Obesity During Pregnancy in Clinical Practice

12. Family-Centered Interventions to Reduce Maternal and Child Obesity

Dianne Stanton Ward^{1, 2} , Temitope O. Erinosho², Heather M. Wasser² and Paula M. Munoz²

(1)

Department of Nutrition, UNC School of Public Health, Chapel Hill, NC, USA

(2)

Department of Nutrition, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA

Dianne Stanton Ward

Email: dsward@email.unc.edu

Abstract

Obesity is associated with multiple health risks for pregnant and postpartum women and can affect their infants, preschoolers, school-aged children, and adolescents. Family-centered intervention strategies may be an important way to prevent or treat maternal and child obesity. This chapter reviews 19 family-centered interventions designed to address excess body weight among mothers and their children. An additional five interventions were classified as “promising.” Six of the studies focused on children age 5 and younger including one study targeting infants; half of these studies were prevention based. Thirteen studies addressed school-aged children; all involved overweight or obese children. Only half of these studies targeted and/or measure parent weight. Results suggest that addressing obesity prevention and treatment from a family perspective could be an effective strategy. Clinicians who care for women of childbearing age should stress the importance of family-centered approaches to develop healthy weight in infants, preschoolers, and children, and when necessary address weight management problems using parents as agents of change both for their children’s weight and for their own. Promising new studies offer new prevention strategies for maternal and child obesity prevention approaches.

Keywords

FamiliesObesity preventionObesity treatmentChildren

To keep the body in good health is a duty otherwise we shall not be able to keep our mind strong and clear. Buddha (c. 563 BC to 483 BC)

Key Points

Family-centered approaches are useful for preventing unnecessary weight gain in infants, preschoolers, and mothers

Parents are important “agents of change” for child weight loss

Targeting family weight loss (rather than child-only) is underutilized strategy

Multi-country evidence supports family-based approaches to weight management

Background

Maternal and child obesity are major public health problems in the United States (USA), including obesity during pregnancy per se, because national data indicate that about one of five pregnant women in the United States is currently obese [1]. In addition, about 56 % of women aged 20–39 years old (childbearing age) are overweight or obese, while even more (66 %) women aged 40–59 years old are overweight or obese [2]. Weight problems for US children (aged 2–19 years) also are alarming: approximately 30 % are overweight or obese [3], with higher rates observed in adolescents (34 %) and school-aged children (33 %) than among preschool-aged children (27 %) [3].

Obesity during pregnancy often results in increased use of health-care services, as well as higher risk for such adverse health conditions as gestational diabetes mellitus [1]. Overweight and obesity in childhood are associated with poor health conditions that include greater risks for developing high blood pressure, type 2 diabetes, breathing problems, fatty liver disease, and gallstones [4]. Further, overweight and obesity that develop in childhood are likely to track into adulthood [4–7], increasing the risk for such chronic diseases as type 2 diabetes, hypertension, heart disease, stroke, and several types of cancers in adult life [8].

The prenatal period is a critical stage for the development of childhood obesity [9]. Research shows that pre-pregnancy and early-pregnancy obesity are related to higher risk of obesity in children born to such mothers [9]. For instance, in a study of more than 30,000 pregnant women in the Norwegian Mother and Child Cohort Study, Stamnes and colleagues [10, 11] found that higher maternal pre-pregnancy weight gain was associated with higher birth weight in their offspring [10] and increased overweight and obesity at age 3 [11]. Other studies also show that maternal obesity in early pregnancy is associated with overweight and obesity in their offspring in early childhood [12–14] and adolescence [15].

In addition to linking childhood obesity to maternal pre- and early-pregnancy weight, studies indicate that parents, in particular mothers, influence children’s weight status through dietary and physical activity practices in the home environment [16, 17]. At home, mothers not only are important role models for children’s dietary behaviors; they often are the gatekeepers for foods in the home [18]. Several studies have shown that the types of foods available and accessible at home, child feeding practices (e.g., use of foods as reward or punishment), and dietary role modeling by parents, especially mothers, influence children’s dietary behaviors and, ultimately, children’s weight [16, 17, 19–28]. In addition, the physical activity of mothers, including their encouragement of children’s activity, and their monitoring of children’s television viewing and media use (e.g., computer, video game) influence children’s physical activity and, consequently, children’s weight [17, 27, 29–35]. It is no surprise, therefore, that studies show that children’s weight is highly correlated with their mothers’ weight [36–38]. Thus, the critical role that mothers play in children’s risk for obesity makes it imperative that interventions to promote healthy weight development in children include them.

Defining Family-Centered Interventions for Preventing and Reducing Childhood Obesity

Family-centered interventions (also known as family-based interventions) to reduce childhood obesity are programs that focus on changing weight-related behaviors of multiple family members, and not just those of the child [39]. Such interventions are based on the premises that childhood overweight and obesity develop and are maintained within the context of the family [40, 41]; that parents play a critical role in shaping children’s dietary intakes, physical activity behaviors, and body weight [17]; and that involving the family in childhood obesity interventions may provide effective strategies for promoting and sustaining healthy changes in children’s diets and physical activity [42].

Since obesity tends to run in families, involving the family in childhood obesity interventions provides an opportunity to simultaneously impact weight-related behaviors of the entire family [42, 43]. Unfortunately, most family-centered interventions focus on obesity treatment, particularly in school-aged children and adolescents [44, 45]; family-centered interventions that focus on the prevention of childhood obesity are limited [46]. Further, although family-centered interventions that focus on multiple members of a family may be an effective approach, most programs that focus on maternal weight do not include children or other members of the family. However, family-based interventions that focus on children’s weight do often include mothers (or fathers). Thus, this chapter will review the evidence base from family-centered interventions for the prevention and treatment of obesity in children and their potential for affecting maternal and/or parent weight as well.

Descriptions of Family-Centered Interventions

Family-Centered Interventions for Infants, Toddlers, and Preschoolers

Six studies were found that used a family-centered intervention approach with infants, toddlers, and/or preschoolers. Details of these interventions are described in Table 12.1.

Table 12.1

Summary of family-based obesity interventions targeting 0–5-year-olds

Author (year)	Designa	Country	Sample size	Age of target child	Focusb		Delivery channel	Intervention target		Intervention dose	Length of follow-up	Improved weight outcomec
					T	P		Parent only	Parent + child			Child		Parent
												PI	FU	PI	FU
Harvey-Berino (2003) [47]	RCT	United States	43	9–36 months		X	Home visits	X		11 home visits over 16 weeks	None
Klohe-Lehman (2007) [48]	Pre-post	United States	91	1–3 years	X		Group sessions in community	X		8 (2-h) weekly sessions with mother weigh-in, education, and 30-min of low-to-moderate exercise	4 months			X	X
Ostybe (2012) [46]	RCT	United States	400	2–6 months		X	Mailed interactive kits + telephone calls + group session	X		8 kits, each followed by 20–30-min telephone coaching plus 1 group session	8 months
Paul (2010) [49]	RCT	United States	160	0–7 days		X	Home visits	X		Up to 2 home visits	1 years		X
Stark (2011) [50]	RCT	United States	18	2–5 years	X		Group sessions in community + home visits			12 (1.5-h) weekly sessions followed by 6 (1.5-h) biweekly sessions, alternating between clinic and home based	6 months	X	X	X	X
Wen (2012) [51]	RCT	Australia	667	0–2 years		X	Home visits	X		8 visits over 2 years + telephone support between visits	None	X

^aRCT = randomized controlled trial; QE = quasi-experimental

^bT = treatment; P = prevention

^cPI = post-intervention; FU = follow-up

Family-centered interventions for promoting healthy weight gain in infants and toddlers often target the mother as the primary agent of change. In a home-based, family-centered study, Paul and colleagues [49] examined the independent and combined effects of two behavioral interventions delivered to mothers of newborns. The first intervention, “soothe/sleep,” was implemented 2–3 weeks after birth and was designed to increase sleep duration in early infancy by teaching mothers to use alternate soothing and calming strategies instead of feeding as a first response to fussiness. The second intervention, “introduction to solids,” was delivered in two parts: the first part taught mothers, at 2–3 weeks after birth, about hunger and satiety cues as well as appropriate timing for introducing solid foods, and the second part, delivered between 4 and 6 months after birth, when mothers reported that their infants were starting to consume solid foods, taught mothers how to use repeated exposure to new foods to overcome infant rejection of healthy foods. One hundred and sixty mother-newborn dyads were recruited from an academic medical center in Hershey, Pennsylvania, and randomized into one of four study arms, using a 2 × 2 design to receive one, both types, or no intervention. Findings from the 110 participants who completed the intervention showed that at age 1, children whose mothers received both interventions had significantly lower mean weight-for-length percentiles than children whose mothers received only the soothe/sleep intervention, or only the introduction to solids intervention, or were in the control group. Parental weight change was not targeted or reported.

In a study conducted in Australia, Wen and colleagues [51, 52] evaluated the effectiveness of a 24-month, home-based early intervention on children’s BMI measured at age 2. Called the “The Healthy Beginnings Trial,” it applied theoretical constructs from the Health Belief Model to 667 first-time mothers and their infants in socially and economically disadvantaged areas of Sydney, Australia. Mother-child dyads were randomly allocated to either receive the intervention or to be in a control condition which included usual practice for new mothers supplemented with safety promotion materials. The intervention focused on educational materials promoting breastfeeding, appropriate time to introduce solid foods, tummy time, active play, and proper nutrition and physical activity for the entire family. Participants received eight home visits from specially trained community nurses, timed to coincide with early childhood development milestones. The first visit was during the antenatal period, and seven additional visits were at 1, 3, 5, 9, 12, 18, and 24 months after birth. Child BMI was measured at 24 months and found to be significantly lower in the intervention group than the control group. Mother’s weight was not addressed.

In a 16-week, home-based, family-centered intervention, Harvey-Berino and colleagues [47] compared maternal participation in a parenting support intervention with participation in a parenting support plus obesity preventionintervention to see whether the latter, combined intervention would reduce the prevalence of obesity in high-risk Native American children in the St. Regis Mohawk community in northern New York State and Ontario and Quebec, Canada. Participants were 40 overweight and obese Native American mothers and their children (mean age: 21 months old). Study findings noted that changes in children’s weight-for-height z scores showed trends toward statistical significance: children in the parenting support plus obesity prevention group had decreased weight-for-height z scores, while children in the parenting support-only group had increased weight-for-height z scores. In addition, children’s energy intake declined in the combined group and increased in the parent support-only group, and these changes also approached significance. Mother’s weight and BMI decreased more in the combined group than the parenting support-only group, but these changes failed to reach statistical significance.

In an 8-week family-centered intervention conducted in Texas, Klohe-Lehman and colleagues [48] examined the effects of a maternal weight loss program on mothers’ BMI, diet, and physical activity as well as the BMI and dietary intake of their 1–3-year-old children. Ninety-one low-income overweight and obese Hispanic, African-American, and White mother-child pairs were recruited from the Special Supplemental Program for Women Infants and Children (WIC) and public health clinics. The intervention was grounded in basic concepts of the social cognitive theory and addressed diet and physical activity. Diet activities included discussion about dietary plans, interactive low-fat cooking demonstrations, recipe modification, and portion size training, while the physical activity component included in-class activities (30 min of walking, stair climbing, and resistance exercises with light weights) and behavioral modification (e.g., self-monitoring, stimulus control, goal setting, and relapse prevention). At the end of the 8-week intervention, children’s BMI (or weight-for-length in children under 2 years of age) did not decrease, but the excess energy intake observed in the children at baseline was reduced at the end of the intervention. Mothers in the study lost an average of 2.7 kg in body weight, and their mean BMI reduced significantly from 34.9 to 33.9 kg/m². The changes in mothers’ weight and BMI were sustained at the 24-week follow-up. It should be noted that this was one of the few interventions that attempted to increase mother’s physical activity.

Only two studies were found that used a family-centered approach for either obesity prevention [46] or treatment [50] in preschool-aged children. Obesity prevention was the focus of the Kids and Adults Now – Defeat Obesity (KAN-DO), a family-centered intervention designed to change child BMI [46]. KAN-DO was a 12-month, randomized controlled trial designed to promote healthy lifestyle behaviors in mother-preschooler (2–5 years old) dyads in North Carolina by changing targeting parenting styles and skills, stress management, and healthy eating and activity behaviors. The KAN-DO intervention was based on models of self-regulation and constructs from social cognitive theory. Participants in KAN-DO were 400 postpartum mothers who were overweight or obese prior to pregnancy and their preschool-aged children (no weight-specific inclusion criteria). While KAN-DO did not lead to significant improvement in children’s or mother’s weight status, an exploratory (completers) analysis showed significant reductions in BMI among mothers who completed at least half of the 16 possible intervention contacts.

Significant improvements in both child and parent weight outcomes were observed in the LAUNCH intervention (Learning about Activity and Understanding Nutrition for Child Health) [50]. LAUNCH was a 6-month, home-based, family-centered intervention conducted at the Cincinnati Children’s Hospital Medical Center and was designed to reduce obesity in preschool children (aged 2–5 years) who were at or above the 95th BMI percentile [50]. LAUNCH also was grounded in the social cognitive theory and taught parents to use such child behavior management strategies as praise and attention, ignoring and time-out, modeling, and stimulus control to increase appropriate eating behaviors in their children and themselves. Children received nutrition education through games and art activities, participated in food taste tests, and completed 15 min of moderate to vigorous physical activity during group sessions. Eighteen preschool-aged children with an average BMI percentile of 98 and an overweight parent were randomized to receive either the LAUNCH intervention or an enhanced standard of care through pediatric counseling. Participation in LAUNCH resulted in significant decreases in weight in both children and parents. At 6-month post-intervention, LAUNCH children had a significantly greater decrease in BMI z, BMI percentile, and weight gain compared to children who received pediatric counseling, and these changes were maintained at the 12-month follow-up. In addition, parents in LAUNCH had a significantly greater weight loss at 6-month post-intervention and at the 12-month follow-up than parents who received pediatric counseling.

Family-Centered Interventions for School-Aged Children and Adolescents

Most of the family-centered studies that include school-aged children or adolescents are treatment rather than prevention studies. Family-based approaches to weight control were first developed more than 35 years ago when it was demonstrated that a more structured “lifestyle modification” approach that included family members was more effective for children’s weight loss rather than standard weight reduction approaches [53]. For this chapter, 13 studies are reviewed, eight representing shorter-term studies. Most of the existing family-centered obesity treatment interventions for children and adolescents are based on the landmark work of Epstein [39, 54, 55] and Golan [45]. Family-centered studies that produced shorter-term impacts on school-aged children or adolescents are described below and reported in Table 12.2. Following this section is a description of five studies from the United States and abroad that report longer-term results from family-centered studies for school-aged children and/or adolescents.

Table 12.2

Summary of family-based obesity interventions targeting 5+-year-olds

Author (year)	Designa	Country	Sample size	Age of target child (years)	Focusb		Delivery channel	Intervention target		Intervention dose	Length of follow-up	Improved weight outcomec
					T	P		Parent only	Parent + child			Child		Parent
												PI	FU	PI	FU
Boutelle (2011) [56]	RCT	United States	80	8–12	X		Group sessions in community	Xd	X	20 (60-min) weekly sessions conducted separately for parents and/or children	6 months	X	X	X	X
Collins (2012) [57]	RCT	Australia	165	5.5–9.9	X		Group sessions in community + telephone calls		X	10 (2-h) weekly sessions + 3 monthly calls	18 months	X	X
Coppins (2011) [58]	RCT	United Kingdom	65	6–14	X		Groups sessions in community		X	2 (8-h) weekly workshops for parents and children conducted separately + 36 biweekly p.a. sessions for children	None
Edwards (2006) [59]	Pre-post	United Kingdom	33	8–13	X		Group sessions in community		X	8 (1.5-h) weekly sessions + 4 (1.5-h) biweekly sessions conducted separately for parents and children	3 months	X	X
Epstein (1990) [60]	RCT	United States	28	6–12	X		Clinic-based individualized treatment meetings		X	8 weekly treatment meetings followed by monthly meetings for 6 months	10 years	X	X	X	X
Golan (2006) [61]	Pre-post	Israel	70	4–18	X		Group sessions in community	X		Either a 5-day (40-h) workshop or 12 (3-h) sessions	None	X		X
Gronbaek (2009) [62]		Denmark	100	10–12	X		Group sessions in community + home visit		X	Children’s exercise class (1.5-h) twice weekly; ~35 (1-h) child-, parent-, or family-based sessions; 1 (1-h) home visit; 1 (1-h) grocery store tour	1 year	X	X
Janicke (2008) [63]	RCT	United States	93	8–14	X		Group sessions in community	X	X	8 (90-min) weekly sessions + 8 (90-min) biweekly sessions conducted for parents only or separately for parents and children	10 months	Xe(PO)	Xe(B)
Kalarchian (2009) [64]	RCT	United States	192	8–12	X		Group sessions in community		X	20 (1-h) sessions beginning with family weigh-ins and goal setting followed by separate sessions for parents and children + 6 booster sessions (3 groups and 3 phone calls during FUf)	6 and 12 monthsf	X	Xf	X	Xf
Margarey (2011) [65]	RCT	Australia	169	5–9.9	X		Group sessions in community	X		8–12 (1.5- to 2-h) sessions plus 4 telephone sessions over 6 months	1.5 y	X	X
Robertson (2008) [66] (2011) [67]	Pre-post	United Kingdom	27	7–13	X		Group sessions in community		X	12 weekly (2.5-h) sessions conducted separately for parents and children	2 y	X	X
Shelton (2007) [68]	RCT	Australia	43	3–10	X		Group sessions in community	X		4 (2-h) weekly sessions	None	X
Williamson (2006) [44]	RCT		57	11–15	X		Face-to-face counseling sessions + secure website	X		4 face-to-face sessions + weekly email counseling for 2 years	Noneg	Xg		Xg

^aRCT = randomized controlled trial; QE = quasi-experimental

^bT = treatment; P = prevention

^cPI = post-intervention; FU = follow-up

^dTested whether parent-only intervention (PO) as effective as parent + child (PC); testing based on noninferiority of PO group versus PC group

^eTwo intervention groups: parent-only (PO), family-based (FB), waitlist control; both groups decreased BMI z score at FU versus control but no differences between PO and FB

^fIntervention families received reduced contact between 6 and 12 months and no contact between 12 and 18 months; significant differences between groups only at 12-month FU for children and parents; no significant differences between groups at 18 months

^gThere was no true FU as participants had access to website for full 2 years; however, weight differences between groups were only significant after the 6-month period in which participants also received counseling sessions; there were not significant differences between groups at 2 years

Shelton and colleagues [68] assessed the impact of a 3-month, parent-based (n = 43 families) behavioral intervention on BMI of overweight and obese children in Australia. Although some younger children were included in this study (ages ranged from 3 to 10 years), the average child’s age was between 7 and 8 years. In four brief sessions, the intervention promoted healthy family lifestyle changes by addressing nutrition, physical activity, motivation, and behavior management strategies. At the end of the 3 months, children in the intervention group experienced a significant decrease in BMI, but the intervention had no significant effect on parental BMI.

In a randomized controlled trial on child weight loss, Boutelle and colleagues [56] evaluated whether a 5-month standardized, behavioral, parent-only treatment program was inferior to a standardized parent-plus-child program. Eighty parents and their overweight or obese children (aged 8–12 years) were recruited in Minnesota and San Diego and randomly assigned to either a parent-plus-child or a parent-only group. This intervention adapted Epstein’s Traffic Light Diet protocol [69] and included strategies for increasing physical activity, behavioral change skills, (viz., self-monitoring of targeted behaviors, positive reinforcement, stimulus control, preplanning, and modeling), and parenting skills specific for use with children who are overweight. Information presented to children in the parent-plus-child group was similar to that taught to the parents, but was presented in an age-appropriate manner. Weight outcomes of children and parents assessed at baseline, 5-month post-intervention, and at an 11-month follow-up showed that the parent-only group was not inferior to the parent-plus-child group in either child weight loss or parent weight loss. Further exploratory analyses [70] also showed that across both study groups, parent BMI was the only significant predictor of child weight, with a 1 BMI unit reduction in parent weight associated with a 0.255 reduction in child BMI.

In another study using the Epstein Traffic Light Diet protocol, Kalarchian and colleagues [64] evaluated the efficacy of a 6-month, clinic-based, family-centered, behavioral intervention on reducing the weight of 192 severely obese children aged 8–12 years. Families were randomized into either an intervention group that received the family-based intervention, or a control group that received a standard care approach that consisted of two consultation sessions to help them develop individual nutrition plans based on the Traffic Light Diet. Adult and child groups met separately, and each group was presented with similar materials. Overweight adults were encouraged, but not required, to lose weight. At 6 months, the intervention was associated with greater decreases in child percent overweight than the decreases for the children in the control group. Intent-to-treat analyses showed that the intervention was associated with a significant 7.58 % decrease in child percent overweight at 6 months, compared to a 0.66 % decrease for the control group, but differences between the two groups were not significant at 12 or 18 months. In addition, children who attended at least 75 % of the intervention sessions maintained decreases in percent overweight through 18 months, while those who attended less than 75 % of the intervention sessions did not. Parent BMI was reduced significantly in the treatment groups at both the 6- and 12-month measurement periods.

In a family-centered intervention, Janicke and colleagues [63, 71] assessed the effects on the weight of underserved children of Project STORY (Sensible Treatment of Obesity in Rural Youth), a 4-month, family-based, behavioral intervention, and a parent-only behavioral intervention delivered through rural cooperative extension service offices. Participants were 93 overweight or obese children (aged 8–14 years) and their parents recruited from four underserved rural counties in North Central Florida. Participants were randomly assigned to one of three groups: a family-based group in which both children and parents were targeted as active agents of change, a parent-only group that targeted parents as the agents of change, and a waitlist control group that received the intervention following the final follow-up assessments. In general, Project STORY focused on five things: building healthier dietary habits via a modified version of Epstein and colleagues’ Traffic Light Diet, increasing moderate intensity physical activity via a pedometer step program, setting goals for reducing sedentary activities, establishing a healthier weight status, and building positive self-worth in participants. Behavioral strategies used in delivering the Project STORY included self-monitoring, goal setting, stimulus control, positive reinforcement, modeling, role playing, and portion size control. At the 4-month assessment, children in the parent-only intervention group showed a greater decrease in BMI z score than children in the waitlist control group. No significant differences, however, were found in BMI z scores between the family-based intervention group and the waitlist control group. At the 10-month follow-up, children in the parent-only and family-based intervention groups showed greater decreases in BMI z score from before treatment (baseline) than the waitlist control group. The intervention did not have any significant effect on parental BMI change score at either month 4 or 10.

In a 2-year randomized controlled trial, Coppins and colleagues [58] evaluated whether a family-based intervention, “The Family Project,” was more effective in reducing BMI z score in overweight children aged 6–14 years than just monitoring body composition alone. The intervention focused on healthy eating, physical activity, reducing sedentary behavior, behavior change, and psychological well-being. Sixty-five overweight and obese children were randomly assigned to receive the family-based intervention in either the first or second year and to be in the control group that received body composition monitoring alone during the year when they are not in the family-based intervention group. Siblings and parents or guardians were also encouraged to participate. After year 1, the intervention and control group crossed over, with the control group receiving the family-based intervention program and the intervention group receiving body composition monitoring alone for year 2 of the project. Children who received the intervention in year 1 reduced their BMI z score significantly in the first 12 months, and that score continued to be reduced over the next 12 months, so that by the end of the 2-year study, their BMI z score was 0.44 lower than at the beginning of the study. Children assigned to the body composition monitoring-alone group in year 1 also reduced their BMI z score in the first 12 months, although not significantly, and when they were put in the active family intervention, their BMI z score continued to fall, but only marginally. At the end of the 2-year study, fewer children in the group that received the active family intervention in year 1 were classified as grossly overweight than children who received only body composition monitoring in year 1. At baseline, about 60 % of all the children in the study were above the 99.6th BMI percentile. By the end of the 24 months, only 19 % of children in the active family intervention group in year 1 were still above the 99.6th BMI percentile, compared with 48 % of children in the group that received only body composition monitoring in year 1. Parent weight was not targeted.

In a one group, pre-post design study conducted in the United Kingdom, Edwards and colleagues [59] assessed the impact of a clinic-based, family behavioral treatment on the weight of obese children aged 8–13 years. Thirty-three families received the 4-month intervention that included two components: advice on whole-family lifestyle change to modify the microenvironment of the home and a behavioral weight control program for the overweight children. The behavioral weight control program was based on learning theory and used such behavior modification techniques as self-monitoring, goal setting, positive reinforcement, and stimulus control to modify the children’s eating and exercise behaviors. At the end of the 4-month intervention, children lost 8.4 % BMI and maintained that reduction at 3-month follow-up. Although the focus was “whole-family” lifestyle change, parental weight was not targeted.

In a study conducted in Copenhagen, Gronbaek and colleagues [62] evaluated the impact of an 18-month community and family-based childhood obesity treatment intervention on weight outcomes of 100 obese school-aged children and their families. The intervention consisted of a 6-month intensive phase and a less intensive 1-year follow-up. The intensive phase of the intervention consisted of physical exercises to reduce sedentary practices and nutrition sessions focused on healthy food choices and portion size regulation. The less intensive follow-up phase consisted of group meetings with all families. The meetings focused on families’ development of healthy lifestyles and well-being, along with healthy weight development in their children. The 81 (of 100) children who completed the full program significantly decreased their BMI z score from 2.9 to 2.6 during the intensive phase of the intervention, and their BMI z score further decreased from 2.6 to 2.4 during the less intensive follow-up phase. Children who completed the full program also showed a significant decrease in percent body fat from 32.2 to 30.1 during the intensive phase, and this decreased further to 29.5 during the less intensive follow-up phase, although that decrease was nonsignificant. In addition to a 20 % loss to follow-up, this study had no comparison group and parent weight was not monitored.

In a study involving preschool and school-aged children in Australia, Magarey and colleagues [65] assessed the effectiveness of Parenting Eating and Activity for Child Health (PEACH), a 6-month hospital-based intervention for overweight children aged 5–9 years. PEACH targeted parents as the agents of change. One hundred and sixty-nine families were randomized into one of two groups: parenting skills plus healthy lifestyle group or a healthy lifestyle-only group. The parenting skills plus healthy lifestyle sessions encouraged parents to anticipate and manage high-risk situations to achieve a positive energy balance using a problem solving approach, while the healthy lifestyle-only sessions focused only on information that was consistent with traditional nutrition education and clinical advice. Overall, between the baseline and 6-month post-intervention, children’s BMI z score decreased by 10 % in both study groups, and this decrease was maintained at the 24-month follow-up assessment. Similar to several studies above, parental weight was not monitored.

Long-Term Effects of Family-Centered Interventions

Researchers in the United States, Australia, United Kingdom, and Israel have demonstrated the long-term effects (up to 2 years) of family-centered obesity interventions on children’s and parents’ weight. Although some of those reported below are smaller studies, they include long-term follow-up data. Their interesting approaches and promising findings merited inclusion in the chapter.

As noted earlier, much of this research has been guided by the seminal work of Epstein and colleagues [39, 54, 55, 72] who pioneered the family-based treatment model for pediatric obesity. In a follow-up study of 10 years, Epstein et al. [60] evaluated the effect of a family-based behavioral treatment on percent overweight and growth in obese 6- to 12-year-olds, with repeated measurements at the 5- and 10-year periods. The study followed 76 obese children and their parents who were randomized into one of three groups: child and parent target group (group 1), child target group (group 2), or nonspecific target control group (group 3). All families received eight weekly treatment meetings and six additional meetings over a 6-month period. The families were then seen at 21-, 60-, and 120-month follow-up meetings. The three study groups were provided similar information about diet, exercise, and behavioral principles (this included the use of contracting, such as having parents deposit $65 at the beginning of the program and returning $5 at each session, contingent on either parent or child weight loss in groups 1 and 2 or attendance in group 3 along with goal setting, self-monitoring, and social reinforcement and modeling). Children in the child and parent target group (group 1) showed significantly greater decreases in percent overweight after 5 and 10 years, respectively, compared to children in the nonspecific target control group that increased in percent overweight. In contrast, children in the child target group (group 2) showed increases in percent overweight after 5 and 10 years that were midway between those for the child and parent target group and the nonspecific target group, but not significantly different from either. Parent weight decreased in all three groups, with effects lasting until the 21-month follow-up period. However, by the 5-year point, parents had returned to their baseline percent of overweight.

The stability of this approach with children was further demonstrated in a recent paper by Epstein and colleagues [73]. Results from contemporary studies using the Epstein model were compared to those conducted 25 years earlier that had similar results (observed over the 2-year follow-up period) [73]. In the more recent studies, the children and adolescents were, as a rule, heavier than in years past, making the task of obesity reduction even more challenging.

In a pilot study, Robertson and colleagues [66, 67] tested “Families for Health,” a 12-week, community-based family intervention for treating obesity in children 7–13 years old in Coventry, England. Twenty-one families (27 children) received the Families for Health intervention that focused on parenting, relationship skills, emotional and social development, and healthy eating strategies in the home environment. Weight outcomes were measured at the end of the 3-month program and at a 9-month follow-up. For the 22 children on whom there is follow-up data, BMI z scores were reduced significantly between baseline and the end of the 3-month intervention, and this reduction was maintained at the 9-month follow-up. In a 2-year follow-up of 19 of the children (13 families), Robertson and colleagues (71 found that the BMI z score observed at 9 months was sustained at 2 years. Although these are promising results, lack of a control group and loss to follow-up prevent further interpretation. Also, parent weight change was neither targeted nor measured.

Most of the family-centered obesity interventions have employed face-to-face counseling. However, compliance (e.g., attendance at group sessions, coming to a university-based program) appears to be difficult for certain populations. Williamson and colleagues [44] evaluated the efficacy of an Internet-based, lifestyle behavior modification program for adolescent African-American girls in a randomized controlled trial and reported their results at the 2-year point. Fifty-seven overweight African-American girls aged 11–15 years and an overweight or obese parent were randomized to receive either an interactive behavioral Internet program or a standard Internet health education program (control condition). The interactive behavioral Internet program included a website that provided family-oriented nutrition education and behavior modification for parents and adolescents using counseling through email communications, weight and activity graphs for weekly self-monitoring of weight and physical activity, and self-monitoring of food intake with feedback modeled after the Traffic Light Diet. For both the intervention and control groups, the parent-child pairs were required to attend four face-to-face counseling sessions during the first 12 weeks of the program (weeks 1, 3, 6, and 12) to encourage adherence to behavioral principles, provide additional training in using their computers to participate in the Internet-based program, and solve any computer problems. Data were collected in the clinic and over the Internet at baseline and at months 6, 12, 18, and 24. Findings at 6 months showed that adolescents in the interactive behavioral program lost significantly more mean body fat and parents in that program also lost significantly more mean body weight. These weight losses, however, were reversed over the next 18 months. After 2 years, the differences in body fat for adolescents and weight for parents did not differ between the behavioral and the control groups.

While Williamson and colleagues did not observe any long-term reductions in weight outcomes of children and parents in their study, other studies show that family-based interventions can be effective in reducing the weight of children and parents in the long term. In a recent study, Collins and colleagues [57] evaluated the 24-month efficacy of a 6-month family-centered intervention, the Hunter Illawarra Kids Challenge Using Parent Support (HIKCUPS) study. Participants were 165 overweight prepubertal school-aged children in Australia who were randomized to receive one of three programs: a child-centered physical activity program (the Activity arm), a parent-centered dietary modification program (the Diet arm), or a combination of both programs (the Diet plus Activity arm). The child-centered Activity program was based on the competence motivation theory and aimed to improve children’s fundamental movement-skill proficiency. The parent-centered Diet program was based on the Health Belief Model and incorporated goal setting, problem solving, role modeling, and positive reinforcement by parents to facilitate changes in eating behaviors. The Diet plus Activity arm was a combination of the diet and activity arms, with parents and children participating concurrently. Findings showed, between baseline and 24 months, that mean BMI z scores decreased significantly among children in all three intervention arms, with the highest decrease observed among children in the Diet arm, followed by the Activity arm, and then the Diet plus Activity arm. Parent weight loss was not discussed.

Another researcher who has contributed greatly to the field of family-based weight loss is Dr. Maria Golan. In a longer-term study conducted in Israel, Golan and colleagues [45] examined the effect of a 12-month family-based treatment intervention in which parents were the exclusive agents of change on weight outcomes of obese children. In this study, participants were 60 obese children aged 6–11 years from public schools in the middle-class town of Rehovot who were randomized into either an intervention or control group. In the intervention group, only parents (not children) participated in group sessions; children were not directly involved in the process of change and had no responsibility concerning the process. At group sessions, parents were taught to change the family’s sedentary lifestyle, provide a prudent diet (reducing total and saturated fat and increasing monounsaturated fatty acids), decrease the family’s exposure to food stimuli, apply behavioral modification strategies with the children, and practice relevant parenting skills (firm but supportive parenting practices). In the control group (child only), only the children participated in group sessions. Each child was prescribed a 6.3 MJ/day diet and attended group sessions lead by a clinical dietitian who provided information on how to follow a prudent diet, restrict energy intake, increase exercise, control food stimuli, use techniques for self-monitoring, practice problem solving and cognitive restructuring, and make use of social support (e.g., asking parents and friends for help). At the end of the 12-month intervention period, children in both groups showed a significant decrease in their degree of overweight, although the change was significantly greater in the parent-only intervention group than in the child-only control group. In addition, at 12-month post-intervention, 35 % of children who were in the parent-only group had attained a non-obese status, compared with 14 % in the child-only group. Change in the percentage of mothers classified as overweight did not differ significantly between the intervention (parent-only) group and control (child-only) group at 12-month post-intervention. However, among fathers there was a significant reduction in the percent of overweight among fathers in the parent-only intervention group, but not in the child-only control group. At a 1-year follow-up, the child-only control group had regained 7 % of their 8 % reduction in overweight, while children in the parent-only intervention group regained only 2 % of their 15 % reduction in overweight. At a 2-year follow-up, there was a mean reduction in overweight of 15 % in children in the parent-only intervention group and an increase of 3 % in children in the child-only control group.

Measurement of 50 of the original 60 children at a 7-year follow-up showed that mean reduction in percent overweight was significantly greater in the parent-only intervention group than in the child-only control group [60]. At the 7-year follow-up, 60 % of children in the parent-only group were classified as non-obese, compared with only 31 % of children in the child-only group [61, 74].

Promising Studies Underway

The importance of family-based approaches for preventing maternal and child weight obesity can also be measured by the numbers of obesity prevention efforts in the research pipeline. Developing initiatives for family-based approaches that can be implemented outside the clinic will allow easier access to difficult-to-reach populations. Seven promising studies designed for obesity prevention or treatments are currently underway: four in Australia, one in Sweden, and two in the United States (see Table 12.3).

Table 12.3

Summary of ongoing studies focusing on family-based obesity interventions

Author	Year	Country	Design	Age of target child	Delivery channel	Intervention groups	Intervention dose
Campbell [75]	2008	Australia	RCT	3–18 months	Group sessions in community + follow-up texting and mailings	2 groups: Parents with dieticians, control group	6 sessions conducted every 3 months for 15 months conducted for parents
Daniels [76]	2009	Australia	RCT	4–7 and 13–16 months	Group sessions in community	1 group: Parents with dietician and psychologist	Fortnightly sessions divided into 2 modules at 4–7 and 13–16 months
Horodynski [77]	2011	United States	RCT	Infants younger than 4 months	Home visits + telephone contact	2 groups: Mothers with instructors, control group families with usual care by ENFEP	6 (60-min) visits reinforced with 3 telephone calls (5 min)
Horodynski [78]	2011	United States	RCT	12–36 months	Home visits + telephone contact	2 groups: Mother-toddler dyad with instructor, control group families	8 (60-min) visits reinforced with telephone contact
Skouteris [79]	2010	Australia	RCT	2–4 years	Group sessions in community	2 groups: Parent-child dyad with MEND leader, control group with delayed intervention	10 weekly sessions (90 min) for parent-child dyad combining joint active play and a 45-min parent-only education session
Sobko [80]	2011	Sweden	RCT	1–6 years	Home visits	1 group: Parents and trained coach	4 (90-min) sessions first year and 2 (60-min) sessions following years
Sacher [81]	2010	Australia	RCT	8–12 years	Group session in community	2 groups: Parent-child dyad with MEND leader, waitlist control group	18 sessions delivered over 9 weeks for child, parents, and siblings; intro and closing plus 16 PA, 8 behavioral change, and 8 nutrition lessons, with post-9-week free family swim pass

Two studies based in Australian are targeting first-time parents. The InFANT study [75] and the NOURISH trial [76] are recruiting first-time parents and their 3–4-month-old children into an intervention that uses anticipatory guidance principles to teach parents proper feeding practices. The InFANT study is also educating parents about activity-promoting (and sedentary reduction) behaviors needed by their children during this early developmental period. Six dietitian-led programs will be held every 3 months, with measures of growth, food intake, and parenting behavior assessment to be made post-intervention and at 9-and 18-month follow-up periods. Although parent weight is not targeted per se, the intervention will focus on the parent’s own obesity-preventing behaviors (healthy eating and regular physical activity) which may result in positive changes in parents’ weight.

The NOURISH trial is recruiting infants born to first-time mothers at major maternity hospitals in Brisbane and Adelaide [76]. Mother-infant dyads will be randomized into usual care or the NOURISH intervention. The intervention will provide anticipatory guidance during two modules (modules implemented at ages 4–7 and 13–16 months) presented through six sessions over a 12-week period. The intervention content will emphasize healthy eating and feeding relationships for health growth – not specifically obesity prevention. Both modules promote authoritative parenting practices and feeding styles; however, physical activity (other than discouraging television viewing while feeding) is not included in the intervention material.The NOURISH trial will neither address parent weight or parental eating and activity behaviors.

In Sweden, a study is enrolling infants of obese parents (two overweight or one obese parent) at 1 year of age and following these children through age 6 [80]. The program is called STOPP, Stockholm Obesity Prevention Program, and consists of an educational component (booklets) for corresponding age groups (1–6 years) and home-based coaching delivered by a health professional four times in year 1 and twice in each of the following years [80]. This multidisciplinary approach uses strategies informed by many disciplines to address eating, activity, and sleep by focusing on parenting skills and styles that create positive habits in the children. Again, parental weight is not a focus, but this program, similar to the other infant interventions, could easily focus on family weight management strategies.

The two US studies focus on parental feeding practices (but do not measure body weight). Important factors in obesity prevention [77, 78]. One of the studies addresses low-income, first-time mothers of infants less than 4 months of age [77], while the second study focuses on infants/toddlers between 12 and 36 months old [78]. Both these studies use the NEAT program, Nutrition Education Aimed at Toddlers. The purpose of NEAT is to assist the mothers in helping their children develop self-regulated feeding, a skill thought to be important in obesity prevention efforts. To date, no significant findings have been observed in parental feeding practices, but these low-income, rural women have improved their knowledge of appropriate feeding practices and, in general, have been receptive to the approach, offering promise for future development of the NEAT intervention. No efforts were directed toward maternal weight management, but role modeling healthy eating behaviors could be integrated into the child-based approach.

Two other promising studies are occurring in Australia, both using the MEND program (Mind, Exercise, Nutrition, Do it), a multi-community-based, healthy lifestyle program to address obesity among preschool children (MEND 2–4) [79] and children ages 8–12 years (MEND) [81]. The MEND 2–4 program is conducted for 10 weeks in community settings by MEND-trained professionals. It is offered free of change, with referrals coming from health-care providers and includes children who have poor eating habits, inactive lifestyles, obese parents, and/or a family history of related diseases (such as diabetes or high blood pressure). The MEND 2–4 study is continuing, but in the MEND program conducted with older obese children (ages 8–12 years, BMI ≥ 98th percentile), Sacher and colleagues report favorable preliminary findings, including excellent attendance by families (86%) and encouraging initial results (reduced waist circumference and BMI z-scores in the children) [81]. The MEND programs show strong promise as family-focused programs that can be implemented within community settings by professionals trained to present them. Although parental weight is not currently a focus of MEND, minor modifications could be made to expand its focus from targeting only children for behavior and weight outcomes to become a more family-focused behavioral program with weight management efforts provided for both parents and children.

Summary and Future Directions

It is clear from the studies described in this chapter that family-centered approaches are promising strategies for addressing obesity issues that might arise within families. Studies targeting newborns show positive trends for helping very young children begin life on a proper trajectory for healthy growth by teaching parenting practices (e.g., helping mothers understand how to sooth, rather than feed, babies back to sleep; importance of tummy time; use of developmentally appropriate feeding practices) [47, 49, 51, 52]. When a focus on maternal weight was added, these cognitive-behavioral strategies for child weight management resulted in weight loss for some or most of the mothers enrolled [46, 48] and, in one small study, significant short- and long-term weight loss in overweight preschoolers [50]. When weight problems are identified in school-aged children or adolescents, family-based solutions prove to be superior to child-focused strategies. Rarely are weight problems isolated to a single child within a family and risk of obesity is increased when one or more caregivers are overweight or obese. Thus, treating obesity as a family issue rather a problem of the child offers the potential for successful long-term solutions.

The majority of family-centered interventions were focused on reducing obesity in school-aged children and adolescents. Many of these family-based treatment programs were modeled after the pioneering work of Epstein [39, 54, 55] and/or Golan [40, 45]. A family-based healthy lifestyle approach characterizes Epstein’s work, while that of Golan includes parent education [53]. Golan’s landmark work focuses on “parent as agent of change,” an approach that suggests it is parents who need to learn parenting strategies in order for children’s weight to be effectively managed. Parent-based weight outcomes are included in the work of both Epstein and Golan, and data from multiple studies have noted improved weight outcomes in both child and parent.

Family-based weight management programs have been increasingly available since the mid-1970s, but the focus continues to be primarily on child outcomes, with parental weight outcomes secondary. Gan and Clark [82] in 1976 were among the first to point out that excess weight runs in families, influenced both by genetics and environment, suggesting that “…identification, therapy, and control of obesity be accomplished on a family-line basis.”

Family-centered interventions have been conducted in multiple setting, including the home [47, 49, 50, 52], the clinic or hospital [59, 65], the community [62, 66], and the Internet [44]. Although family systems theories may drive these interventions, few describe the theoretical framework on which their family-centered interventions are based [48, 51, 57, 59]. Six of the interventions reviewed adapted Epstein’s Traffic Light Diet [69] and these produced positive results in terms of preventing or reducing child weight outcomes [44, 56, 60, 63, 71].

While the family-based studies in this review include both the parent and child in the prevention or treatment programs, not all of the studies actually targeted and/or measured weight-related outcomes in the parent. More than half of the interventions targeting children five and younger [46–48, 50] and six of 13 in the school-aged studies [44, 56, 60, 61, 63, 64] provided a specific focus on parental weight outcomes. Only a few of those interventions that measured weight outcomes in parents actually found that the interventions had significant effects on parents’ weight status, but the long-term studies by Epstein seem to underscore the importance of a family-based weight management approach [73]. Wrotniak and colleagues [83] analyzed the findings from three family-based studies in which one parent and one child (both overweight) were recruited for participation. At the 2-year follow-up, parent z-BMI change predicted child z-BMI change. Parents in the highest quartile of z-BMI change had children weight significantly greater z-BMI change than children with parents at other weight levels. Although named “family-centered interventions,” none of the studies measured weight outcomes in siblings of children enrolled in the studies.

Studies conducted in the United States [73], United Kingdom [67], Israel [74], and Australia [57] show that in the long term, family-centered interventions are effective in promoting and sustaining weight reduction in children. In addition, the study by Golan et al. [45] shows that involving the parent in childhood obesity interventions results in greater improvements in weight outcomes when compared to child-only interventions.

Clinicians who care for mothers with infants should encourage a family-centered approach for healthy weight development in the young child and positive weight-related behaviors for the entire family. Mothers of children of all ages should be taught that obesity prevention is a family issue and that families should adopt nutrition and physical activity practices that result in healthy weight development for children and appropriate weight management for adult caregivers. Future research should expand family-centered obesity prevention strategies for children of all ages as a strategy for positive weight management in mothers and other family members.

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