Childhood Obesity Clinical Trial
Official title:
Childhood Obesity; a Randomized Controlled Study of Group Treatment Targeting Parents Behaviour
Long term effects of treatment of childhood obesity are not well documented but there is
growing evidence that parental involvement and behavioral changes are strong predictors of
children weight loss. However, which form and content of parental involvement are most
effective is not studied. In the present randomized controlled study we compare the effect
of parent manualized group treatment ("experimental group") to the effect of parent
self-help groups on changes in children Body Mass Index, food intake, physical activity,
quality of life and self esteem. We pose the following hypotheses:
1. Parents participating in the experimental group will have children who achieve a larger
reduction in BMI than children with their parents in the control group.
2. This treatment effect will be mediated by changes in one of several elements of
parents' cognition: outcome expectancies, perceived control, perceived value of
outcome, self-efficacy, perceived reduction in barriers, and subjective norms.
3. Reduction in BMI will correlate with increased quality of life, reduced number and
severity of mental health problems, and increased self-concept.
The prevalence of obesity as increased dramatically in substantial parts of the world during
the last decade, a weight increase also seen in children. This epidemic has also reached
Norway, with a worrying increase in the prevalence of overweight and obese school aged
children. Reports from US studies show a substantial increase in diabetes II among
overweight children. Such an increase is currently not detected among Norwegian children.
However, if the increase in childhood obesity continues or worsens, we should expect the
onset of weight related disorders such as Diabetes II and Cardio-vascular to take place
earlier in life. In addition, there would be an expected increase in psychosocial problems
(poor self-concept, social isolation) and psychiatric symptoms and disorders associated with
obesity (e.g. eating problems and depression). Hence, both preventive and treatment efforts
are called for.
Parents need to be included The treatment of obesity among children has traditionally
addressed the child by means of diet and exercise, often involving in-patient treatment.
Slowly, the evidence concerning the importance of including the parents in the treatment
have emerged as well as the need for addressing the child's wider social context. Hence,
childhood obesity should first and foremost be conceived of as a behavioral problem.
Generally, behaviorally oriented approaches have emerged as the most successful. Such
behavioral procedures have been conducted within a framework of individual consultations to
each child/family. It was reported that after family oriented behavioral treatment 30 % of
the previously overweight children no longer qualified for overweight, whereas 34 % had
sustained minimum 20 % reduction in their overweight. The best predictors of the long term
course of overweight reduction were the family eating and exercise environment, in addition
to support from friends and family. Notably, the intervention group targeting both children
and parents fared best. Such a finding concurs with the conclusion that family and parent
based approaches are associated with weight loss among obese children.
Less is known concerning the specifics of effective parental involvement, that is which form
of parental involvement are most effective and the content of effective interventions.
Therapies targeting individual families are costly to undertake and time consuming for the
family. We therefore need to balance the benefits of family treatment with their costs,
aiming at an optimal intervention level that provides the best therapeutic results with the
lowest degree of investments. We will therefore adopt a group treatment paradigm.
Lessons should be learned from the treatment of other childhood behavioral problems.
Moreover, interventions within pediatric obesity has to a surprisingly little extent drawn
upon the mounting knowledge from successful interventions regarding other types of childhood
behavioral problems, e.g. conduct problems. Such interventions generally try to strengthen
general parenting practices (e.g. limit setting, consistency, anger management, affective
availability) in order to increase the parents' competencies in regulating the child's
problem behavior. The behavioral techniques that traditional obesity intervention programs
try to get parents to adapt at home (e.g. getting their children to exercise more or eat
smaller portions) seem to require some basic parenting skills. When parents fall short of
actually doing what they have learned, it may be due to the fact that regarding eating and
physical activity, the behavior of obese children are especially demanding and putting
parenting skills to the test. Hence, specific training of skills that increase the
likelihood of behavioral change in the parent and in the child should be included in
intervention programs. In doing so, manualized treatment should be encouraged in order to
facilitate replications and clinical use, but is often left wanting. Although some exception
do exist, many studies only include short-term post-treatment outcomes only. Thus, children
need to be followed for longer time periods, due to the fact that short-term weight
reduction is achieved by numerous intervention strategies, whereas long-term weight
reduction should be the primary goal.
Lessons should be learned from general models of health behavior Within a preventive
framework several theoretical models have been devised pinpointing the cognitive and social
factors determining health promoting behaviors, also including health behaviors important
for the development of adiposity in childhood. The predictive power of such models in
determining future health behaviors is high, also when eating and physical activity in
children and adolescents are considered. Such basic knowledge has only to a very limited
extent been integrated into treatment models of obesity in childhood. We hence aim at
targeting those behaviors in parents that may facilitate health promoting behavior in their
offspring. Numerous models of health behaviors exist. Their construct overlap to some
extent, but each have some merits of their own. Our vantage point has therefore been the
arguably most widely accepted model of health behavior, namely Ajzen's Theory of Planned
Behavior, and supplementing it with the barriers towards health promoting behavior element
stemming from the "Health Belief Model" and Bandura's concept of self-efficacy (1977), viz.
the person's beliefs in her/his ability to perform the behavior in question. Figure 1
depicts our theoretical model for the content of the parent based group intervention
program. In addition, we expect that weight reduction will imply additional positive
outcomes for the child including increased quality of life, increased self-concept and
reduction in psychiatric symptoms. However, we should expect that such characteristics of
the child may moderate the effect of the intervention.
The considerations above imply that treatment programs for childhood obesity should:
1. Aim for enduring life-style changes with respect to eating and physical activity. The
treatment should target the family members' habits and cognitions. Low intensity
interventions are the ones that are applicable in most practical contexts, and such
programs demand less extensive efforts and changes of the family's way of living, are
ones that also have the potential for success in the long run.
2. Target the children's behavior by means of involving their parents. We contend that it
is more effective to have the parents regulating their child's eating and exercising
behavior than having health personnel trying to do this directly by treating the child
on his or her own. Parents can thus regulate the stimulus conditions that govern the
child's eating and exercising behavior by reducing cues and possibilities for excessive
intake of fattening foods, and increasing cues and opportunities for physical activity
and healthy eating.
3. Strengthen general and specific parenting skills. Teaching parents about the importance
of healthy eating, meal preparation, and physical activity is not enough to achieve
enduring effects. The main challenge is not for parents not knowing what to do, but
rather actually being able to carry through the behavior in front of challenges or
barriers (e.g. being bereaved of the opportunity to having a snack themselves;
guilt-inducing behavior from the child). By addressing their own behavior and by
teaching specific skills to overcome such barriers, parents may learn new parenting
skills that alter the conditions for their child's behavior in a long-term perspective.
4. Target the parents' cognitions about the effect of their own behavior. The treatment
should address those cognitions that maintain their weight related behavior towards the
child. These cognitions are outlined in Figure 1.
5. Treat parents in groups. Group treatments are cost-effective. In addition, parents of
obese children may learn from the experience of other parents, and they may provide
emotional and social support. Finally, the social control element of reporting of
completion or failure to perform homework between sessions should not be
underestimated. However, in order to secure that the needs of each family/child are
met, individual sessions including weight control should be scheduled.
6. Focus on mastery and solutions. In order to promote treatment optimism the treatment
should address what the family actually has achieved at the expense of failures.
At present we have little knowledge about the demographics and psychosocial characteristics
of clinic-referred children with adiposity in Norway. We will provide descriptive
information about this population concerning medical conditions and nutritional status, as
well as psychological factors and potential psychiatric symptoms associated with overweight.
Moreover, we will address the issue whether successful treatment also will alleviate
psychosocial problems such as self-concept problems and increases quality of life. Finally,
we ask whether weight reduction in the child are associated with changes in the parents'
health beliefs, whether the expected changes in parental health beliefs mediate the effect
of the intervention.
;
Allocation: Randomized, Endpoint Classification: Efficacy Study, Intervention Model: Parallel Assignment, Masking: Open Label, Primary Purpose: Treatment
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