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

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<ul><li><p>Obesity Treatment/Childhood Obesity</p><p>Parent-only vs. parent-child (family-focused)approaches for weight loss in obese and overweightchildren: a systematic review and meta-analysis</p><p>A. Jull1,2 and R. Chen1</p><p>1School of Nursing, University of Auckland,</p><p>Auckland, New Zealand; 2National Institute of</p><p>Health Innovation, University of Auckland,</p><p>Auckland, New Zealand</p><p>Received 7 March 2013; revised 21 March</p><p>2013; accepted 28 March 2013</p><p>Address for correspondence: Dr A Jull,</p><p>School of Nursing, University of Auckland,</p><p>Private Bag 92019, Auckland 1142,</p><p>New Zealand.</p><p>E-mail: a.jull@auckland.ac.nz</p><p>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 childrens 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.</p><p>Keywords: Children, parents, systematic review, weight loss.</p><p>obesity reviews (2013) 14, 761768</p><p>BackgroundOverweight 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</p><p>approaches in anxiety disorders in children (6,7), whichfound no clear differences between the two approaches.</p><p>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</p><p>obesity reviews doi: 10.1111/obr.12042</p><p>761 2013 The Authorsobesity reviews 2013 International Association for the Study of Obesity 14, 761768, September 2013</p></li><li><p>interventions is to prevent further excess weight gain, thusencouraging growth into the weight as the children get older.</p><p>MethodsWe 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.</p><p>Search strategyWe 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.</p><p>Data extraction and analysisData 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</p><p>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%.</p><p>Results</p><p>Description of studiesA 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 studys 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).</p><p>Four trials met the inclusion criteria (11,1416). Two ofthe trials were conducted in the United States (11,16), one</p><p>514 potential citationsobtained from database</p><p>searches</p><p>Total = 514</p><p>195 potential citationsscreened for retrieval</p><p>Total = 195</p><p>21 potentially appropriatepapers obtained</p><p>1 additional paper identifiedfrom Boutelle et al. 2011</p><p>Total = 22</p><p>Databases merged andduplicate citations removed</p><p>Total = 319</p><p>Note: studies could beexcluded for multiple reasons the first obvious reason is</p><p>reported here55 not RCT/not yet completed</p><p>5 not in children2 not published in English4 not in obese/overweight</p><p>children108 not parent-only vs. parent-</p><p>vs. parent-</p><p>childTotal excluded = 174</p><p>Relevant trials included</p><p>Total = 4</p><p>14 not parent-onlychild</p><p>2 not RCT/not yet completed2 duplicate publications</p><p>Total excluded = 18</p><p>Figure 1 Flow diagram of study selection process.</p><p>762 Parent vs. parent-child for weight loss A. Jull &amp; R. Chen obesity reviews</p><p> 2013 The Authorsobesity reviews 2013 International Association for the Study of Obesity14, 761768, September 2013</p></li><li><p>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).</p><p>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.</p><p>Risk of bias in included studiesOverall, 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.</p><p>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).</p><p>Allocation concealment: Two trials reported themethod of allocation concealment, with one trial usingconcealed 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 reportedallocation was concealed from those recruiting withoutreporting the method (14).</p><p>Blinding: One trial blinded outcome assessment withdata gathered by an MSc student blinded to treatmentallocation (14).</p><p>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, withnonsubstantive 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.</p><p>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.</p><p>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).</p><p>Table 1 Excluded studies and reasons for exclusion</p><p>Study Rationale</p><p>Cliff et al. 2011 (23) Parent- vs. child-only interventionsDe Bock et al. 2010 (24) RCT not completed; parents focus of</p><p>interventionsEpstein et al. 1981 (4) Family vs. child-only interventionsGaripagaoglu et al. 2009 (25) Group family sessions vs. individual</p><p>family sessionsGolan et al. 1998 (26) Parent- vs. child-only interventionsGolan et al. 1998 (5) Duplicate parent- vs. child-only</p><p>interventionsGolan et al. 1999 (27) Duplicate parent- vs. child-only</p><p>interventionsGolan &amp; 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</p><p>vs. low contact usual careKingsley &amp; Shapiro 1977 (10) Not randomized controlled trialMagarey et al. 2009 (33) Parents the targets in both</p><p>interventionsSteele et al. 2012 (34) Families the focus of both</p><p>interventions</p><p>obesity reviews Parent vs. parent-child for weight loss A. Jull &amp; R. Chen 763</p><p> 2013 The Authorsobesity reviews 2013 International Association for the Study of Obesity 14, 761768, September 2013</p></li><li><p>Types of interventionThe 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.</p><p>Effect of the interventions at completionof treatmentAll 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 publishedsufficie...</p></li></ul>

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