Parents as Agents of Change in Managing Pediatric Obesity: A Randomized Controlled Trial Comparing Cognitive Behavioral Therapy versus Psychoeducation Interventions.

Background: Obesity interventions for parents of children with obesity can improve children's weight and health. This randomized controlled trial (RCT) evaluated whether a parent-based intervention based on cognitive behavioral therapy (CBT) principles was superior to a parent-based intervention based on a psychoeducation program (PEP) in improving children's obesity. Methods: This study was a pragmatic, two-armed, parallel, superiority RCT. Conducted at a Canadian outpatient pediatric obesity management clinic (September 2010-January 2014), this trial included families with children 8-12 years with an age- and sex-specific BMI ≥85th percentile. The 16-week manualized interventions were similar in content and delivered to parents exclusively, with different theoretical underpinnings. The primary outcome was children's BMI z-score at postintervention (4 months). Secondary outcomes included anthropometric, lifestyle, psychosocial, and cardiometabolic variables. Data were collected at preintervention (0 months), postintervention (4 months), 10, and 16 months. Intention-to-treat analysis using linear mixed models was used to assess outcomes. Results: Among 52 randomly assigned children, the mean age (standard deviation) was 9.8 (1.7) years and BMI z-score was 2.2 (0.3). Mean differences in BMI z-score were not significantly different between the CBT (n = 27) and PEP (n = 25) groups from 0 to 4-, 10-, and 16-month follow-up. At 4 months, the mean difference in BMI z-score from preintervention between the CBT (-0.05, 95% CI = -0.09 to 0.00) and PEP (-0.04, 95% CI = -0.09 to 0.01) groups was -0.01 (95% CI = -0.08 to 0.06, p = 0.80). Similar results were found across all secondary outcomes. Conclusions: Our CBT-based intervention for parents of children with obesity was not superior in reducing BMI z-score vs. our PEP-based intervention.

Using Intervention Mapping to develop the Parents as Agents of Change (PAC©) intervention for managing pediatric obesity.

BACKGROUND: Pediatric obesity has become increasingly prevalent over recent decades. In view of the psychosocial and physical health risks, and the high likelihood that children with obesity will grow to become adults with obesity, there is a clear need to develop evidence-based interventions that can be delivered in the health care system to optimize the health and well-being of children with obesity and their families. The aim of this paper is to describe the development, implementation, and planned evaluation of a parent-based weight management intervention designed for parents of 8-12 year olds with obesity. METHODS/RESULTS: The principles of Intervention Mapping (IM) were used to develop an intervention called Parents as Agents of Change (PAC©). From 2006 to 2009, an environmental scan plus qualitative (individual interviews with parents and children), quantitative (medical record reviews), and literature review data were collected to gain broad insight into family factors related to pediatric obesity and its management. Theoretical frameworks and empirical evidence guided curriculum development, which was founded primarily on the tenets of family systems theory and cognitive behavioral theory. PAC was developed as a manualized, 16-session, group-based, health care professional-led intervention for parents to address individual, family, and environmental factors related to the management of pediatric obesity. The intervention was refined based on feedback from local and international experts, and has been implemented successfully in a multi-disciplinary weight management centre in a children's hospital. CONCLUSION: IM provided a practical framework to guide the systematic development of a pediatric weight management intervention for parents of children with obesity. This logical, step-by-step process blends theory and practice and is broadly applicable in the context of obesity management intervention development and evaluation. Following intervention development, the PAC intervention was evaluated within a randomized clinical trial. Trial registration NCT01267097; clinicaltrials.gov.

Predictors of Short- and Long-Term Attrition From the Parents as Agents of Change Randomized Controlled Trial for Managing Pediatric Obesity.

INTRODUCTION: Attrition in pediatric weight management is a substantial problem. This study examined factors associated with short- and long-term attrition from a lifestyle and behavioral intervention for parents of children with overweight or obesity. METHOD: Fifty-two families with children ages 6 to 12 years old and body mass index at or above the 85th percentile participated in a randomized controlled trial focused on parents, comparing parent-based cognitive behavioral therapy with parent-based psychoeducation for pediatric weight management. We examined program attrition using two clinical phases of the intervention: short-term and long-term attrition, modeled using the general linear model. Predictors included intervention type, child/parent weight status, sociodemographic factors, and health of the family system. RESULTS: Higher self-assessed health of the family system was associated with lower short-term attrition; higher percentage of intervention sessions attended by parents was associated with lower long-term attrition. DISCUSSION: Different variables were significant in our short- and long-term models. Attrition might best be conceptualized based on short- and long-term phases of clinical, parent-based interventions for pediatric weight management.

Families' Perceptions of and Experiences Related to a Pediatric Weight Management Intervention: A Qualitative Study.

OBJECTIVE: To examine parents' and children's perceptions of and experiences related to a Parents as Agents of Change (PAC) intervention for managing pediatric obesity. METHODS: Ten families were recruited from a PAC intervention. Participants were interviewed before (10 adults and 9 children), during (9 adults and 8 children), and after (8 adults) the intervention. RESULTS: Before the intervention, families reported goals to increase physical activity, plan and eat healthier meals, reduce screen time, and lose weight. During the intervention, families described different approaches to making behavior changes depending on who assumed responsibility (parent, child, or shared responsibility). After the intervention, group setting, goal setting, and portion size activities were viewed positively. Suggestions for improvement included engaging children and reducing intervention length. CONCLUSIONS AND IMPLICATIONS: Practitioners delivering PAC interventions should discuss families' goals and concerns, and who is responsible for making lifestyle changes. Practical activities are valuable. The length of interventions and engagement of children should be considered.

Lifestyle Behaviors of Parents of Children in Pediatric Weight Management: Are They Meeting Recommendations?

OBJECTIVE: Our objective was to examine the lifestyle behaviors of parents of children in pediatric weight management. METHODS: Parents were recruited upon presentation of their children (body mass index [BMI] ≥85th percentile) to a pediatric weight management clinic. Parents' demographic, anthropometric, and lifestyle habit data were collected by self-report. Parents were grouped into weight status categories based on their BMIs; lifestyle data were compared across BMI categories and to national recommendations. RESULTS: Parents (n = 266; 84% women; BMI, mean ± SD, 31.8 ± 7.2 kg/m(2)) were predominantly overweight/obese (82%), and most did not meet dietary recommendations (71%). Healthy-weight parents reported more daily steps versus parents who were overweight/obese (all P < .05). Most parents (~60%) met guidelines for physical activity, sedentary activity, and sleep. CONCLUSION: The high prevalence of overweight and obesity combined with suboptimal dietary behaviors highlight the need to address both children's and parents' lifestyle habits in pediatric weight management.

The CANadian Pediatric Weight management Registry (CANPWR): study protocol.

BACKGROUND: Over recent decades, the prevalence of pediatric obesity has increased markedly in developed and developing countries, and the impact of obesity on health throughout the lifespan has led to urgent calls for action. Family-based weight management interventions that emphasize healthy lifestyle changes can lead to modest improvements in weight status of children with obesity. However, these interventions are generally short in duration, reported in the context of randomized controlled trials and there are few reports of outcomes of these treatment approaches in the clinical setting. Answering these questions is critical for improving the care of children with obesity accessing outpatient health services for weight management. In response, the CANadian Pediatric Weight management Registry (CANPWR) was designed with the following three primary aims: 1. Document changes in anthropometric, lifestyle, behavioural, and obesity-related co-morbidities in children enrolled in Canadian pediatric weight management programs over a three-year period; 2. Characterize the individual-, family-, and program-level determinants of change in anthropometric and obesity-related co-morbidities; 3. Examine the individual-, family-, and program-level determinants of program attrition. METHODS/DESIGN: This prospective cohort, multi-centre study will include children (2-17 years old; body mass index ≥85(th) percentile) enrolled in one of eight Canadian pediatric weight management centres. We will recruit 1,600 study participants over a three-year period. Data collection will occur at presentation and 6-, 12-, 24-, and 36-months follow-up. The primary study outcomes are BMI z-score and change in BMI z-score over time. Secondary outcomes include anthropometric (e.g., height, waist circumference,), cardiometabolic (e.g., blood pressure, lipid profile, glycemia), lifestyle (e.g., dietary intake, physical activity, sedentary activity), and psychosocial (e.g., health-related quality of life) variables. Potential determinants of change and program attrition will include individual-, family-, and program-level variables. DISCUSSION: This study will enable our interdisciplinary team of clinicians, researchers, and trainees to address foundational issues regarding the management of pediatric obesity in Canada. It will also serve as a harmonized, evidence-based registry and platform for conducting future intervention research, which will ultimately enhance the weight management care provided to children with obesity and their families.

Characterizing severe obesity in children and youth referred for weight management.

BACKGROUND: Severe obesity (SO) in pediatrics has become increasing prevalent in recent decades.The objective of our study was to examine differences in demographic, anthropometric, cardiometabolic, and lifestyle variables in children and youth with SO versus their less overweight/obese (OW/OB) peers. METHODS: A retrospective medical record review of 6-19 year old participants enrolled in an outpatient pediatric weight management clinic was conducted. SO (body mass index [BMI] ≥99(th) percentile) and OW/OB (BMI ≥85(th) and <99(th) percentile) groups were created according to Centers for Disease Control and Prevention definitions. Demographic, anthropometric, cardiometabolic and lifestyle data reported at baseline (pre-intervention) were retrieved. RESULTS: Of the 345 participants, most were girls (56.2%), Caucasian (78.7%), and had family incomes > $50,000/year (65.7%). The SO group (n = 161) had lower HDL-cholesterol and higher liver enzymes, insulin resistance and blood pressure than the OW/OB group (n = 184; all p < 0.01). They also reported higher total energy intakes, fewer steps/day, less moderate-to-vigorous physical activity, and more leisure time screen time (all p < 0.02) than their leaner peers. Compared to the OW/OB group, a higher proportion of individuals in the SO group possessed cardiometabolic risk factors, including high triglycerides (45.8% vs 58.5%), alanine aminotransferase (55.4% vs 81.4%), insulin resistance (55.6% vs 82.1%), systolic blood pressure (11.5% vs 27.3%), diastolic blood pressure (17.8% vs 30.0%), and low HDL-cholesterol (44.6% vs 64.6%; all p < 0.02). Aside from the ~75% of participants (groups combined) who met the daily recommended intakes of grain and meat products, <50% of boys and girls met any of the remaining nutrition and physical activity-related recommendations. Compared to the OW/OB group, greater proportions of children and youth in the SO group failed to meet moderate-to-vigorous physical activity (48.4% vs 31.9%) and leisure-time-screen-time recommendations (43.4% vs 28.3%; both p < 0.05). CONCLUSION: Children and youth with SO have a worse cardiometabolic profile and less favorable lifestyle habits than their OW/OB peers. These differences emphasize the heightened obesity-related health risks associated with SO in the pediatric years.

Predictors of metabolically healthy obesity in children.

OBJECTIVE: To determine the prevalence of metabolically healthy obesity (MHO) in children and examine the demographic, adiposity, and lifestyle predictors of MHO status. RESEARCH DESIGN AND METHODS: This cross-sectional study included 8-17 year olds with a BMI ≥85th percentile who were enrolled in a multidisciplinary pediatric weight management clinic from 2005-2010. Demographic, anthropometric, lifestyle, and cardiometabolic data were retrieved by retrospective medical record review. Participants were dichotomized as either MHO or metabolically unhealthy obese (MUO) according to two separate classification systems based on: 1) insulin resistance (IR) and 2) cardiometabolic risk (CR) factors (blood pressure, serum lipids, and glucose). Multivariable logistic regression was used to determine predictors of MHO using odds ratios (ORs) with 95% CIs. RESULTS: The prevalence of MHO-IR was 31.5% (n = 57 of 181) and MHO-CR was 21.5% (n = 39 of 181). Waist circumference (OR 0.33 [95% CI 0.18-0.59]; P = 0.0002) and dietary fat intake (OR 0.56 [95% CI 0.31-0.95]; P = 0.04) were independent predictors of MHO-IR; moderate-to-vigorous physical activity (OR 1.80 [95% CI 1.24-2.62]; P = 0.002) was the strongest independent predictor of MHO-CR. CONCLUSIONS: Up to one in three children with obesity can be classified as MHO. Depending on the definition, adiposity and lifestyle behaviors both play important roles in predicting MHO status. These findings can inform for whom health services for managing pediatric obesity should be prioritized, especially in circumstances when boys and girls present with CR factors.

Modest treatment effects and high program attrition: The impact of interdisciplinary, individualized care for managing paediatric obesity.

BACKGROUND: There is an urgent need to identify effective weight management interventions in real-world, clinical settings to improve the health of children with obesity. OBJECTIVES: To determine the impact of individualized, interdisciplinary care on the weight status of children with obesity; to assess the relationship between clinical interactions and change in participants' weight status; and to document the degree of program attrition. METHODS: A retrospective medical record review of clinical and administrative data from a paediatric weight management clinic in Edmonton, Alberta, was performed, which included data from a group of five- to 18-year-olds (body mass index [BMI] ≥85th percentile) collected from 2008 to 2012. Demographic, anthropometric and attendance data were retrieved from baseline and follow-up at three-, seven- and 11-month timepoints. The primary outcomes were participants' BMI z-score and change in BMI z-score over time. RESULTS: Data from 165 individuals were included. Among those with follow-up anthropometric data, weight stabilization occurred at three (n=127) and seven months (n=84). For individuals with follow-up anthropometric data at 11 months (n=44), BMI z-score tended to decrease over time (-0.05±0.12 units; P=0.06). Program attrition increased over time (23%, 49% and 73% at three-, seven- and 11-month follow-ups, respectively). Between presentation and three-month follow-up, there was an inverse relationship between the number of clinical appointments attended and change in BMI z-score (r= -0.18; P=0.04), an association that became nonsignificant at seven and 11 months (both P>0.05). CONCLUSION: An individualized, interdisciplinary weight management intervention led to weight stabilization and a modest weight reduction in children with obesity. Strategies to minimize program attrition are needed to optimize family engagement in care and success in managing paediatric obesity.

HISTORIQUE: Il est urgent de trouver des interventions efficaces de gestion du poids en milieu clinique pour améliorer la santé des enfants obèses. OBJECTIFS: Déterminer les effets de soins personnalisés et interdisciplinaires sur le poids d'enfants obèses, évaluer le lien entre les interactions cliniques et les modifications au poids des participants et établir le taux d'abandon du programme. MÉTHODOLOGIE: Les chercheurs ont procédé à une analyse rétrospective des dossiers médicaux et des données administratives d'une clinique pédiatrique de gestion du poids d'Edmonton, en Alberta, qui incluait les données d'un groupe de jeunes de cinq à 18 ans (indice de masse corporelle [IMC] ≥85e percentile) colligées entre 2008 et 2012. Ils ont extrait les données démographiques, anthropométriques et de participation initiales, puis aux suivis de trois, sept et 11 mois. Les résultats primaires étaient l'écart réduit de l'IMC et le changement à cet écart au fil du temps. RÉSULTATS: Les données de 165 personnes ont été incluses dans l'étude. Parmi les personnes qui possédaient des données anthropométriques de suivi, on a observé une stabilisation du poids au bout de trois (n=127) et sept mois (n=84). Chez les personnes qui possédaient des données anthropométriques au suivi de 11 mois (n=44), l'écart réduit de l'IMC avait tendance à diminuer au fil du temps (−0,05±0,12 unités; P=0,06). L'abandon du programme a augmenté dans le temps (23 %, 49 % et 73 % au suivi de trois, sept et 11 mois, respectivement). Entre la présentation et le suivi de trois mois, le lien entre le nombre de rendez-vous cliniques auquel les patients avaient assisté était inversement proportionnel à la modification de l'écart réduit de l'IMC (r= −0,18; P=0,04), une association qui n'était plus significative au suivi de sept et 11 mois (tous deux P>0,05). CONCLUSION: Une intervention personnalisée et interdisciplinaire a suscité la stabilisation du poids et une légère perte de poids chez des enfants obèses. Des stratégies pour réduire au minimum l'abandon du programme s'imposent pour optimiser la participation familiale aux soins et réussir à gérer l'obésité en pédiatrie.

Parents as agents of change (PAC) in pediatric weight management: the protocol for the PAC randomized clinical trial.

BACKGROUND: There is an urgent need to develop and evaluate weight management interventions to address childhood obesity. Recent research suggests that interventions designed for parents exclusively, which have been named parents as agents of change (PAC) approaches, have yielded positive outcomes for managing pediatric obesity. To date, no research has combined a PAC intervention approach with cognitive behavioural therapy (CBT) to examine whether these combined elements enhance intervention effectiveness. This paper describes the protocol our team is using to examine two PAC-based interventions for pediatric weight management. We hypothesize that children with obesity whose parents complete a CBT-based PAC intervention will achieve greater reductions in adiposity and improvements in cardiometabolic risk factors, lifestyle behaviours, and psychosocial outcomes than children whose parents complete a psycho-education-based PAC intervention (PEP). METHODS/DESIGN: This study is a pragmatic, two-armed, parallel, single-blinded, superiority, randomized clinical trial. The primary objective is to examine the differential effects of a CBT-based PAC vs PEP-based PAC intervention on children's BMI z-score (primary outcome). Secondary objectives are to assess intervention-mediated changes in cardiometabolic, lifestyle, and psychosocial variables in children and parents. Both interventions are similar in frequency of contact, session duration, group facilitation, lifestyle behaviour goals, and educational content. However, the interventions differ insofar as the CBT-based intervention incorporates theory-based concepts to help parents link their thoughts, feelings, and behaviours; these cognitive activities are enabled by group leaders who possess formal training in CBT. Mothers and fathers of children (8-12 years of age; BMI ≥85th percentile) are eligible to participate if they are proficient in English (written and spoken) and agree for at least one parent to attend group-based sessions on a weekly basis. Anthropometry, cardiometabolic risk factors, lifestyle behaviours, and psychosocial health of children and parents are assessed at pre-intervention, post-intervention, 6-, and 12-months follow-up. DISCUSSION: This study is designed to extend findings from earlier efficacy studies and provide data on the effect of a CBT-based PAC intervention for managing pediatric obesity in a real-world, outpatient clinical setting. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT01267097.

Pediatric weight management programs in Canada: where, what and how?

Our purpose was to conduct a national environmental scan of pediatric weight management programs in Canada. Data were entered by program representatives regarding the history, structure, and function of their weight management programs using an online survey that our team developed in partnership with the Canadian Obesity Network ( www.obesitynetwork.ca ). Of the 18 programs that were identified, all included multidisciplinary teams that take a family-centred, lifestyle/behavioural therapeutic approach; health services were accessed primarily through physician referral. Most programs were launched in the past five years with public funding and enrolled ∼125 clients/year into one-on-one and/or group-based weight management care. Although many participated in research and were affiliated with academic institutions, most did not systematically evaluate their obesity-related programming. Based on these observations, recommendations related to program evaluation, health services delivery, and network collaborations are provided to inform future directions for research and clinical care that have both domestic and international relevance.

Referrals for pediatric weight management: the importance of proximity.

BACKGROUND: Limited access to weight management care can have a negative impact on the health and well-being of obese children and youth. Our objectives were to describe the characteristics of clients referred to a pediatric weight management centre and explore potential differences according to proximity. METHODS: All demographic and anthropometric data were abstracted from standardized, one-page referral forms, which were received by a pediatric weight management centre in Edmonton, AB (Canada) between April, 2005 and April, 2009. RESULTS: Referrals (n = 555; 52% male; age [mean +/- standard deviation]: 12.4 +/- 2.6 y; BMI: 32.3 +/- 6.8 kg/m2; BMI percentile: 98.4 +/- 1.7; BMI z-score: 2.3 +/- 0.4) were received from 311 physicians. Approximately 95% of referrals were for boys and girls classified as obese or very obese. Based on postal code data, individuals were dichotomized as either living within (local; n = 455) or beyond (distant; n = 100) the Edmonton Census Metropolitan Area. Numerous families resided several hundred kilometres away from our centre. Overall, distant clients were taller, weighed more, and were more overweight than their local counterparts. For distant clients, the degree of overweight was higher in youth versus children. CONCLUSION: Pediatric weight management services must be designed to optimize access to health services, especially for distant clients who may be at increased obesity-related health risk.