Family-Based Approach Effective for Treating Childhood Obesity

It takes a family to help children with obesity.

A randomized trial from Leonard H. Epstein, PhD, of the Department of Pediatrics, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, and colleagues found that involving the family in behavioral treatment is effective in improving weight outcomes in pediatric primary care settings.

The typical approach to obesity within families, he continued, "is for a parent with obesity to get treatment for their problem, and for them to take their child with obesity to the pediatrician for help. In this way, they may be getting different advice, at different times…[family-based treatment] FBT is designed to target both the child and their parent with obesity, so that both have behavior change goals, and parents are taught positive parenting methods to motivate their children to change, and they learn to model healthy behaviors."

Further, Epstein said, FBT is "much more cost effective than separate treatment for a parent or each parent, and each child."

Their study, published in JAMA, found that FBT improved weight outcomes significantly better than usual care, not only in participants ages 6 through 12 years with overweight or obesity, but also in their parents and even in siblings not directly treated, over time frames of 6 to 24 months and added that "this treatment may offer a novel approach for families with 2 or more children with excess body weight."

The report noted that FBT is "an evidence-based, cost-effective treatment associated with significant weight changes in both children and parents," but currently is available mostly in specialty clinics, not in the pediatric primary care settings where most children receive medical care.

Participants in the study were children ages 6 through 12 years with overweight or obesity (>85th percentile for body mass index [BMI]), a parent with overweight or obesity (BMI >25), and, when available, siblings ages 2 through 18 years with overweight or obesity.

The study was conducted from November 2017 to August 2021 across practice-based research networks in four cities: Buffalo, New York (nine practices, 109 parent-child dyads); Rochester, New York (six practices; 93 dyads); St. Louis (six practices; 134 dyads); and Columbus, Ohio (15 practices; 116 dyads).

Pediatricians referred 2,083 families, of whom 898 were screened and 452 were enrolled, then randomized to FBT or usual care. In addition, 106 siblings from 94 families were included in the analysis.

The mean age among children enrolled was 9.8 years and the mean percentage above median BMI at baseline was 59.4%. Demographically, 123 children (27.2%) were Black, 258 (57.1%) were White, and 40 (8.8%) were Hispanic.

Parents had a mean age of 41 and a mean BMI of 37.0; siblings had a mean age of 10 years and a mean percentage above median BMI of 49.6%. Median parent education was 14 years, and the median annual family income was about $70,000 to $75,000.

The study did not assess the participating clinics’ "usual care" for obesity, Epstein told BreakingMED. In general, he explained, pediatric primary care settings might simply provide ideas about a diet or an activity plan.

Epstein added that "treatment for obesity generally requires a very intensive healthy lifestyle program (26-plus sessions, including weekly sessions) which is not realistic for most pediatric practices."

As applied in this study, FBT included materials covering "the Traffic Light Eating and Activity Plans, parenting and behavioral techniques, and facilitation of support in family and peer environments," the authors wrote. "Families were seen in individual sessions that incorporated parent and child weigh-ins, review of eating and activity self-monitoring in habit books, review of weight change and problem solving and goal setting for the next meeting in relationship to behavior change, and review of treatment manuals and handouts."

FBT was implemented by coaches who in nearly all cases had master’s degrees in psychology, counseling, or social work, or were master’s degree–level registered dietitians. In addition, coaches underwent a 30-hour certification process.

Weekly meetings were planned during the first four months, as families learned the program; the schedule then shifted to biweekly for two months and then to monthly. The target was for families to attend 26 sessions over the 24-month intervention and follow-up period. However, the frequency of sessions could be increased or decreased based on family progress in meeting goals or on difficulties in attending meetings.

The primary outcome was change in percentage above median BMI for the child at 24 months. This was significantly better in the FBT group than the usual care group (P=0.002).

At six months, the between-group differences in change in percentage above median BMI between the FBT and usual care groups were −6.5% (−3.2% for FBT versus 3.3% for usual care; P<0.001) for children, −4.0% (−4.2% for FBT versus −0.2% for usual care; P<0.001) in parents, and −5.3% (−3.1% versus 2.2%; P=0.001) in siblings. Differences between the FBT and usual care groups were maintained at 12, 18, and 24 months.

FBT resulted in greater reductions in parent BMI than usual care (P<0.001).

Almost three times as many children receiving FBT met a clinically meaningful weight outcome, versus those receiving usual care (27.0% versus 9.3%; P<.001).

In an accompanying editorial, William J. Heerman, MD, MPH, of Vanderbilt University Medical Center, Nashville, and colleagues called the study and its findings "timely," given that earlier this year the American Academy of Pediatrics released a clinical practice guideline calling for renewed emphasis on intensive behavioral interventions for childhood obesity.

They remarked that while FBT "has been tested before in non–primary care settings and led to sustained improvements in both parent and child weight outcomes," this study "advances the field by embedding this previously tested obesity treatment intervention into pediatric primary care practices."

Heerman et al noted, however, that the average effect on child weight was lower in this study than in previous studies of FBT and that it did not meet a threshold of clinical relevance.

Further, the editorialists commented, the percentage above median BMI at 24 months returned to the baseline level for children in the FBT group, and the parent weight loss of 5% at six months returned almost to baseline by 24 months. "This raises the question of whether the intervention is merely delaying the inevitable long-term outcome for participating families," they wrote.

Despite the emergence over the last several years of additional treatment options for children with more severe obesity, such as pharmacological management with glucagon-like polypeptide-1 receptor agonists, and surgical weight loss options, the editorialists emphasized, "behavioral interventions serve as the cornerstone for obesity management for several reasons:

"First, medications and surgical weight loss may not be affordable and/or accessible and they may not meet a family’s preference in young children. Second, the use of weight loss medications and the choice to proceed with surgery require the adjunctive and concurrent treatment with behavioral interventions. As such…there is a continued need to advance the field of behavioral obesity management."

Heerman and colleagues concluded that embedding FBT into primary care clinics "is of paramount importance as a means of improving the reach of behavioral obesity interventions, especially as weight management services in tertiary care hospitals are overwhelmed."

Responding to the editorial, Epstein acknowledged to BreakingMED, "The effects were less than we usually observe when we implement the treatment in specialty clinics with highly trained personnel. This ’voltage drop’ in treatment outcomes when moving from efficacy studies in specialty clinics to effectiveness studies in primary care is commonly observed."

There are two potential reasons, he explained. First, because the study was done during the Covid-19 pandemic, when many children and parents gained weight, it’s difficult to estimate what the results might have been had the study been implemented under normal circumstances.

Second, Epstein said, previous studies on FBT with children in this age group took place "in specialty clinics with highly trained personnel with experience in behavior therapy, and families were seen in combined individual and group settings, so they could learn from other families. In this study, children and their parents were seen individually, in the same format as usual pediatric clinic visits, and all the coaches were newly trained personnel to replicate what would happen if FBT was implemented in primary care with newly trained personnel."

Among their study’s limitations, the authors noted that "the intensity of the family-based treatment intervention evaluated here could pose a barrier in time and expertise for many primary care settings. It generally requires at least 26 sessions with the family, consistent with previous reports that found that such intensity is required to achieve benefits."

In addition, the study’s having taken place during the Covid-19 pandemic might have decreased the magnitude of change in the participants’ weight outcomes.

Neither Epstein nor Heerman declared any conflicts of interest.

The study was supported by the National Institutes of Health.

Epstein LH, et al "Family-based behavioral treatment for childhood obesity implemented in pediatric primary care: A randomized clinical trial" JAMA 2023; 329 (22): 1947-1956.

Heerman WJ, et al "Behavioral interventions for treating childhood obesity" JAMA 2023; 329 (22): 1920-1921.