A meta-analysis of family-behavioral weight-loss treatments for children
Introduction
Obesity is a major concern for both adults and children. Approximately 30% of American 6 to 12 year old children are overweight (i.e., at or above the 85th percentile for age and gender-specific BMI), and between 15 and 16% are obese (i.e., at or above the 95th percentile for age and gender-specific BMI; American Obesity Association, 2002, Center for Disease Control: National Center for Health Statistics, 2004). Childhood obesity, as well as its prevention and treatment, has been of great interest to researchers because of its health implications. Specifically, obese children are at higher risk for type II diabetes, asthma, hypertension, sleep apnea, orthopedic complications, increased low-density lipoprotein, and decreased high-density lipoprotein cholesterol (Leung and Robson, as cited in Haddock et al., 1994, Epstein and Wing, 1987). Additionally, children who are overweight are more likely to experience peer disapproval, bullying and teasing, academic discrimination, poorer self-image, eating disorders, and depression (American Obesity Association, 2002, Edmunds et al., 2001, Eisenberg et al., 2003, Griffiths et al., 2006, Grilo et al., 1994, Janssen et al., 2004). Also, despite the increased prevalence of adult overweight and obesity, as well as the seriousness of the consequences that have been found to be associated with obesity, treatment programs for adults typically have met with only modest weight-loss and lack of successful long-term maintenance of weight-loss (Perri, 1998, Perri et al., 1984).
Because childhood obesity is a growing problem that appears to have significant health implications, many researchers have attempted to reverse this trend in the population by developing weight-loss interventions. Most treatment plans for childhood obesity include one or more of three components: dietary education and restriction, physical activity/lifestyle activity increases and/or sedentary behavior decreases, and behavior therapy (Fowler-Brown and Kahwati, 2004, Haddock et al., 1994, Reinehr et al., 2003).
Behavioral treatments for weight-loss in pediatric obesity produce better results than other weight-loss treatments that do not include behavioral modification (Haddock et al., 1994). It also appears that the behavioral treatment of obesity is more effective for long-term maintenance of weight-loss for children than for adults (Wilson, 1994). Other studies, however, have found contradictory results. Although behavior therapy has been successful during the first six months of childhood obesity treatment, there is a need to determine better long-term approaches (Varni & Banis, 1985). Other critiques of childhood behavioral weight-loss programs are that the outcomes are mixed when taking into account parental involvement (Epstein & Wing, 1987), that programs typically have small outcomes that vary widely among individual participants, and that there is an overall inconsistency of perceived effectiveness of these programs due to limitations within childhood obesity treatment literature (e.g., small number of studies, limited details given about program components; Haddock et al., 1994).
Because children are less developmentally sophisticated than adults and their environment is more determined by decisions made by adult family members, researchers have focused on the role family plays in the process of treating childhood obesity. It has been proposed that if variables influencing obesity are learned and maintained early in life at a familial and cultural level, then obesity management becomes even more complicated (Coates & Thorensen, 1978). This rationale suggests that treating childhood obesity in a family context is important. Parental involvement in weight-loss interventions can range from high (involvement in all aspects of the program) to low (minimal inclusion during the program and responsibility for few aspects of the intervention; Haddock et al., 1994). Parental influences on a child's weight include determining the structure of the child's home environment, encouraging and discouraging behaviors, and exerting pressure to maintain a certain physical appearance (Brownell & Wadden, 1984). Thus, family-based interventions may be able to capitalize on these and other similar processes in order to enhance the effectiveness of behavioral weight-loss programs.
Components of a family-based weight-loss program include praising the child's healthy behavior, limiting or eliminating food as a reward, establishing stable meal and snack times, determining what foods are offered, offering only healthy food options, removing temptations from the child's environment, modeling desired behaviors, and providing consistency within the home (Barlow & Dietz, 1998). The differences in the amount and type of parent/child interactions, as well as the difficulties involved in observing parent and child behaviors outside of a laboratory environment have presented problems for measuring parent/child behavior. These problems are samples of the many reasons why the effectiveness of family-based weight-loss interventions have been difficult to determine.
Other reviews have been conducted to determine the effectiveness of family-based treatments for weight-loss in children. These reviews have mixed results. For instance, a meta-analysis conducted by Haddock et al. (1994) suggested that parental involvement did not affect the results of child weight-loss programs. A review by Wilson, O'Meara, Summerbell, and Kelly (2003) concluded that there is some evidence that behavioral weight-loss programs involving a parent taking an active role as an agent of change helps children lose weight. However, this review failed to calculate effect sizes. Another review by McLean, Griffen, Toney, and Hardeman (2003) found evidence that parent involvement was effective in the treatment of childhood obesity. However, this review did not include studies beyond those published in 1994 and also did not report effect sizes. The present study attempts to clarify these discrepancies and extend the body of literature by conducting a carefully designed meta-analysis of post-treatment and follow-up outcomes.
Section snippets
Selection of studies
Before potential articles for analysis could be identified, criteria for inclusion in the meta-analysis and operational definitions were developed. The age range of children examined in this study was from 5 to 12 years old, which prior literature indicates as the target age group for childhood behavioral weight-loss programs (Varni & Banis, 1985). Weight-loss treatment was defined as a program conducted with the primary goal of child weight-loss. Behavioral treatment was determined by a
Methodological characteristics of the included studies
Many of the 16 studies were similar. A typical study recruited subjects through a combination of newspaper ads, self-referrals, and physician referrals. Inclusion criteria consisted of some cutoff for being classified as overweight, age restrictions, no history of psychiatric problems for the child, no current child involvement in other forms of treatment for his or her weight, and at least one parent willing to attend therapy meetings. The mean initial treatment period lasted 11.56 (SD = 5.27)
Discussion
Including parents in weight-loss interventions for children produced inconsistent findings in prior literature reviews and meta-analyses. Part of the inconsistency in the reported outcomes of these reviews may be attributable to methodological variations and limitations in the samples of studies used. The present meta-analysis was designed to carefully evaluate the effectiveness of family-behavioral treatments using a comprehensive population of studies and carefully defined treatment, methods,
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References marked with an asterisk indicate studies included in the meta-analysis.