Download - Parent-only vs. parent-child (family-focused) approaches for weight loss in obese and overweight children: a systematic review and meta-analysis

Obesity Treatment/Childhood Obesity

Parent-only vs. parent-child (family-focused)approaches for weight loss in obese and overweightchildren: a systematic review and meta-analysis

A. Jull1,2 and R. Chen1

1School of Nursing, University of Auckland,

Auckland, New Zealand; 2National Institute of

Health Innovation, University of Auckland,

Auckland, New Zealand

Received 7 March 2013; revised 21 March

2013; accepted 28 March 2013

Address for correspondence: Dr A Jull,

School of Nursing, University of Auckland,

Private Bag 92019, Auckland 1142,

New Zealand.

E-mail: [email protected]

SummaryFamilies are recommended as the agents of change for weight loss in overweightand obese children; family approaches are more effective than those that focus onthe child alone. However, interventions that focus on parents alone have not beensummarized. The objective of this review was to assess the effectiveness of inter-ventions that compared a parent-only (PO) condition with a parent-child (PC)condition. Four trials using a similar between-group background approaches tooverweight and obese children’s weight loss met the inclusion criteria, but onlyone trial reported sufficient data for meta-analysis. Further information wasobtained from authors. Meta-analysis showed no significant difference in z-BMIfrom baseline to end of treatment between the conditions (three trials) or to endof follow up (two trials). The trials were at risk of bias and no single trial was atlower risk of bias than others. There is an absence of high quality evidenceregarding the effect of parent-only interventions for weight loss in children com-pared to parent-child interventions, but current evidence suggests the need forfurther investigation.

Keywords: Children, parents, systematic review, weight loss.

obesity reviews (2013) 14, 761–768

Background

Overweight and obesity in childhood increases the risk ofbeing overweight or obese in adulthood (1). To preventsuch a trajectory, clinical guidelines recommend familiesas the agents of change by including parents and childrenin the interventions rather than focusing on the childalone (2,3). Such recommendations are based on seminalevidence that including parents is more effective thanworking with the child alone (4). However, some researchthat suggests interventions that focus on the parentsproduce greater weight loss than interventions that focuson parent-child dyads (5). Similar investigations haveexamined the effect of parent-only and parent-child

approaches in anxiety disorders in children (6,7), whichfound no clear differences between the two approaches.

Parent-child interventions for children are typicallyresource-intensive, making for greater difficulties creatingscalable approaches. Interventions that focus on parentsmay be more scalable, but the evidence for such approacheshas not been summarized in a meta-analysis. Therefore, theaim of this review was to assess the effectiveness of weightloss interventions that compared a parent-only conditionwith a parent-child condition in overweight and obese chil-dren. It is worth noting that the term ‘weight loss interven-tion’ has a somewhat different usage here compared withstudies in adults. In adults, the intent is that the participantsdo lose weight, whereas in children the intent of such

obesity reviews doi: 10.1111/obr.12042

761© 2013 The Authorsobesity reviews © 2013 International Association for the Study of Obesity 14, 761–768, September 2013

interventions is to prevent further excess weight gain, thusencouraging growth into the weight as the children get older.

Methods

We included studies if they were randomized controlledtrials of a weight loss strategy that recruited overweight orobese children (defined for example by BMI-based defini-tions) and compared a parent-only condition to a parent[s]and child condition. The weight loss intervention could beany intervention for weight loss. Child was defined by anupper age limit of 14 years and the child must not have hada disorder that suppressed voluntary appetite control, suchas Prada-Willi syndrome. The studies’ outcome measuresmust have included body mass index standard deviationscore (BMI-SDS or z-BMI) or percent overweight. Nodate restriction was applied, but only papers published inEnglish were included.

Search strategy

We searched the Cochrane Controlled Trials Register,Medline, Embase, PsycInfo and CINAHL in December2011, and again in August 2012, using the keywords (orvariants) obesity, overweight, weight reduction, weightcontrol, body mass index (BMI), parents, parenting,parent-child relations, family, family based or family rela-tions. These keyword searches were then restricted to ran-domized controlled trials using the publication type limitsfor each database. The full search strategies for each data-base are available from the corresponding author. Studieswere imported into an Endnote library for review. In addi-tion, the reference lists in the retrieved studies werereviewed for additional studies of interest. Two reviewersindependently checked the titles and abstracts of studies forcongruence with inclusion criteria. Differences of opinionwere resolved by discussion or the full papers wereobtained where there remained uncertainty after the dis-cussion. Full text articles were retrieved where studies metor might have meet the inclusion criteria.

Data extraction and analysis

Data were extracted using a standardized form. The dataextraction form included study population and setting,interventions and outcomes. One reviewer extracted thedata (RC), which was independently checked by the secondreviewer (AJ). The risk of bias was also assessed accordingto methods recommended through the Cochrane Collabo-ration (8): risk of selection bias was determined by exam-ining sequence generation and allocation concealment, riskof performance bias by participant and personnel blinding,risk of detection bias by blinding outcome assessors, risk ofattrition bias by assessing completeness of data and risk of

reporting bias by selective outcome reporting. Studies thatused the same metric were combined in a meta-analysisusing RevMan 5.2.1 (9), using a fixed effects model whereheterogeneity as measured by the I2 was less than 40%.

Results

Description of studies

A total of 514 potential citations were identified from thedifferent databases, which decreased to 195 studies whenduplicates were removed (Fig. 1). A total of 174 studies didnot meet the inclusion criteria, and 21 studies were there-fore retrieved for further screening. One further study (10)was identified through another study’s references (11).Eighteen studies were excluded after review of the retrievedpapers (Table 1), including two that were secondary pub-lications of a main paper (12,13).

Four trials met the inclusion criteria (11,14–16). Two ofthe trials were conducted in the United States (11,16), one

514 potential citations

obtained from database

searches

Total = 514

195 potential citations

screened for retrieval

Total = 195

21 potentially appropriate

papers obtained

1 additional paper identified

from Boutelle et al. 2011

Total = 22

Databases merged and

duplicate citations removed

Total = 319

Note: studies could be

excluded for multiple reasons

– the first obvious reason is

reported here

55 not RCT/not yet completed

5 not in children

2 not published in English

4 not in obese/overweight

children

108 not parent-only vs. parent-

vs. parent-

child

Total excluded = 174

Relevant trials included

Total = 4

14 not parent-only

child

2 not RCT/not yet completed

2 duplicate publications

Total excluded = 18

Figure 1 Flow diagram of study selection process.

762 Parent vs. parent-child for weight loss A. Jull & R. Chen obesity reviews

© 2013 The Authorsobesity reviews © 2013 International Association for the Study of Obesity14, 761–768, September 2013

trial was conducted in Israel (14) and one trial was con-ducted in Switzerland (15). One trial was a three armparallel group trial that included a wait-list condition (11),while the remaining trials were two arm parallel grouptrials. One trial was described as a cluster randomized trialas the family was considered the unit of randomization andwhere two children meet the inclusion criteria, both chil-dren were included in the group to which the family wasallocated (14). A second trial employed a similar strategy,but was not described as a cluster randomized trial (16).One trial was a non-inferiority trial, which aimed to showthe parent-only intervention was not worse than thecomparison, and the bound for non-inferiority specified apriori (11).

The sample sizes in the trials were small, ranging from 37to 80 participants, and the mean age of children across thetrials was 10.2 years (8.7 to 11.2 years) with more femalethan male participants (56.4%). All the trials defined over-weight as a BMI greater than the 85th percentile for ageand sex. No trial reported weight loss separately for over-weight and obese participants.

Risk of bias in included studies

Overall, the included trials were at unclear or high risk ofbias (Fig. 2) and no individual trial was clearly at lower riskof bias than the other trials.

Sequence generation: Two trials reported the methodof sequence generation, with one trial using ‘computer-generated random numbers’ (11), and the other trialreporting ‘families were assigned according to a permutedblock design’ (15).

Allocation concealment: Two trials reported themethod of allocation concealment, with one trial using‘concealed opaque envelopes’ (14), and the other trialreporting ‘all families were randomised via computerassignment’ (16). The method of allocation concealmentwas unclear in two trials, although one trial reported‘allocation was concealed from those recruiting’ withoutreporting the method (14).

Blinding: One trial blinded outcome assessment withdata ‘gathered by an MSc student blinded to treatmentallocation’ (14).

Incomplete outcome data: Three of the four trialsincluded a CONSORT flow diagram in their reports (11,15,16). Total loss to follow-up was 25% (16), 35% (11)and 52% (15). In two trials, intention to treat analysiswas not attempted (15,16). The third trial reported thatan analysis using multiple imputation of missing data wascompared to the ‘completed treatment’ dataset, with‘nonsubstantive differences in the results’, but the imputeddata was not reported (11). The trial without aCONSORT flow diagram reported drop-out rates with anoverall rate of 14%, although the rate was 24% in onearm (parent-only) and 5% in the other arm (parent andchild) (14). The report stated ‘all those who terminatedthe study attended the follow up meeting’ but analysis ofgroup differences over time ‘was an intention to treatanalysis where the missing values were replaced withbaseline values.’ Thus, we considered it was unclear whatdrop-out meant in this trial and whether there wasincomplete outcome data.

Selective reporting: We did not have access to trial pro-tocols for three trials (11,14,15), and no report stated thetrial was registered. Although we had no reason tosuspect that outcome data was selectively reported, weconsidered three trials to be of unclear risk on thisdomain. The fourth trial published the trial protocol (13),and while most secondary outcomes were not reported inthe trial report (16), weight loss outcome data werereported and we considered this trial to be at low risk ofbias on this domain.

Other bias: Two trials reported sufficient information inthe baseline tables to assure the reader of baseline equiva-lence with respect to the randomized children (11,14),although in one trial the percentage of female children washigher in one arm than the other (11). However, thenumber of children included in the baseline tables wasfewer than the number randomized in two trials and weconsidered these trials to be of unclear risk of bias on thisdomain (15,16).

Table 1 Excluded studies and reasons for exclusion

Study Rationale

Cliff et al. 2011 (23) Parent- vs. child-only interventionsDe Bock et al. 2010 (24) RCT not completed; parents focus of

interventionsEpstein et al. 1981 (4) Family vs. child-only interventionsGaripagaoglu et al. 2009 (25) Group family sessions vs. individual

family sessionsGolan et al. 1998 (26) Parent- vs. child-only interventionsGolan et al. 1998 (5) Duplicate – parent- vs. child-only

interventionsGolan et al. 1999 (27) Duplicate – parent- vs. child-only

interventionsGolan & Crow 2004 (28) Parent- vs. child-only interventionsGolley et al. 2007 (29) Parent skills training vs. wait listGolley et al. 2011 (30) Parent skills training vs. wait listIsrael et al. 1994 (31) Parent- vs. child-only interventionJanicke et al. 2008 (13) Duplicate publicationJanicke et al. 2009 (12) Duplicate publicationJanicke et al. 2011 (32) Parent-only vs. wait listKalarchian et al. 2009 (18) High contact adult and child groups

vs. low contact usual careKingsley & Shapiro 1977 (10) Not randomized controlled trialMagarey et al. 2009 (33) Parents the targets in both

interventionsSteele et al. 2012 (34) Families the focus of both

interventions

obesity reviews Parent vs. parent-child for weight loss A. Jull & R. Chen 763

© 2013 The Authorsobesity reviews © 2013 International Association for the Study of Obesity 14, 761–768, September 2013

Types of intervention

The four trials included 266 children, including one three-arm trial randomized that allocated 26 children to a wait-list condition (16). Out of a possible 240 children, only 174were available for analysis due to loss to follow-up. Thetrials used similar approaches to weight loss with the par-ticipating children. Dietary habits were addressed by theaim to increase consumption of healthy food through use oftraffic light diets or similar. Activity was addressed by theaim to increase physical activity and decrease sedentaryactivity, either through stated targets, or through individu-alized goal setting. Behavioural approaches to change werecommon, as was training in parenting skills to cope withdifficult situations. The treatment period ranged between10 weeks and 6 months, and the duration of studyfollow-up ranged from 6 to 18 months. Only one trial usedan a priori calculation to specify the required sample size(15), although in this instance a ‘medium effect’ was speci-fied without quantifying the anticipated effect. Two trialsrandomized by cluster (family) (14,16), but analysed themain effects by individual children, without adjustment forclustering. Such an approach is known to produce inaccu-rate P values and increase the likelihood of rejecting thenull hypothesis (17), although one trial then conducted asensitivity analysis by excluding the additional children(14). The findings for the main weight loss effects in theindividual trials are reported below and summarized inTable 2.

Effect of the interventions at completionof treatment

All studies reported the effect of the interventions at thecompletion of treatment. Three studies reported this effectusing z-BMI (11,14,16), but only one of the trials publishedsufficient information for use in meta-analysis (16). Addi-

tional information (standard deviation of the within groupchange for each group) was sought from and provided bythe other trial investigators. The duration of the interven-tions was 4 to 6 months. The weighted mean difference(WMD) between interventions for z-BMI was -0.16 (95%confidence interval [CI] -0.44 to 0.11, Fig. 3) in the 137participants that completed treatment.

One trial reported the effect of the interventions usingpercentage overweight (15). There was no significant dif-ference between the groups in change from baseline tocompletion of treatment (10 weeks) in percentage over-weight (-3.50 vs. -2.47) in the 37 participants that com-pleted treatment. However, there was differential loss tofollow-up with 52% loss at end of treatment in the parentonly condition compared to 19% loss at end of treatmentin the parent-child condition (Table 2).

Effect of the interventions at completionof follow-up

Only one of the trials published sufficient information foruse in meta-analysis (16), but additional information(standard deviation of the within group change for eachgroup) was sought from trial investigators, and one othertrial investigator provided the additional information (11).The duration of follow-up was 10 to 11 months afterrandomization (respectively 4 and 6 months after comple-tion of treatment). There was no significant differencebetween the interventions for z-BMI (WMD 0.0, 95%CI-0.10 to 0.09, Fig. 4) in the 102 participants that com-pleted follow-up.

One trial reported the effect of the interventions usingpercentage overweight (15). There was no significant dif-ference between the groups in change from baseline tocompletion of follow-up (6 months) in percentage over-weight at 6 months (-4.52 vs. -1.91) in the 27 participantsthat completed follow-up. However, there was differential

0% 25% 50% 75% 100%

Other bias

Selective reporting (reporting bias)

Incomplete outcome (attrition bias)

Blinding (performance and detection bias)

Allocation concealment (selection bias)

Random sequence generation (selection bias)

Low risk Unclear risk High risk Figure 2 Risk of bias assessment.



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loss to follow-up with 72% loss at 6 months in the parentonly condition compared to 35% loss at 6 months in theparent-child condition (Table 2).

Discussion

The superiority of interventions that focus on family com-pared to child-only interventions has been established byearlier studies (4,18). This is the first review to investigatethe effect in studies comparing parent-only to familyapproaches. The lack of a clear effect for either parents-alone or the parent-child condition suggests training theparents alone could be an alternative to approaches thatinclude children. Overweight and obesity in children aresensitive issues, complicating weight loss approaches andcreating potential for stigmatization. Guidance thereforesuggests the focus be on changes in behaviour rather thanweight loss (19). Focusing on the parents as agents of anintervention offers another strategy to further distance thechildren from a focus on their weight. The age of thechild does need to be considered and intuitively it seemsthat using parents as the agents would only work withage groups where the parents can exert considerablecontrol.

The cost of interventional approaches seems likely tofavour a parent-only approach. The programme costs of aparent-only and a family-focused approach were assessedwithin one trial in our review (16), with the incremental costper 0.1 standard deviation unit change in z-BMI beingUS$179 higher in the parent-child condition (US$579 vs.US$758) (12). However, this cost analysis did not considerdirect costs to the participating families (travel, childcare orhealthcare utilization costs) or the health service costs, orindirect costs. Thus, there is still doubt regarding any costbenefit until a fulsome cost-effectiveness analysis using

either a health services or a societal perspective becomesavailable.

This review is subject to three limitations. First, anEnglish language limitation may have led to a publicationbias. However, of the two non-English language papersidentified in the search (20,21), one appears to be alonger term follow on an earlier trial included in thereview (15), and the second addressed the effect of aweight loss intervention in children on c-peptide and lipidprofile compared to no weight loss intervention (21).Second, the studies did not separate outcome data on thebasis of whether children were overweight or obese andthus it was not possible to explore the isolated effect ofthe interventions in these groups. Third, the quality of theincluded trials, particularly with respect to loss to follow-up, means that the effect of a parent-only intervention canonly be suggestive. Parent-only approaches to weight lossin children would benefit from further investigation inwell-powered studies that minimize bias. Such trialsshould report their design in a manner consistent the rel-evant CONSORT statement (22), and use metrics thatcan be incorporated into a meta-analysis by publishingchange in outcome from baseline to endpoints for eachgroup along with the measurement of spread (or error)for the change. Furthermore, the trials should make everyattempt to follow-up all randomized participants andblind outcome assessors.

Conclusion

A small number of underpowered trials suggest that parent-only interventions might have a similar effect as parent-child interventions for weight loss in children, but the riskof bias is such that further well-designed comparisons arerequired.

Study or Subgroup

Boutelle et al. 2011

Golan et al. 2006

Janicke et al. 2008

Total (95% CI)

Heterogeneity: Chi² = 0.63, df = 2 (P = 0.73); I² = 0%

Test for overall effect: Z = 1.16 (P = 0.25)

Mean [z-BMI]

–0.19

–0.4

–0.14

SD [z-BMI]

0.87

0.96

0.78

Total

24

17

24

65

Mean [z-BMI]

–0.17

–0.1

0.08

SD [z-BMI]

0.82

0.92

0.72

Total

28

20

24

72

Weight

36.2%

20.9%

42.9%

100.0%

IV, Fixed, 95% CI [z-BMI]

–0.02 [–0.48, 0.44]

–0.30 [–0.91, 0.31]

–0.22 [–0.64, 0.20]

–0.16 [–0.44, 0.11]

Parents only Parent-child Mean Difference Mean Difference


–1 –0.5 0 0.5 1Favours parents only Favours parent-child

Figure 3 Mean difference in z-BMI from baseline to completion of treatment (4 to 6 months after randomization).

Study or Subgroup

Boutelle et al. 2011

Janicke et al. 2008

Total (95% CI)

Heterogeneity: Chi² = 0.88, df = 1 (P = 0.35); I² = 0%

Test for overall effect: Z = 0.10 (P = 0.92)

Mean [z-BMI]

–0.18

–0.09

SD [z-BMI]

0.34

0.2

Total

24

26

50

Mean [z-BMI]

–0.12

–0.12

SD [z-BMI]

0.15

0.22

Total

28

24

52

Weight

38.7%

61.3%

100.0%


–0.06 [–0.21, 0.09]

0.03 [–0.09, 0.15]

–0.00 [–0.10, 0.09]

Parents only Parent-child Mean Difference Mean Difference


–1 –0.5 0 0.5 1Favours parents only Favours parent-child

Figure 4 Mean difference in z-BMI from baseline to completion of follow-up (10 to 11 months after randomization).



Conflict of Interest Statement

No conflict of interest was declared.

Acknowledgements

Richard Chen’s summer scholarship was funded by theHeart Foundation of New Zealand. We are grateful toDoctors Kerri Boutelle and Jordan Carlson of the Univer-sity of California San Diego and Dr Moria Golan of theHebrew University of Jerusalem, for providing extra infor-mation about their studies. Without their kind and promptresponses to our enquiries, this review would not have beenpossible.

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