A Systematic Review of Home-Based ChildhoodObesity Prevention Studies

abstractBACKGROUND AND OBJECTIVES: Childhood obesity is a global epi-demic. Despite emerging research about the role of the family and homeon obesity risk behaviors, the evidence base for the effectiveness ofhome-based interventions on obesity prevention remains uncertain.The objective was to systematically review the effectiveness of home-based interventions on weight, intermediate (eg, diet and physical activity[PA]), and clinical outcomes.

METHODS: We searched Medline, Embase, PsychInfo, CINAHL, clinical-trials.gov, and the Cochrane Library from inception through August 11,2012. We included experimental and natural experimental studies with$1-year follow-up reporting weight-related outcomes and targetingchildren at home. Two independent reviewers screened studies andextracted data. We graded the strength of the evidence supportinginterventions targeting diet, PA, or both for obesity prevention.

RESULTS:We identified 6 studies; 3 tested combined interventions (dietand PA), 1 used diet intervention, 1 combined intervention with primarycare and consumer health informatics components, and 1 combinedintervention with school and community components. Select combinedinterventions had beneficial effects on fruit/vegetable intake and sedentarybehaviors. However, none of the 6 studies reported a significant effect onweight outcomes. Overall, the strength of evidence is low that combinedhome-based interventions effectively prevent obesity. The evidence isinsufficient for conclusions about home-based diet interventions orinterventions implemented at home in association with other settings.

CONCLUSIONS: The strength of evidence is low to support the effec-tiveness of home-based child obesity prevention programs. Additionalresearch is needed to test interventions in the home setting, particularlythose incorporating parenting strategies and addressing environmentalinfluences. Pediatrics 2013;132:e193–e200

AUTHORS: Nakiya N. Showell, MD, MPH,a OluwakemiFawole, MD, MPH,b Jodi Segal, MD, MPH,b,c,d Renee F.Wilson, MS,b Lawrence J. Cheskin, MD,d,e Sara N. Bleich,PhD,c Yang Wu, MS,f Brandyn Lau, MPH,b and Youfa Wang,MD, PhDf

aDivision of General Pediatrics, Department of Pediatrics; dDivisionof General Internal Medicine, Department of Medicine, JohnsHopkins School of Medicine, Baltimore, Maryland; bJohns HopkinsUniversity Evidence-based Practice Center, Baltimore, Maryland;cDepartment of Health Policy and Management; eDepartment ofHealth, Behavior and Society, Johns Hopkins Bloomberg School ofPublic Health, Baltimore, Maryland; and fJohns Hopkins GlobalCenter on Childhood Obesity, Department of International Health,Center for Human Nutrition, Johns Hopkins Bloomberg School ofPublic Health, Baltimore, Maryland

KEY WORDSchild, obesity, overweight, intervention, home, BMI

ABBREVIATIONSKQ—key questionPA—physical activity

Dr Showell participated in data acquisition and data analysis,wrote the first draft of the manuscript, revised subsequentdrafts of the manuscript, and approved the final manuscript assubmitted; Drs Fawole and Bleich, Ms Wu, and Mr Lauparticipated in data acquisition and data analysis, revieweddrafts of the manuscript, and approved the final manuscript assubmitted; and Drs Segal, Cheskin, and Wang and Ms Wilsonconceptualized and designed the study, reviewed drafts of themanuscript, and approved the final manuscript as submitted.

www.pediatrics.org/cgi/doi/10.1542/peds.2013-0786

doi:10.1542/peds.2013-0786

Accepted for publication Mar 26, 2013

Address correspondence to Nakiya N. Showell, MD, MPH, Divisionof General Pediatrics and Adolescent Medicine, Department ofPediatrics, Johns Hopkins School of Medicine, David RubensteinChild Health Building, 200 N Wolfe St, Room 2085, Baltimore, MD21287. E-mail: nshowel1@jhmi.edu

(Continued on last page)

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Childhood obesity has become a majorpublic health epidemic.1–3 At present,more than one-third of American chil-dren and adolescents are overweightor obese, reflecting a nearly threefoldincrease in obesity prevalence since1980.3,4 The consequences of obesityare numerous. Overweight children aremore likely to become obese adults.5

Additionally, overweight children aredisproportionately affected by adversephysical and psychosocial health out-comes, including hypertension, diabetes,low self-esteem, and increased engage-ment in high-risk behaviors.6,7

It is widely recognized that the familyand home environment significantlyinfluence child diet andphysical activity(PA) behaviors.8,9 Three recent sys-tematic reviews have highlighted theimportance of these influences onchild obesity prevention and treatment,mainly for young children.10–12 A 2011review identified studies that sup-ported a small to moderate effect ofparenting interventions on weight-related outcomes.10 Another 2011 re-view identified studies that reporteda favorable effect of key parental vari-ables (eg, parental feeding practices,parental style, etc) on risk behaviors forchild obesity in preschool-aged chil-dren.11 The third review reported thatthe majority of studies reported a fa-vorable effect of family and home-basedinterventions on the treatment of over-weight and obesity among young chil-dren aged 2 to 7 years.12

To additionally examine the evidencebase for the effectiveness of home-based prevention programs on childobesity, our team completed an Agencyfor Healthcare Research and Quality–funded systematic review on childhoodobesity prevention studies conductedin high-income countries. The presentreport represents a component of ourlarger systematic review of childhoodobesity prevention studies.13 The largersystematic review addresses 6 key

questions (KQs 1-6) evaluating the ef-fectiveness of obesity prevention pro-grams conducted in various settingsfor the prevention of obesity or over-weight in children. This article describesthe results of home-based obesity pre-vention studies (KQ2). Findings address-ing other KQs are available in our fullevidence report.

METHODS

We developed and followed a standardprotocol for this review following therecommended methods as describedin the Methods Reference Guide for Ef-fectiveness and Comparative Effective-ness Reviews.14 Additional details of theprotocol are available in our full evi-dence report.13

Literature Search Strategy

We searched Medline, Embase, Psy-chInfo, CINAHL, clinicaltrials.gov, andthe Cochrane Library through August11, 2012, and identified additionalstudies from reference lists of eligiblearticles and relevant systematic reviews.Our electronic search strategy includedmedical subject headings (MeSH) andkeywords related to childhood obesityand overweight prevention. We alsoconducted a gray literature search inclinicaltrials.gov to identify unpublishedresearch thatwas relevant toour reviewon July 23, 2012.

Study Selection

We identifiedstudies conducted inhigh-income countries that reported theeffects of interventions to preventobesity in children and adolescentsaged 2 to 18 years old. We includedrandomized controlled trials, quasi-experimental studies, and natural ex-perimental studies with at least 1-yearfollow-up that targeted children in theirhomes or included significant familyinvolvement. Interventions of interestinvolved a modification of diet, PA,sedentary behaviors, or a combination

of these. Additionally, the study was re-quired to report the effect(s) of the in-tervention on weight-related outcomes.We excluded studies that targetedonly overweight or obese childrenor children with preexisting medicalconditions such as diabetes or heartdisease.

Data Extraction and Quality (Risk ofBias) Assessment

Two reviewers independently screenedfirst the abstract and then the full ar-ticle for eligibility (Fig 1). One reviewerabstracted data from included articlesand a second reviewer checked theabstracted data for accuracy. We ab-stracted information on study charac-teristics, study participants, eligibilitycriteria, interventions, outcome mea-sures, the method of ascertainment, andthe outcomes. We assessed the qualityof included studies by using the Downs& Black instrument.15 We categorizedthe studies as having low, moderate, orhigh risk of bias. We rated a study ashaving a low risk of bias only when ithad met all of the following require-ments:

1. stated the objective clearly;

2. described the main outcomes;

3. described the characteristics ofthe enrolled subjects;

4. described the intervention clearly;

5. described the main findings;

6. randomly assigned the subjects tothe intervention group; and

7. concealed the intervention assign-ment until recruitment was com-plete.

Additionally, the study had to haveat least partially described the dis-tributions of (potential) principal con-founders in each treatment group.

Outcome Variables

We compared the effects of interventionson weight- or body composition–relatedoutcomes (eg, BMI, BMI z score, weight),

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obesity-related clinical outcomes (eg,blood pressure, lipids), intermediateoutcomes (dietary intake, PA), and ad-

verse effects of interventions. Bodycomposition–related outcomes wereour primary focus. Outcomes were ei-

ther compared between 2 groups,both of which received an intervention,or 2 groups, 1 of which received the

FIGURE 1Results of the literature search on home-based childhood obesity prevention studies in high-income countries. a Sum of excluded abstracts exceeds 5600because reviewers were not required to agree on reasons for exclusion. b Sum of excluded articles exceeds 470 because reviewers were not required toagree on reasons for exclusion. KQ, key question.

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intervention and the other usual careor no intervention.

Data Synthesis and Analysis

We created a set of detailed evidencetables containing all information ab-stracted from eligible studies. Resultswere first organized by setting orcombination of settings where the in-tervention took place (eg, home, schoolsettings or home, community settings,etc) and then by intervention. We de-scribed the interventionson thebasisoftheir focus (eg, change in dietary intakeor PA) and the modality of interventiondelivery (eg, education, environmentmodification, or self-management tech-nique). We reviewed studies for out-comes of relevant subgroups (eg, age,gender, race), and reported them sep-arately by subgroup.

We present qualitative summaries ofincluded studies in this review. Due tointervention and outcome heteroge-neity, meta-analyses could not beconducted.

Strength of the Evidence

We graded the quantity, quality, andconsistency of thebest available resultsor evidence by adapting an evidence-grading scheme recommended in theMethods Reference Guide for Effec-tiveness and Comparative Effective-ness Reviews.14 We classified evidenceinto 4 categories:

1. “high” grade (indicating high confi-dence that the evidence reflectsthe true effect and that additionalresearch is very unlikely to changeour confidence in the estimate ofthe effect);

2. “moderate” grade (indicating mod-erate confidence that the evidencereflects the true effect and that ad-ditional research may change ourconfidence in the estimate of the ef-fect and may change the estimate);

3. “low” grade (indicating low confi-dence that the evidence reflects

the true effect and that additionalresearch is likely to change ourconfidence in the estimate of theeffect and is likely to change theestimate); and

4. “insufficient” grade (indicating evi-dence is unavailable; there wasonly 1 study and it had moderateto high risk of bias, or a conclusioncould not be drawn on the basis ofdata).

RESULTS

Search Results

We identified 34 545 unique citations.During the title screening, we excluded28 344 citations, and excluded an ad-ditional 5600 during abstract screen-ing. During article screening, weexcluded an additional 470 articles.Six studies reporting on home-basedinterventions (KQ2) were included inthis review: 3 home-based combined(diet and PA) intervention studies,16–18

1 home-based diet intervention study,19

1 combined home-based study withprimary care and consumer health in-formatics components,20 and 1 com-bined home-based study with schooland community components (Fig 1).21

The results of the gray literature searchdid not yield studies eligible for in-clusion in this review.

Description of Included Studies

Study characteristics are summarizedin Table 1. All studies were randomizedcontrolled trials conducted in theUnited States.16–21 The majority of in-cluded studies were conducted exclu-sively in the home setting (n = 4).16–19

The sample size of included studiesranged from 26 to 1323 participants.Intervention length varied between 14and 104 weeks, and participant follow-up ranged from 52 to 104 weeks. Onestudy specifically targeted girls,19 and2 other studies targeted preschool-18

and adolescent-aged participants(Table 1).20

Overall Findings on theEffectiveness of Home-BasedInterventions

The results of home-based obesityinterventions on weight-related andintermediate outcomes are summa-rized in Tables 1 and 2, respectively.None of the 6 studies reported a sig-nificant intervention effect on weight-related outcomes, whereas 3 reportedstatistically significant effects of acombined intervention on fruit/vegetableintake17,21 or sedentary behaviors.20 Nostudies reported on clinical outcomesor adverse effects of the interventions.

Effectiveness of Home-BasedInterventions by Setting(s) andIntervention Type

Home-Based Diet and PA Interventions

Three randomized controlled trialstested such interventions over a 52-week study period.16–18 These studiesenrolled a total of 262 participantsaged 4 to 17 years. One reported on theeffect of 2 educational diet and PAinterventions, each targeting a differ-ent dietary behavior (increased fruitand vegetable intake versus decreasedintake of high-fat/high-sugar foods).16

The second study evaluated the effectof the intervention on television view-ing, snack/sweet intake, eating out, andPA among entire households.17 The thirdstudy assessed the effect of the in-tervention on dietary fat, fruit and veg-etable intake, television viewing, and PAamong preschool-aged children.18

None of these studies reported signif-icant beneficial intervention effects onBMI, BMI z score, weight, or prevalenceof obesity/overweight.16–18

With regard to intermediate outcomes,in 2 studies there were no differencesbetween the intervention and controlgroups inminutesperdayofPA, televisionviewing, or general screen time.17,18 All 3studies16–18 reported a favorable in-tervention effect on fruit and vegetableintake, but only 1 study reported

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a statistically significant intervention ef-fect on fruit and vegetable intake(P = .05).17 In 1 study there was no dif-ference in sugar-sweetened beverageintake between the intervention andcontrol groups.17 Similarly, another studyreported no difference between the in-tervention and control groups in energyintake.18

The strength of evidence is low toconclude that combined diet and PAinterventions in a home setting preventchild obesity. We graded the strength ofevidence as low because it included 3moderate to high risk of bias studiesthat were inconsistent (1 reported afavorable but not statistically signifi-cant effect, 2 reported anegative effect)and imprecise (Table 3).

Home-Based Diet Intervention

One randomized controlled trial reportedon an educational diet intervention thatrandomlyassigned59girls to interventionand control groups.19 This study includedonly 9-year-old girls with a BMI ,85thpercentile. The study evaluated the effectof a calcium-rich diet on weight gain overa 104-week study period.

TherewasnoreporteddifferenceinBMIat104 weeks between the intervention andcontrol arms.19 Similarly, there was noreported difference in fat mass or weightat 104 weeks between the interventionand control arms and no difference inreported hours of PA. At 104 weeks, theintervention group had a higher totalenergy intake compared with the controlgroup. However, this between-group dif-ference was not significant.19

Home-, Primary Care–, and ConsumerHealth Informatics–Based Diet and PAIntervention

A single study enrolled 878 participantsaged 11 to 15 years. The interventiontargeted diet and PA behaviors by usingseveralmodalities: computer-supportedassessment,providercounseling,monthlymail and telephone counseling, and familyparticipation.TA

BLE1

Summaryof

theResults

ofHome-BasedChildhood

Obesity

PreventionStudiesConductedin

High-IncomeCountrieson

Weight-Related

Outcom

es

Study,Design

NIntervention

Agerange,y

Girls,%

Follow-up,wk

BMIz

Score

BMI

Body

Fat,%

Prevalence

Obesity/Overw

eight

Weight,kg

Type

Description

Epsteinetal

(16),RCT

26D,PA

26-weekparent-focusedbehavioral

interventionto

reduce

high-fat/high-sugar

intake

orincrease

fruit/vegetableintake;

increase

access

toPA;reduceaccess

tosedentarybehaviors

8.6–8.8

6552

——

—NS

c—

Fitzgibbon

etal

(18),RCT

146

D,PA

14-weekfamily-based

intervention(parent-

child

dyads)

toincrease

fruit/vegetable

intake,decreasefatintake,reduce

television

view

ing,andincrease

PA

3–5

5052

0.03

(95%

CI,

20.28

to0.34)

0.17

(95%

CI,

20.45

to0.80)

——

0.57

(95%

CI,

20.55

to1.68)

French

etal

(17),RCT

90a

D,PA

52-weekbehavioralandenvironm

ental

interventionto

preventw

eightgain

amongentirehouseholds

5–17

—52

0.06

(P=.53)

——

——

Lappeetal

(19),RCT

59D

104-weekcalcium-richdietaryintervention

designed

toassess

effecton

weightgain

9100

104

—NS

cNS

c—

NSc

Patricketal

(20),RCT

878

D,PA

52-weekPACE+computer-supported

behavioralinterventionto

modify

totalintakeoffat,fruit/vegetableintake,

PA,and

sedentarybehaviors

11–15

49.9

52–(P

$.05fornorm

alandoverweight

participants)

——

——

Gentile

etal

(21),RCT

1323

D,PA

30-week“Switch”

behavioralintervention

tomodify

nutrition,television

view

ing/screen

timeandPA

9.6b

53.0

61—

–(P

$.05overall

sample,P,.05

boys)

——

—

CI,confidenceinterval;D,diet;NR

,not

reported;NS,notsignificant;RCT,randomized

controlledtrial.—,resultsnotreported.

aN=90

households.

bPACE+,Patient-centeredAssessmentandCounselingforExercise

+Nutrition.

cOnlymeanagereported.

d95%CIor

Pvaluenotreported.

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The study did not find a significant dif-ference in BMI z score at 52 weeks be-tween the intervention and control armsamong all participants or among par-ticipants with a BMI $95th percentile.20

It also did not find significant differencesin minutes per week of moderate plusvigorous PA, percentage of calories fromfat, or fruit and vegetable intake betweenthe intervention and control groups.However, the intervention resulted ina significant decrease in hours perday of sedentary behaviors amongboys and girls (P = .001).

Home-, School-, and Community-BasedDiet and PA Intervention

One randomized controlled trial evalu-ated suchan interventiononweight andintermediate outcomes at 34 and 61

weeks.21 This study was conducted in theUnited States and enrolled 1323 partic-ipants with a mean age of 9.6 years. Theintervention targeted 3 behaviors at thefamily, school, and community levels: in-crease in fruit and vegetable intake, in-crease in PA, anddecrease in screen time.

There was no overall difference in BMIbetween the control and interventiongroups at the 34- or 61-week follow-up.However, when analyzed by gender,boys had significantly lowered BMI dueto the intervention (P , .05).21

There was no statistically significantdifference in PA or screen time betweenthe intervention and control groups ateither follow-up time period.21 However,children in the interventiongroup reportedsignificantly more fruit and vegetable

consumption compared with the con-trol group at 61 weeks (P , .05).21

DISCUSSION

We identified 6 childhood home-basedobesity prevention studies conducted inhigh-income countries. The majority ofthem (n = 4) were conducted exclusivelyin the home setting. The remainingstudies included intervention compo-nents implemented in other settingssuch as the school and local community.

Overall, none of the home-based inter-ventions revealed a statistically signifi-cant desirable effect on weight-relatedoutcomes such as BMI and prevalence ofoverweight/obesity. However, 3 studiesassessed and reported significant de-sirable intervention effects on diet or PA

TABLE 2 Summary of the Results of Home-Based Childhood Obesity Prevention Studies Conducted in High-Income Countries on Intermediate Outcomes

Study, Design N InterventionType

Follow-up,wk

Fruit and Vegetable Intake Energy Intake,kcal

PA SedentaryBehavior

Epstein et al (16), RCT 26 D, PA 52 P = .12 — — NSc

Fitzgibbon et al (18), RCT 146 D, PA 52 Vegetable intake: 20.18 servings/d(95% CI, 21.35 to 0.99)

226.3 (95% CI,20.96 to 43.5)

9 min/d MVPA (95% CI,235.1 to 53.2)

0.26 h/d screentimed (95% CI,20.58 to 1.10)

Fruit intake: 0.28 servings/d(95% CI, 20.36 to 0.92)

French et al (17), RCT 90a D, PA 52 0.47 portions/d (P = .05) — 24.3 min/d MVPA(P = .39)

0.11 h/d televisionviewing (P = .79)

Lappe et al (19), RCT 59 D 104 — NSc NSc —

Patrick et al (20), RCT 878 D, PA 52 –(P = .49 for boys, P = .07 for girls) — –(P = .17 for boys,P = .90 for girls)

–(P = .001 forboys and girls)

Gentile et al (21), RCT 1323 D, PA 61 –(P , .05) — –(P . .05) –(P . .05)

CI, confidence interval; D, diet; MVPA, moderate-to-vigorous PA; NR, not reported; NS, not significant; RCT, randomized controlled trial; —, results not reported.a N = 90 households.b 95% CI or P value not reported.c Time spent watching television, DVDs, or videos; playing video games; or using a computer.

TABLE 3 Summary of the Strength of Evidence for Weight-Related Outcomes in Studies Taking Place in the Home

Setting Intervention,No. of Studies

Year ofPublication

EnrolledParticipants, N

Number ofStudies with Low/Moderate/HighRisk of Bias

Percentage WithFavorable Outcome

Risk ofBiasa

Consistencyb Precisionc Strength ofEvidenced

P , .05 P , .05 NotNecessary

Home D, 1 2004 59 0/1/0 0 0 Moderate NA Imprecise InsufficientC, 3 2001–2012 262 0/2/1 0 33 Moderate Inconsistent Imprecise Low

Home, PC, CHI C, 1 2006 878 1/0/0 0 0 Low NA Imprecise InsufficientHome, school,community

C, 1 2009 1323 0/0/1 0 0 High NA Imprecise Insufficient

C, combination of diet and PA interventions; D, diet; CHI, consumer health informatics; NA, not applicable; PC, primary care.a The Downs & Black instrument15 was used to assess the risk of bias in the included studies.b The body of evidence was considered as consistent in direction if $70% of the studies had an effect in the same direction.c We considered the body of evidence precise if $70% of the studies reported statistically significant results (P , .05) or had narrow confidence intervals that excluded the null).d We considered the 4 recommended domains: (1) risk of bias in the included studies, (2) directness of the evidence, (3) consistency across studies, and (4) precision of the pooled estimate orthe individual study estimates. We identified all studies as providing direct evidence because all of the studied interventions directly affected one of our primary outcomes of interest.

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outcomes.17,20,21 There were severalcharacteristics of these 3 studies thatmay have contributed to their beneficialeffect on intermediate outcomes. Two ofthese studies included significantlylarger sample sizes (N= 878,N= 1323) ofparticipants in comparison with theother home-based interventions.20,21

These same studies also tested the effectof intervention components imple-mented in other settings (eg, school,community, primary care settings),which may enhance their effectivenesson behavior change by virtue of theirgreater reach to targeted participants.Finally, one of the studies targeted entirefamilies in households.17 Hence, theintervention’s effect on child dietary in-take may have been facilitated throughdirect modification of the physical homeenvironment and emphasis on familyinvolvement.

Despite demonstration of favorableeffects on intermediate outcomes, noneof the 6 studies included in our reviewreported a significant overall effect onweight-related outcomes. This findingsuggests that longer intervention dura-tion and/or greater intensity of in-terventiondosemaybenecessary to fullyrealize the impact of the interventions onweight-related outcomes. Second, manyof the included studies targeted in-dividual behavior change without con-current modifications to the child’s foodenvironment (eg, increased availabilityof healthful foods) or PA environment(eg, increased access to neighborhoodrecreational space, neighborhood walk-ability). It is widely recognized that en-vironmental factors such as these mayinfluence child obesity risk.22–24 There-fore, without systematically addressingphysical environmental factors andtheir potential influence on individual-level behaviors, the impact of inter-ventions on obesity-risk behaviors andresultant obesity may be attenuated.Finally, the inclusion of studies withsmall sample sizes and studies that did

not primarily aim to prevent obesitymay have also contributed to the lack oftreatment effect observed.

This review has several key strengths.We used a systematic and rigorousreview process to identify the relevantliterature, asstandardizedby theAgencyfor Healthcare Research and Quality.Additionally, we evaluated the effects ofthe interventions on multiple outcomesincluding weight-related outcomes andbehavioral outcomes and used a widelyacceptedgradingscheme togradestudyquality and strength of evidence.

Several factors also limited our review.We identified only 6 studies, and dueto the considerable heterogeneity inpopulations, approaches, outcomes,andmeasurement tools among studies,we were unable to conduct a quantita-tive synthesis of the literature. Addi-tionally, we limited our review to dietandPA intervention studieswith at least1 year of follow-up and only includedthose from high-income countries.Hence, we excluded some studies withpotentially useful interventions (eg,parenting interventions).However,manyof these studies have been includedin other, more general, systematicreviews.10,11,25 Finally, we excludedinterventions that were primarilyconducted in other settings but in-cluded components conducted in thehome setting (eg, school- and home-based interventions), because theseinterventions may differ from thoseincluded in this review and hence limitthe ability to collectively examine theireffectiveness on child obesity pre-vention. Details of the findings fromthese other studies are available inour full evidence report.

Our study contributes valuable in-formation to the existing literature onhome-based obesity interventions. Incomparison with other recent system-atic reviews that examined the effect ofparenting or treatment interventionsmainly among young children,10–12 this

review systematically assessed theimpact of diet or diet and PA inter-ventions on prevention of obesity amongchildren and adolescents. On the basisof the paucity of the evidence, however,it is clear that more research is neededto evaluate the impact of home- andfamily-based interventions on child obe-sity. Specifically, additional researchis needed to test home-based inter-ventions with larger sample sizes,greater intervention duration and in-tensity, and adequate participant follow-up to improve statistical power ofstudies. Given the important role par-enting plays on child behaviors and thedemonstrated effectiveness of parent-ing intervention components on weight-related outcomes and obesity risk,11,26

widespread integration of parentingstrategies in home-based interventionsshould also be considered and addition-ally evaluated. Finally, implementing andtesting the effectiveness of home-basedinterventions that address importantphysical environmental influences onobesity-risk behaviors should be a prior-ity of the child obesity research agenda.

CONCLUSIONS

Only a small number of studies exam-ined childhood obesity preventionprograms in the home setting. Thestrength of evidence is low, at best, tosupport the effectiveness of home-based programs on childhood obesityprevention. Additional research isneeded to test interventions in thehomesetting, particularly those integratingparenting and addressing importantenvironmental sources of influence.

ACKNOWLEDGMENTSWe thank Mr Allen Zhang for his techni-cal assistance with this report. We alsothank all of the members of the JohnsHopkins University Evidence-basedPractice Center who assisted withdata abstraction and analysis for thisproject.

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PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).

Copyright © 2013 by the American Academy of Pediatrics

FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.

FUNDING: This project was funded under contract 290-2007-10061-I from the Agency for Healthcare Research and Quality, US Department of Health and HumanServices. Drs Wang, Cheskin, and Wu’s efforts in the study were also supported by a childhood obesity–related center grant from the Eunice Kennedy ShriverNational Institute of Child Health & Human Development (NICHD; U54HD070725), which is cofunded by the NICHD and the Office of Behavioral and Social SciencesResearch at the National Institutes of Health. Dr Showell was supported by an Agency for Healthcare Research and Quality, Comparative Effectiveness DevelopmentTraining grant T32 HS19488-01. The content is solely the responsibility of the authors and does not necessarily represent the official views of the funders. Fundedby the National Institues of Health (NIH).

COMPANION PAPER: A companion to this article can be found on page e201, online at www.pediatrics.org/cgi/doi/10.1542/peds.2013-0886.

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