Parent skills training to enhance weight loss in overweight children: Evaluation of NOURISH

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<ul><li><p>ss</p><p>n a</p><p>ik, Uni</p><p>C 27nd, V</p><p>genfew studies have investigated the effectiveness of interventions that target parents exclusively. Moreover, the</p><p>ch has not been adequately assessed with racially diverse families, particularly</p><p>mains a signicant public health concern. African American and low- only with a mother and child obesity intervention. No group differences</p><p>y interventions in thefound that, comparedintervention showed</p><p>Eating Behaviors 15 (2014) 225229</p><p>Contents lists available at ScienceDirect</p><p>Eating Be(Adkins, Sherwood, Story, &amp; Davis, 2004; Fisher, Mitchell, Smiciklas-Wright, &amp; Birch, 2002).</p><p>Few parent-exclusive interventions have been empirically evalua-</p><p>greater BMI decreases. Parent satisfaction and adherence were alsohigher in the parent-only condition. A similar study (Boutelle, Cafri, &amp;Crow, 2011) found that parent-only and parent and child conditionsand avoid making the overweight child the identied patient, a situa-tion which could reduce self-esteem and increase disordered eating(Golan &amp; Crow, 2004). Moreover, parents purchase children's food, con-trol mealtime routines, and role-model eating and activity behaviors</p><p>dren in the United States.Preliminary outcomes of parent-only obesit</p><p>United States are promising. Janicke et al. (2008)with a control group, children in a parent-onlyincome children are at high risk of obesity (Ogden, Lamb, Carroll, &amp;Flegal, 2010; Rossen &amp; Schoendorf, 2012). Interventions must addressbarriers to healthy eating and exercise that disproportionally affectthese groups.</p><p>One approach to enhancing pediatric obesity interventions involvestargeting parents exclusively (Janicke et al., 2008). Parent-only inter-ventions are less costly than family approaches (Janicke et al., 2009),</p><p>emerged with respect to children's weight; both groups reduced theirBMI. Trials conducted in Australia (Golley, Magarey, Baur, Steinbeck, &amp;Daniels, 2007; Shelton et al., 2007; West, Sanders, Cleghorn, &amp; Davies,2010) and the Netherlands (Jansen, Mulkens, &amp; Jansen, 2011) yieldedsimilar results. Although these ndings support the utility of a parent-only approach to childhood obesity treatment, it is unclear whetherthey would generalize to racially and socio-economically diverse chil-ted, and most studies have been conducted in</p><p> Corresponding author at: Virginia Commonwealth UnP.O. Box 842018, Richmond, VA 23284-2018, United State</p><p>E-mail address: semazzeo@vcu.edu (S.E. Mazzeo).</p><p>1471-0153/$ see front matter 2014 Elsevier Ltd. All rihttp://dx.doi.org/10.1016/j.eatbeh.2014.01.010amb, &amp; Flegal, 2010) re-tervention experienced greaterweight reductions than those in standardtreatment. In a Swiss study, Munsch et al. (2008) compared a mother-Pediatric obesity (Ogden, Carroll, Curtin, L1. IntroductionKeywords:Pediatric obesityOverweightAfrican AmericanParentingIntervention</p><p>Families (N= 84; 61% AA, 37%White) were randomly assigned to NOURISH or a control group.Results:NOURISH families signicantly improvedon child BMI frompre- to post-testing after adjustment for randomeffects, baseline BMI, and child race. NOURISH parents were very satised with the intervention and would recom-mend it to other parents; 91% strongly or moderately agreed that NOURISH helped them eat in a healthier manner.Conclusions: These pilot data suggest that NOURISH is acceptable and, with renement, offers promise for reducingpediatric BMI. Outcomes, lessons learned, and parent feedback will inform a larger randomized controlled trial.</p><p> 2014 Elsevier Ltd. All rights reserved.</p><p>Crow (2004) found that Israeli children of caregivers in a parent-only in-a culturally-sensitive parenting intervention targeting overweight (AA) children (ages 611; MBMI = 98.0%ile).Available online 03 February 2014 Methods: NOURISH (Nourishing Our Understanding of Role modeling to Improve Support and Health) isAccepted 22 January 2014 African Americans(AA), a group at high risk for elevated Body Mass Index (BMI).Received in revised form 12 December 2013 effectiveness of this approaParent skills training to enhance weight loEvaluation of NOURISH</p><p>Suzanne E. Mazzeo a,, Nichole R. Kelly b, Marilyn SterLaura M. Thornton c, Ronald K. Evans d, Cynthia M. Bula Department of Pediatrics and Psychology, Virginia Commonwealth University, Richmond, VAb Department of Psychology, Virginia Commonwealth University, Richmond, VA, United Statesc Department of Psychiatry, University of North Carolina at Chapel Hill, CB 7160, Chapel Hill, Nd Department of Health and Human Performance, Virginia Commonwealth University, Richmo</p><p>a b s t r a c ta r t i c l e i n f o</p><p>Article history:Received 25 September 2013</p><p>Objective: Although there isternationally. Golan and</p><p>iversity, 806 West Franklin St.,s. Tel.: +1 804 827 1708.</p><p>ghts reserved.in overweight children:</p><p>, Rachel W. Gow b, Elizabeth W. Cotter b,c</p><p>ted States</p><p>599, United StatesA, United States</p><p>eral agreement that parents should be involved in pediatric obesity treatment,</p><p>haviorsyielded similar weight loss and activity outcomes. However, attritionwas higher in the parent-only condition.</p><p>Thus, results of a relatively small number of studies (Boutelle et al.,2011; Golan &amp; Crow, 2004; Janicke et al., 2008) support the feasibilityand effectiveness of a parent-only approach to childhood obesity treat-ment. Most trials included moderately afuent (Boutelle et al., 2011)</p></li><li><p>and ethnically homogeneous samples (Golan &amp; Crow, 2004; Janickeet al., 2007). Research is needed to determine whether results general-ize to low income racially diverse children in the urban United States.Thus, this study evaluated the feasibility, acceptability, and preliminaryeffectiveness of NOURISH (Nourishing Our Understanding of Rolemodeling to Improve Support and Health), a culturally-sensitive,parent-only group pediatric obesity intervention.</p><p>2. Methods</p><p>2.1. Procedure</p><p>To qualify for participation, caregivers had to be at least 18 years oldand have a child (ages 611) with BMI the 85th%ile who primarily</p><p>resided with them. Participants also had to speak English, be able to un-derstand basic instructions, and perform simple exercises. NOURISHand the control group are described in detail elsewhere (Mazzeo et al.,2012). A modication was made to NOURISH implementation afterthe rst two waves of data collection. Parents in these waves reportedthat, although they enjoyed NOURISH, they felt the number of sessions(which was initially 12) should be reduced. To maximize parents' satis-factionwhilemaintaining intervention integrity, the number of sessionswas reduced to six. All topics remained covered by extending the lengthof each session.</p><p>The control group involved one, in-person group session focused onnutrition, exercise, and pediatric obesity. Subsequently, control partici-pants received three mailings of publicly available information onpediatric obesity.</p><p>Assessed for eligibility (n=235 families)</p><p>Excluded (n=151 families) Not meeting inclusion criteria (n=64 families) Declined to participate (n=13 families) Failed to attend orientation (n=74 families) </p><p>Lost to follow-up at post-testing: (n= 15 parents/caregivers, 18 children)*does not include official withdrawal familyParent/Caregiver Reasons: work conflicts (4), phone number disconnected (1), family illness/death (1), failure to return repeated attempts to contact (7), lack of family support (1), no reason given (1)</p><p>Lost to follow-up at 6 months: (n= 30 parents/caregivers, 35children) *does not include official withdrawal familyParent/Caregiver Reasons: work conflicts (3), phone number disconnected (1), family illness/death (2), failure to return repeated attempts to contact (21), lack of family support (1), moved out of country (1), sought out more child-focused services (1), no reason provided (1)</p><p>Discontinued intervention (n=2 families; 2 </p><p>Assigned to intervention (n=44 families; 44 parents/caregivers, 48 children) Attended &gt;50% of sessions (n=22 parents/caregivers) Attended </p></li><li><p>227S.E. Mazzeo et al. / Eating Behaviors 15 (2014) 2252292.2. Participants</p><p>Data were collected at baseline, post-intervention, and 6-monthfollow-up (see Fig. 1). Families were recruited via yers distributed inlocal schools, recreation centers, and pediatric specialists' practices. Eli-gibility was assessed via a phone screen prior to baseline assessment.Approximately 235 caregivers expressed interest in participating.About one third were ineligible, most commonly because child BMIwas below the 85th%ile. Eligible families were invited to an orientation;at this session, consent and assentwere obtained and baselinemeasurescompleted.</p><p>Eighty-four families completed baseline: 91 children (Mage = 8.6 1.5 years) and 90 caregivers (Mage=39.97.4 years). Most participantswere female (85.6% of caregivers; 67.0% of children). The average BMI%ilefor children was 98.0 2.7); mean caregiver BMI was 34.2 9.3 kg/m2.</p><p>The majority of families identied as African American (60.7%),followed by White (36.9%), Hispanic/Latino/a (1.2%) and multiracial(1.2%); 41.7% reported an annual incomeof less than $35,000. Educationalattainment among caregivers varied, the greatest percentage reported ahigh school diploma or more (79.1%); 47.2% of adults were married,34.8% were single, 12.4% were divorced, and 5.6% were separated.</p><p>Overall, 61.9% (n= 52) of enrolled families completed post-testing.Likelihood of post-test completionwas not dependent onwhether care-givers completed the six- or 12-session group (2 = 2.84; p b .10);32.1% (n= 27) of enrolled families completed 6-month follow-up, butparticipating in the six-session compared with the 12-session groupwas not associated with follow-up completion (2 = 0.04; p b .84).For families enrolled in the intervention, average session attendancewas 52.9%.</p><p>2.3. Parent measures</p><p>2.3.1. Three Factor Eating Questionnaire (TFEQ)The restraint and disinhibition subscales of the TFEQ (Stunkard &amp;</p><p>Messick, 1985, 1988) assessed eating behaviors.</p><p>2.3.2. Child Feeding Questionnaire (CFQ)Parental approaches to and attitudes about feeding their children</p><p>were measured with the CFQ (Birch et al., 2001). This measure includesseven subscales: perceived responsibility, perceived parentweight, per-ceived child weight, concern about child weight, pressure to eat, moni-toring, and restriction.</p><p>2.3.3. Anthropometric measuresHeight was measured to the nearest in. using a stadiometer and</p><p>weight was measured to the nearest lb by trained staff; data wereused to calculate BMI.</p><p>2.3.4. Block Food ScreenerDietary intake was assessed by using the Block Food Screener. This</p><p>instrument has been validated against the Block 100-item FFQ (Block,Gillespie, Rosenbaum, &amp; Jenson, 2000). Correlations between theshorter and longer Block FFQ are .69 for total fat (grams/day) and .71for total fruit/vegetable (servings/day; Block et al., 2000).</p><p>2.4. Child measures</p><p>2.4.1. Anthropometric MeasuresHeight was measured to the nearest in. using a stadiometer.</p><p>Weight was measured to the nearest lb; data were used to calculateBMI in kg/m2, which were plotted on the CDC Growth Charts (Ogdenet al., 2002) to obtain BMI%ile for age and gender.</p><p>Items on the following measures were read to children by staff:</p><p>Pediatric Health-Related Quality of Life (PedsQL4.0). The PedsQL</p><p>(Varni, Seid, &amp; Kurtin, 2001; Varni, Seid, &amp; Rode, 1999) assesseshow health affects daily life in four areas: physical, emotional, social,and school. A psychosocial health quality of life score can beascertained by averaging totals of three of these subscales (emo-tional, social, and school functioning).Pubertal status. Children (8 years or older) completed a self-assessment of pubertal status using a pictorial measure (Tayloret al., 2001). This measure was signicantly associated with resultsof physical examinations and is recommended for use in studieswhere clinical examinations are not feasible (Taylor et al., 2001).For children younger than eight, parents reported pubertal status.</p><p>2.5. Statistical analysis</p><p>Independent samples t-tests examined differences in outcomesbetweenparticipantswho completed six versus 12 sessions. To evaluatethe primary outcome of changes in child BMI%ile and the secondary out-comes, analyses of variance were applied using PROC GENMOD. Differ-ence scores were calculated by subtracting post-test values frombaseline values. These difference scores were then considered the out-come variables. Six-month follow-up data were not analyzed becauseof high attrition; only 32.1% (n=27; 16 control, 11 intervention partic-ipants) provided data at this assessment point, thus yielding insufcientpower. Therefore, only pre and post scores were examined. For all anal-yses, child's race, child's sex, and pubertal status were entered as covar-iates. For families with two parents participating, only mothers' scoreswere used in analyses as each family only had one set of CFQ scores.The oldest child's data were used when multiple children within a fam-ily were enrolled. Analyses of differences from baseline to post-testwere conducted on a sample derived by using intent-to-treat metho-dology and also on a sample comprised of only those who completedpost-testing.</p><p>3. Results</p><p>3.1. Primary outcomes</p><p>3.1.1. Child BMI%ileAt baseline, the mean (std) BMI%ile for the NOURISH group was</p><p>98.47 (2.24); for the control group it was 97.86 (2.67). At post-test,the NOURISH group showed a decrease in mean BMI%ile [mean(std) = 98.19 (2.73)]. For the control group, there was virtually nochange in BMI%ile at post-test [mean (std) = 97.86 (2.61)]. Thebetween-group change from baseline to post-test was signicant(2 = 7.14; p-value b .008). Results remained signicant in an ana-lysis including only individuals who completed post-testing (2 =8.67; p-value b .004).</p><p>3.1.2. Secondary outcomesBetween group differences from baseline to post-testwere observed</p><p>for parental fat intake (2 = 5.16; p-value = .024). In the intent-to-treat sample, fat intake in the NOURISH group declined from 147.19(19.15)g to 140.39 (19.38)g. In the control group, fat intake decreasedonly slightly from 142.20 (20.95)g at baseline to 141.41 (23.34)g atpost-testing. This difference in changes remained signicant in analysesincluding only those who completed post-testing. Additionally, therewas a between-group difference on CFQ concern about child weight(2 = 4.20; p-value = .041). Parental concern about child weight de-creased from4.74 (0.48) to 4.58 (0.65) in theNOURISH group comparedto virtually no change in the control group [4.69 (0.47) to 4.66 (0.46)].This difference did not persist in analyses including only those whocompleted post-testing. No group differences were observed for theother variables from baseline to post-test.</p><p>3.1.3. Feasibility and acceptabilityIn addition to completing the measures described above, caregiversin NOURISH completed an exit interview at post-testing (Table 1).</p></li><li><p>Participants were very satised with NOURISH; 79% strongly agreedwith the statement I enjoyed attending eachNOURISH session. The re-maindermoderately agreed; 91.7% strongly agreed that theywould rec-ommend this group...</p></li></ul>

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