 0208

Duration of intervention 374 004 0612

Number of intervention sessions 264 020 0514

Percentage of females participants in

intervention

068 281 0234

Age of child participants 305 014 0169

Methodological rigor of study 003 831 0193

Amount of minutes child in

treatment

795 000 0892

Amount of minutes parent in

treatment

017 603 0131

818 Janicke et al

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Dow

nloaded from

outcomes (Jelalian amp Saelens 1999 Kitzmann et al 2010

Oude-Luttikhuis et al 2009 Whitlock et al 2010

Wilfley et al 2007) While very informative these reviews

included heterogeneous groups of studies with varied types

of lifestyle intervention programs The current meta-analy-

sis extends the literature by examining studies published in

2013 and being the first to examine only multi-component

CBFLIs to treat obesity in children and adolescents who are

overweight or obese Specifically our inclusion criteria re-

quired that intervention programs address three compo-

nents improvements in dietary intake increases in

physical activity and the use of behavioral strategies to

achieve improvements in these two areas The overall

effect size of 047 for change in BMi z-score although

small was approaching Cohenrsquos requirement of 05 for a

medium effect size This finding is consistent with similar

past reviews (Whitlock et al 2010 Wilfley et al 2007)

and suggests that multi-component CBFLIs are efficacious

in improving weight outcomes in children who are over-

weight or obese Follow-up analysis found that effect sizes

did not significantly differ between results at posttreatment

and follow-up assessments providing evidence that im-

provements in weight outcomes are maintained at follow-

up The length of follow-up assessments ranged from 10 to

24 months after baseline with a majority (8 of 10 studies)

including 12-month follow-up assessment The analyses of

effect sizes examining maintenance of outcomes at follow-

up assessments were based on a relatively small number of

studies Thus results should be interpreted with caution

Exploratory analyses were also conducted to examine

potential moderators of treatment outcome Most notably

dose of treatment as measured by the number of interven-

tion sessions and the number of minutes children spent in

treatment sessions was positively related to effect size

This is consistent with previous reviews (Whitlock et al

2010 Wilfley et al 2007) Our results in combination

with these previous reviews provide support for the notion

that greater intervention duration and intensity are associ-

ated with better weight outcomes which is similar to find-

ings reported in the adult obesity literature (Middleton

Patidar amp Perri 2012) However more research

specifically examining dosendashresponse relationships of

CBFLIs to weight and behavioral outcomes is needed

before definitive conclusions can be drawn

Figure 3 Risk of bias

Table III Categorical Moderator Analyses

Moderator

variables Categories N Effect size

Intent to treata Yes (1) 7 0658 (0491 0824)

No (2) 13 0290 (0141 0440)

Type of control

group

Standard care 10 0430 (0280 0572)

Waitlist 9 0470 (0290 0650)

Use of

manualized

treatment

Yes 5 0546 (0314 0747)

No 7 0360 (0115 0605)

Not reported 8 0437 (0279 0596)

BMI gt 99th as

exclusion

Yes (1) 4 0352 (0279 0596)

No (2) 11 0392 (0239 0546)

Not reported 5 0812 (0546 1075)

Parent targeted

for change

Yes (1) 6 0268 (0049 0486)

No (2) 12 0502 (0366 0638)

Not reported 2 0689 (0265 1113)

Form of therapya Individual 2 1291 (0889 1693)

Group 13 0372 (0240 0504)

Both 5 0426 (0240 0665)

Form of contacta In person 14 0642 (0498 0786)

Phone only 1 0219 (0363 0801)

In personthornOther 5 0176 (0007 0359)

Timing of

measurement

Post-Treatment 20b 0416 (0307 0526)

Follow-up 11b 0386 (0248 0524)

Note aIndicates statistically significant moderating variablebDue to multiple measurements taken within the same study this number does

not represent studies instead representing measurements taken within a study

Meta-Analysis of Family Interventions for Obesity 819

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Dow

nloaded from

The level of parent involvement relative to weight out-

comes in pediatric lifestyle interventions has received grow-

ing attention in the literature in recent years Neither the

amount of time parents spent in treatment nor whether the

parents were targeted for their own lifestyle behavior

change was related to child weight outcomes in this anal-

ysis This is consistent with a review by Faith and col-

leagues (2012) who found limited support for the notion

that greater parental involvement in treatment leads to

better child weight outcomes However Faith and col-

leagues did find that greater parent adherence to core be-

havioral strategies was related to greater child weight status

outcomes It may be that the actual application of behav-

ioral strategies to address lifestyle issues within the home

leads to better child weight outcomes which was not as-

sessed in our analysis As noted by Faith et al (2012) only

a few studies have reported on this important relationship

(Epstein 1993 Wrotniak Epstein Paluch amp Roemmich

2005) Future intervention trials should include data col-

lection to examine if parent use of behavioral strategies

mediates the relationship between treatment participation

and key outcomes such as changes in dietary intake phys-

ical activity and weight status

A number of other potential moderators of effect size

outcomes were examined in this review Age was a mod-

erator such that larger effect sizes for weight outcomes

were positively associated with the mean age of child

participants This is consistent with a review by

Oude-Luttikhuis (2009) who found larger effects for stud-

ies with children 12 years of age compared with studies

with children lt12 years of age Weight outcomes were

moderated by form of therapy (individual vs group) and

form of contact (in person vs phone only vs in-person

plus other) such that therapy with individual families

and therapy delivered via in-person contacts related to

larger effect sizes However the number of studies in-

cluded in this moderator analyses were heavily skewed

toward group and in-person contacts that these findings

must be viewed as preliminary The current review also

found that studies that used ITT analysis (kfrac14 7) were as-

sociated with better weight outcomes than studies that did

not use ITT analysis While one could speculate that stud-

ies including ITT analysis are methodologically stronger

than those studies that do not include ITT analysis our

moderator analysis examining methodological rigor of in-

cluded studies was not significant and thus did not sup-

port this conclusion

Data from eight studies found that CBFLIs do not have

significant effects on change in caloric intake This is sur-

prising given the effects that CBFLIs were found to have on

weight change It is likely that the imprecise nature of as-

sessing caloric intake at least partially impacted these re-

sults (Schoeller 1995) as it seems unlikely that the weight

changes observed were entirely due to increases in energy

expenditure These findings highlight the need for innova-

tive future research designs to examine the specific

Table IV Summary of Findings for Multi-Component Behavioral Family Interventions to Treat Obesity in Children and Adolescents

Patient or population Overweight and obese children and adolescents

Outcomes Illustrative comparative risks (95 CI) Relative effect

(95 confi-

dence interval)

No of partici-

pants

(studies)

Quality of the

evidence

(GRADE)

Comments

Assumed risk Corresponding risk

Control Behavior Family Therapy

BMI z-score (overall)

Investigators used

objective measurement

of anthropometric

variables

The overall mean decrease in

BMI z-score in the inter-

vention groups was 047

standard deviations more

than the control groups

(036ndash058 lower)

- 1671 (20

studies)

moderate

Results were statisti-

cally significant As

a rule of thumb

02 SD represents a

small 05 a moder-

ate and 08 a large

difference

Caloric Intake

Investigators used objec-

tive measurement of ca-

loric intake (ie 24-hr

recalls food frequency

questionnaires)

The overall mean decrease in

caloric intake in the inter-

vention groups was 009

standard deviations more

than the control groups

(009ndash026 lower)

- 542 (8

studies)

low

quality

Results were not sta-

tistically significant

Note GRADE Working Group grades of evidence

High quality () Further research is very unlikely to change our confidence in the estimate of effect

Moderate quality () Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate

Low quality () Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate

Very low quality () We are very uncertain about the estimate

820 Janicke et al

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ber 13 2014httpjpepsyoxfordjournalsorg

Dow

nloaded from

mechanisms by which the interventions exert their influ-

ence One such example may be the use of sequential

multiple assignment randomized trials (SMART Designs)

that provide data to enable assessment of optimal compo-

nent sequencing that can facilitate the development of

high-quality adaptive interventions (Almirall Compton

Gunlicks-Stoessel Duan amp Murphy 2012)

Consistent with the other systematic reviews in this

special issue the GRADE system (Guyatt et al 2011)

was used to assess the strength and quality of the evidence

of our findings Evidence for changes in BMI z-score from

the reviewed studies was assigned a lsquolsquomoderatersquorsquo GRADE

rating indicating that lsquolsquofurther research is likely to have an

important impact on our confidence in the estimate of

effect and may change the estimatersquorsquo However evidence

for our finding on caloric intake was assigned a lsquolsquolow qual-

ityrsquorsquo rating indicating that further research is likely to have

an important impact on our confidence in the estimate of

effect and is likely to change the estimate Characteristics of

the studies included in this meta-analysis that strength-

ened the GRADE rating for weight outcomes included

the use of RCTs evidence of a dosendashresponse relationship

between weight and treatment (eg better weight out-

comes were associated with greater treatment duration

and intensity) and an overall small effect size approaching

a medium effect There were however also some

weaknesses in this literature which precluded a stronger

GRADE rating for each outcome For example 75 of

studies were rated as having unclear or high risk of bias

of incomplete reporting of outcome data due to large

amounts of missing data insufficient details regarding rea-

sons for missing data or the use of inadequate methods for

managing missing data which diminishes confidences in

estimation of treatment effects Moreover half the studies

included in this analysis were rated high on risk of bias for

allocation concealment (ie investigators were not blind to

randomized assignment of participants) In addition effect

sizes across studies for weight outcomes were somewhat

inconsistent Finally as noted previously the imprecise

nature of assessing caloric intake negatively impacted our

Grade rating for changes in caloric intake

There are a variety of steps that can be taken by future

research to address these methodological limitations and

improve the scientific rigor in this area First many studies

were excluded from the meta-analysis owing to failure to

provide sufficient information to allow for calculation of

effect size or properly classify the study intervention or

methodology Similar concerns have been noted by

Klesges and colleagues who called for researchers to

improve the reporting of contextual and generalizability

elements central to translational research

(Klesges Dzewaltowski amp Glasgow 2008) We echo this

call and also encourage researchers to more clearly opera-

tionally define and describe both the active intervention

and control condition on which the intervention is tested

against Second the overall GRADE rating for this analysis

was negatively impacted by the high risk of bias in a

number of areas To reduce this risk of potential bias and

increase our confidence in the efficacy of CBFLIs it is also

important for future studies to ensure proper concealment

of randomization and treatment condition assignment to

investigators and assessment staff With regards to data

analysis future studies should conduct ITT analyses

when examining primary and secondary outcomes and

should clearly document why data are missing and what

strategies and assumptions used for handling missing data

There are some important additional limitations of the

current analysis that have implications for future research

The clinical significance of weight outcomes associated

with CBFLIs is an on-going question Few studies in this

review reported on metabolic parameters associated with

weight changes While these data are admittedly difficult to

gather with children it will be critical to document

improvements not only in weight outcomes but also

metabolic parameters Similarly only eight studies in the

literature contained sufficient information to examine

change in dietary intake Moreover there were not

enough articles identified to calculate effect sizes for both

physical activity and sedentary behavior Future studies of

lifestyle interventions for obesity should include sufficient

objective information to allow effect sizes to be calculated

for dietary intake physical activity and sedentary behavior

as these effect sizes likely moderate overall effect sizes for

lifestyle interventions Admittedly reliable and valid assess-

ment of dietary intake is an ongoing challenge Repeated

24-hr recalls offer the best combination of feasibility and

strong psychometric properties but are expensive

time-consuming and still subject to self-reporting bias

Strategies to reduce reporting bias and further improve

the reliability and validity of assessing dietary intake are

sorely needed In addition compared with other meta-

analyses only a relatively small number of studies and

participants were included in this meta-analysis As such

findings from our analysis of moderators should be viewed

with caution Finally there is the risk of publication bias in

any meta-analysis the discovery of additional studies of

CBFLIs might have affected the results obtained here

However the fail-safe calculation indicated that 75 stud-

ies with an effect size of 0 would need to be added to this

meta-analysis to result in an effect size of 01

The potential for adverse events is important to con-

sider when evaluating interventions to address childhood

Meta-Analysis of Family Interventions for Obesity 821

by guest on Novem

ber 13 2014httpjpepsyoxfordjournalsorg

Dow

nloaded from

obesity not only in terms of the potential for delayed linear

growth but also for negative outcomes such as the devel-

opment of disordered eating behaviors and reductions in

self-esteem (Satter 2005) Eight of the 20 studies included

in this analysis reported on adverse events Only four of

these reported on potential changes in problematic eating

attitudes and behaviors or self-esteem (DeBar et al 2012

Janicke et al 2008 Jiang Xia Greiner Lian amp

Rosenqvist 2005 Williamson et al 2005) One study

specifically assessed for slowed linear growth (Golley

Magarey Baur Steinbeck amp Daniels 2007) while three

other studies reported on lsquolsquogeneric adverse eventsrsquorsquo (Nemet

et al 2005 Reihner et al 2010 Sacher et al 2010)

Across these eight studies there was no data suggestive of

an increase in negative outcomes or adverse events subse-

quent to participating in CBFLIs This is consistent with

the findings from previous reviews (Carter amp Bulik 2008

Oude-Luttikhuis et al 2009 Whitlock et al 2010) While

testing the efficacy or effectiveness of CBFLIs on reducing

or slowing weight gain in youth has important public

health implications it is equally important that families

participating in these interventions are not exposed to ad-

ditional causes of harm Therefore researchers should

place a high priority on reporting information on the

number and types of adverse events associated with

tested interventions

Given the lack of interventions addressing obesity in

young children as well as recent findings showing that

children who are overweight at 5 years of age are four

times more likely to be obese between 5 and 14 years of

age compared with children who are normal weight

(Cunningham Kramer amp Narayan 2014) there is great

need for more prevention and intervention research focus-

ing on the impact of behavioral family interventions in

families of young children Another important question is

the issue of generalizability as well as translation and dis-

semination to real world settings There is growing support

for the notion that longer and more intense treatment re-

sults in better weight outcomes However the question

arise as to how can higher intensity interventions that

seem to be related to better outcomes be delivered in

real-world settings by individuals with less expertise than

many of the obesity experts that served as interventionists

in these outcome studies Moreover how can we help fam-

ilies sustain participation for the longer durations neces-

sary for better weight outcomes given the documented

barriers that many families face in real world settings

(Kottyan Kottyan Edwards amp Unaka 2014 Lim amp

Janicke 2013) Future research is needed to develop and

examine innovative strategies for implementing CBFLIs

that can be delivered with fidelity reach large numbers

of families in community settings and that are feasible

for both families and providers Telehealth technology-

aided and internet-based social media interventions are

areas that hold promise and are deservedly garnering

more attention (Davis Sampilo Gallagher Landrum amp

Malone 2013) Finally developing broader multi-layered

intervention efforts that include CBFLIs within larger com-

munity change efforts such as by Rogers and colleagues

(Rogers et al 2013) can build awareness as well as envi-

ronmental and social supports that have the potential to

facilitate long-term behavior change that can reach larger

numbers of children and families

Conclusion

The current study provides evidence that CBFLIs address-

ing pediatric obesity lead to improvements in child weight

outcomes While the overall effect size was small it ap-

proached the medium range There was no difference in

effect sizes for weight outcomes at posttreatment relative to

long-term follow-up Greater duration and intensity of

treatment as well as greater child age were all related to

better weight outcomes Future research is needed to better

document changes in caloric intake physical activity and

metabolic parameters associated with participation in

CBFLIs Future research is also needed to develop innova-

tive strategies for feasibly implementing CBFLIs in real-

world settings while preserving the core components of

treatment with established efficacy

Conflicts of interest None declared

References

Almirall D Compton S N Gunlicks-Stoessel M

Duan N amp Murphy S A (2012) Designing a pilot

sequential multiple assignment randomized trial for

developing an adaptive treatment strategy Statistics

in Medicine 31 1887ndash1902

Bocca G Corpeleijn E Stolk R P amp Sauer P J

(2012) Results of a multidisciplinary treatment pro-

gram in 3-year-old to 5-year-old overweight or obese

children A randomized controlled clinical trial

Archives of Pediatrics and Adolescent Medicine 166

1109ndash1115

Boudreau A D Kurowski D S Gonzalez W I

Dimond M A amp Oreskovic N M (2013) Latino

families primary care and childhood obesity A ran-

domized controlled trial American Journal of

Preventive Medicine 44 S247ndashS257

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Card N A (2012) Applied meta-analysis for social science

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Carter F A amp Bulik C M (2008) Childhood obesity

prevention programs How do they affect eating pa-

thology and other psychological measures

Psychosomatic Medicine 70 363ndash371

Cohen J (1969) Statistical power analysis for the

behavioral sciences New York NY Academic Press

Cohen J C Thombs B D amp Hagedoorn M (2010)

Ainrsquot necessarily so Review and critique of recent

meta-analyses of behavioral medicine interventions in

Health Psychology Health Psychology 29 107ndash116

Cunningham S A Kramer M R amp Narayan K M

(2014) Incidence of childhood obesity in the United

States The New England Journal of Medicine 370

403ndash411

Daniels S R (2006) The consequences of childhood

overweight and obesity The Future of Children 16

47ndash67

Davis A M Sampilo M Gallagher K S Landrum Y

amp Malone B (2013) Treating rural pediatric obesity

through telemedicine Outcomes from a small ran-

domized control group Journal of Pediatric

Psychology 38 932ndash943 doi101093jpwpayjst005

DeBar L L Stevens V J Perrin N Wu P

Pearson J Yarborough B J Lynch F (2012)

A primary care-based multicomponent lifestyle inter-

vention for overweight adolescent females Pediatrics

129 e611ndashe620

Diaz R G Esparza-Romero J Moya-Camarena S Y

Robles-Sardin A E amp Valencia M E (2010)

Lifestyle intervention in primary care settings im-

proves obesity parameters among Mexican youth

Journal of the American Dietetic Association 110

285ndash290

Ebbeling C B Leidig M M Sinclair K B

Hangen J P amp Ludwig D S (2003) A reduced-

glycemic load diet in the treatment of adolescent

obesity Archives of Pediatric and Adolescent Medicine

157 773ndash779

Epstein L H (1993) Methodological issue and ten-year

outcomes for obese children Annals of the New York

Academy of Sciences 699 237ndash249

Faith M S Van Horn L Appel L J Burke L E

Carson J A S Franch H A Wylie-Rosett J

(2012) Evaluating parents and adult caregivers as

lsquolsquoagents of changersquorsquo for treating obese children

Evidence for parent behavior change strategies and

research gaps A scientific statement from the

American Heart Association Circulation 125

1186ndash1207

Golan M Kaufman V amp Shahar DR (2006)

Childhood obesity treatment Targeting parents ex-

clusively v parents and children The British Journal

of Nutrition 95 1008ndash1015

Golley R K Magarey A M Baur L A Steinbeck K S

amp Daniels L A (2007) Twelve-month effectiveness of

a parent-led family-focused weight-management pro-

gram for prepubertal children A randomized con-

trolled trial Pediatrics 119 517ndash525

Guyatt G Oxman A D Akl E A Kunz G Vist G

Brozek J Schunemann H J (2011) GRADE

guidelines 1 Introduction - GRADE evidence pro-

files and summary of findings tables Journal of

Clinical Epidemiology 64 383ndash394

Hedges L V amp Olkin I (1985) Statistical methods for

meta-analysis San Diego CA Academic Press

Higgins J P T amp Green S (Eds) (2011) Cochrane

handbook for systematic reviews of interventions

(version 510) The Cochrane Collaboration

Retrieved from wwwcochrane-handbookorg

Janicke D M Sallinen B J Perri M G Lutes L D

Huerta M Silverstein J H amp Brumback B

(2008) Comparison of parent-only vs family-based

interventions for overweight children in underserved

rural settings Outcomes from project STORY

Archives of Pediatrics and Adolescent Medicine 162

1119ndash1125

Jelalian E amp Saelens B E (1999) Empirically sup-

ported treatments in pediatric psychology Pediatric

obesity Journal of Pediatric Psychology 24 223ndash248

Jiang J X Xia X L Greiner T Lian G L amp

Rosenqvist U (2005) A two year family based be-

haviour treatment for obese children Archives of

Disease in Childhood 90 1235ndash1238

Kalarchian M A Levine M D Arslanian S A

Ewing L J Houck P R Cheng Y

Marcus M D (2009) Family-based treatment of

severe pediatric obesity Randomized controlled trial

Pediatrics 124 1060ndash1068

Kalavainen M P Korppi M O amp Nuutinen O M

(2007) Clinical efficacy of group-based treatment for

childhood obesity compared with routinely given in-

dividual counseling International Journal of Obesity

31 1500ndash1508

Kitzmann K M Dalton W T Stanley C M

Beech B M Reeves T P Buscemi J

Midget E L L (2010) Lifestyle interventions for

youth who are overweight A meta-analytic review

Health Psychology 29 91ndash101

Klesges L M Dzewaltowski D A amp Glasgow R E

(2008) Review of external validity reporting in

Meta-Analysis of Family Interventions for Obesity 823

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ber 13 2014httpjpepsyoxfordjournalsorg

Dow

nloaded from

childhood obesity prevention research American

Journal of Preventive Medicine 34 216ndash223

Koletzko B Brands B Poston L Godfrey K amp

Demmelmair H (2012) Early nutrition program-

ming of long-term health Symposium on metabolic

flexibility in animal and human nutrition Proceeding

of the Nutrition Society 71 371ndash378

Kottyan G Kottyan L Edwards N M amp

Unaka N I (2014) Assessment of active play

inactivity and perceived barriers in an inner city

neighborhood Journal of Community Health 39

538ndash544

Kuczmarski R J Ogden C L Grummer-Strawn L M

Flegal K M Guo S S Wei R Curtin L R

(2000) CDC growth charts United States Advance

Data 314 1ndash27

Lim C S amp Janicke D M (2013) Barriers related to

delivering pediatric weight management interventions

to children and families from rural communities

Childrenrsquos Health Care 42 214ndash230

Lioret S Volatier J L Lafay J Touvier M amp

Maire B (2009) Is food portion size a risk factor of

childhood overweight European Journal of Clinical

Nutrition 63 382ndash391

Lundahl B W Kunz C Brownell C Tollefson D amp

Burke B L (2010) A meta-analysis of motivational

interviewing Twenty-five years of empirical studies

Research on Social Work in Practice 20 137ndash160

McGovern L Johnson J N Paulo R Hettinger H

Singhal V Kamath C Montori V M (2008)

Treatment of pediatric obesity A systematic review

and meta-analysis of randomized trial Journal of

Clinical Endocrinology and Metabolism 93

4600ndash4605

Middleton K Patidar S amp Perri M G (2012) The

impact of extended care on the long-term mainte-

nance of weight loss A systematic review Obesity

Review 13 509ndash517

Nemet D Barkan S Epstein Y Friedland O

Kowen G amp Eliakim A (2005) Short- and long-

term beneficial effects of a combined dietary-behav-

ioral-physical activity intervention for the treatment

of childhood obesity Pediatrics 115 e443ndashe449

Nemet D Barzilay-Teeni N amp Eliakim A (2008)

Treatment of childhood obesity in obese families

Journal of Pediatric Endocrinology and Metabolism 21

461ndash467

Ogden C L Carroll M D Kit B K amp Flegal K M

(2012) Prevalence of obesity and trends in body

mass index among US children and adolescents

1999-2010 Journal of the American Medical

Association 307 483ndash490

Oude-Luttikhuis H Baur L Jansen H

Shrewsburgy V A OrsquoMalley C Stolk R P amp

Summerbell C D (2009) Interventions for treating

of childhood obesity The Cochrane Collaboration

Puhl R M Luedicke J amp Heuer C (2011) Weight-

based victimization toward overweight adolescents

Observations and reactions of peers Journal of School

Health 81 696ndash703

Reinehr T Schaefer A Winkel K Finne E

Toschke A M amp Kolip P (2010) An effective life-

style intervention in overweight children Findings

from a randomized controlled trial on lsquolsquoObeldicks

lightrsquorsquo Clinical Nutrition 29 331ndash336

Rogers V W Hart P H Motyka E Rines E N

Vine J amp Deatrick D A (2013) Impact of Letrsquos

Go 5-2-1-0 A community-based multisetting child-

hood obesity prevention program Journal of Pediatric

Psychology 38 1010ndash1020

Rosenthal R (1979) The lsquolsquofile drawer problemrsquorsquo and tol-

erance for null results Psychological Bulletin 86

638ndash641

Sacher P M Kolotourou M Chadwick P M

Cole T J Lawson M S Lucas A amp Singhal A

(2010) Randomized controlled trial of the MEND

program A family-based community intervention for

childhood obesity Obesity 18 S62ndashS68

Satter E (2005) Young childrsquos weight Helping without

hurting Madison WI Kelcy Press

Savoye M Nowicka P Shaw M Yu S Dziura J

Chavent G Caprio S (2011) Long-term results

of an obesity program in an ethnically diverse pediat-

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Savoye M Shaw M Dziura J Tamborlane WV

Rose P Guandalini C Caprio S (2007)

Effects of a weight management program on body

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children A randomized controlled trial JAMA 297

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Schoeller D A (1995) Limitations in the assessment of

dietary energy intake by self-report Metabolism

44(Suppl 2) 18ndash22

Senediak C amp Spence S H (1985) Rapid versus grad-

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based behavioral weight control program for children

Behavioural Psychotherapy 13 265ndash287

Seo D C amp Sa J (2010) A meta-analysis of obesity in-

terventions among US minority children Journal of

Adolescent Health 46 309ndash323

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Shelton D Le Gros K Norton L Stanton-Cook S

Morgan J amp Masterman P (2007) Randomised

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programme for overweight children Journal of

Paediatrics and Child Health 43 799ndash805

Singh A S Mulder C Twisk J W van Mechelen W

amp Chinapaw M J (2008) Tracking of childhood

overweight into adulthood A systematic review of

the literature Obesity Reviews 9 474ndash488

Spear B Barlow S Ervin C Ludwig D Saelens B

Schetzina K amp Taveras E (2007) Recommendations

for treatment of child and adolescent overweight and

obesity Pediatrics 120 S254ndashS288

Task Force on Promotion and Dissemination of

Psychological Procedures (1995) Training in and

dissemination of empirically-validated psychological

treatments Report and recommendations Clinical

Psychologist 48 3ndash23

Vos R C Huisman S D Houdijk E C Pijl H amp

Wit J M (2012) The effect of family-based

multidisciplinary cognitive behavioral treatment on

health-related quality of life in childhood obesity

Quality of Life Research 21 1587ndash1594

Wafa S W Talib R A Hamzaid N H McColl J H

Rajikan R Ng L O Reilly J J (2011)

Randomized controlled trial of a good practice ap-

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Malaysia Malaysian Childhood Obesity Treatment

Trial (MASCOT) International Journal of Pediatric

Obesity 6 e62ndashe69

West F Sanders M R Cleghorn G J amp Davies P S

(2010) Randomised clinical trial of a family-based

lifestyle intervention for childhood obesity involving

parents as the exclusive agents of change Behaviour

Research and Therapy 48 1170ndash1179

Whitaker R C Wright J A Pepe M S Seidel K D

amp Dietz WH (1997) Predicting obesity in young

adulthood from childhood and parental obesity New

England Journal of Medicine 337 869ndash873

Whitlock E P OrsquoConnor E A Williams S B

Beil T L amp Lutz K W (2010) Effectiveness of

weight management interventions in children A tar-

geted systematic review for the USPSTF Pediatrics

125 e396ndashe418

Wilfley D E Tibbs T L Van Buren D J

Reach K P Walker M S amp Epstein L H

(2007) Lifestyle interventions in the treatment of

childhood overweight A meta-analytic review of

RCTs Health Psychology 26 521ndash532

Williamson DA Martin PD White MA Newton R

Walden H York-Crowe E Ryan D (2005)

Efficacy of an internet-based behavioral weight

loss program for overweight adolescent African-

American girls Eating and Weight Disorders 10

193ndash203

Wrotniak B H Epstein L H Paluch R amp

Roemmich J (2005) The relationship between

parent and child self-reported adherence and weight

loss Obesity Research 13 1089ndash1096

Young K M Northern J J Lister K M

Drummond J A amp OrsquoBrien W H (2007) A

meta-analysis of family-behavioral weight-loss treat-

ments for children Clinical Psychology Review 27

240ndash249

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ber 13 2014httpjpepsyoxfordjournalsorg

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nloaded from