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Guided Self-Help for the Treatment of Pediatric Obesity Kerri N. Boutelle, Gregory J. Norman, Cheryl L. Rock, Kyung E. Rhee and Scott J. Crow Pediatrics 2013;131;e1435 ; originally published online April 1, 2013; DOI: 10.1542/peds.2012-2204

 

The online version of this article, along with updated information and services, is located on the World Wide Web at: http://pediatrics.aappublications.o rg/content/131/5/e1435.full.html /e1435.full.html http://pediatrics.aappublications.org/content/131/5

PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly publication, it has been published continuously since 1948. PEDIATRICS is owned, published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk Grove Village, Illinois, 60007. Copyright © 2013 by the American Academy of Pediatrics. All rights ri ghts reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.

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Guided Self-Help for the Treatment of Pediatric Obesity AUTHORS:  Kerri N. Boutelle, PhD,a,b Gregory J. Norman, PhD,c Cheryl L. Rock, PhD, RD, c Kyung Kyung E. Rhee, MD, MSC,a and Scott J. Crow, MDd Departments of    a Pediatrics,   b Psychiatry, and   c Family and  Preventive Medicine, University of California, San Diego, La Jolla, California; and   d Department of Psychiatry, University of    Minnesota, Minneapolis, Minnesota  KEY WORDS

childhood, obesity, guided self-help, treatment

WHAT S KNOWN ON THIS SUBJECT:   Clinic-based weight control programs for pediatric obesity are time and personnel intensive and not accessible to a large proportion of the population. ’

WHAT THIS STUDY ADDS:  This is the   󿬁rst study to reveal the ef 󿬁cacy of a low-intensity, 5-month, guided self-help treatment of  childhood obesity with effects on the target child ’s weight immediately posttreatment and 6 months later.

ABBREVIATIONS

DHQ—Dietary History Questionnaire FFQ—food-frequen food-frequency cy questionnaire questionnaire GSH-PO—guided self-help treatment of pediatric obesity MAR—missing at random T— time %OW—percentag percentagee overweight Dr Boutelle conceived of the project, designed the study, collected the data, supervised the interventionists, contributed  to data analysis and interpretation, and drafted the manuscript manuscript;; Dr Norman collaborated on project conception and design of the study, analyzed the data and contributed to the interpretation, and revised the manuscript for intellectual content, speci 󿬁cally focusing on methods and physical activity; Dr Rock collaborated on project conception and the design of the study, contributed to data analysis and interpretation, and collaborated in writing and revising the manuscript, speci 󿬁cally focusing on nutritional assessment and interpretation; Dr Rhee collaborated on the design of the study, assisted with data collection, contributed to data analysis and interpretation, collaborated on supervising  the interventionists, and collaborated collaborated in writing and revising the 󿬁 manuscript, speci cally focusing on medical and parenting issues; and Dr Crow conceived of the project (with Dr Boutelle), collaborated on the design of the study, contributed to data analysis and interpretation, collaborated on supervising the interventionists, and collaborated in writing and revising the manuscript,, speci󿬁cally focusing on the provision of the guided manuscript self-help intervention. All of the authors contributed to the manuscript and publically take responsibility for its content. This trial has been registered at   www.clinicaltrials.gov (identi󿬁er NCT01145833). www.pediatrics.o www .pediatrics.org/cgi/doi/10.15 rg/cgi/doi/10.1542/peds.2012-2204 42/peds.2012-2204 doi:10.1542/peds.2012-2204 Accepted for publication Jan 3, 2013 Address correspondence to Kerri N. Boutelle, PhD, Pediatrics and Psychiatry, University of California, San Diego, 9500 Gilman Dr, MC 0985, La Jolla, CA 92037. E-mail:  E-mail:   [email protected] [email protected] sd.edu (Continued on last page)

PEDIATRICS Volume 131, Number 5, May 2013 May 2013

abstract BACKGROUND AND OBJECTIVE:   Clinic-based programs for childhood obesit obe sityy are not availab available le to a large large proport proportion ion of the pop popula ulatio tion. n. The purpose of this study was to evaluate the ef 󿬁cacy of a guided

self-h sel f-help elp treatm treatment ent of pediat pediatric ric obe obesit sityy (GS (GSH-P H-PO) O) compar compared ed with with a dela delayed yed treat treatmen mentt contro controll and to evalua evaluate te the imp impact act of GSH-PO GSH-PO 6-months posttreatment. METHODS:  Fifty overweight or obese 8- to 12-year-old children and  their parents were randomly assigned to immediate treatment or  to delayed treatment. The GSH-PO includes 12 visits over 5 months and addresses key components included in more intensive clinic-based progr programs ams.. Childr Children en and parent parentss in the imm immedia ediate te treatm treatment ent arm weree assess wer assessed ed at tim timee 1 (T1), (T1), particip participate ated d in GSH-PO GSH-PO between between T1 and T2, and completed their 6-month posttreatment assessment at T3. Children and parents in the delayed treatment arm were assessed at T1, participated in GSH-PO between T2 and T3, and completed their 66-mo mont nth h po post sttr trea eatm tmen entt as asse sess ssme ment nt at T4. T4. Th Thee main main ou outc tcom omee measures were BMI, BMI   z  score,  score, and percentage overweight (%OW). RESULTS: Children in the immediate treatment GSH-PO arm decreased  their BMI signi󿬁cantly more than did the delayed treatment arm (BMI group 3  time = 21.39;  P  , .001). Similar results were found for BMI   score and %OW. At the 6-month posttreatment assessment, changes z  score resulting resu lting from GSH-PO were maintained for BMI  z  score and %OW but not BMI (BMI time effect =   20.06, not signi󿬁cant; BMI   z  score time effect =   20.10,   P  ,  .001; %OW time effect =   24.86,   P   , .05). CONCLUSIONS: The GSH-PO showed initial ef 󿬁cacy in decreasing BMI for children in this study. Additional ef 󿬁cacy and translational studies are needed to additionally evaluate GSH-PO.  Pediatrics  2013;131:e1435   2013;131:e1435– e1442

 

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Recent data suggest that 31% of childrenintheUnitedStatesareoverweight or obese,1 affecting 4 to 5 million children. Family-based behavioral treatment of childhood obesity that combines nu trition  triti on and exercise exercise educatio education n with behavio haviorr thera therapy py tec techni hnique quess has has been been shown to be effective,2 and one-third of 

a decrease in BMI in children. We also evalua eva luated ted whet whether her the int interv ervent ention ion promoted improvements in eating behavior hav ior and phy physic sical al act activit ivityy among among children and parents and a decrease in BMI in the the pare parent nts. s. In addi additi tion on,, we evaluated whether the guided self-help  treatment of pediatric obesity (GSH-PO)

control. Parents and children assigned  to the immediate intervention started GSH-PO after the baseline assessment [timee (T) 1]. Immedi [tim Immediate ate int interv ervent ention ion families also attended attended postt posttreatm reatment ent (T2) and 6-month posttreat posttreatment ment (T3) assessments. Delayed treatment families attended attended a baseline baseline assessment assessment

childr children en tr treat eated ed are no longer longer overoverweightt in adul weigh adulthoo thood. d.3,4 However However,, there are a number of barriers that limit accessibility to these treatments for overweight wei ght and obe obese se child childre ren, n, includ including ing  time needed needed to cou counsel nsel families, families, reimbursement, and the ability of primary care practitioners to deliver behavioral  treatmen  trea tment. t.5 Ve Very ry few provi provider derss have have  training  tra ining in the theo theory ry and techniqu techniques es of  behav beh avior ior the thera rapy py nee needed ded to provi provide de 6  thesee trea  thes treatmen tments. ts. Moreover, childhood obesity obes ity is cons consider idered ed an epid epidemic, emic, and it

int interv ervent ention ion led to mainte maintenan nance ce of  int interv ervent ention ion out outcom comes es at 6-month 6-monthss posttreatment.

(T1) and waited 5 months before at tending another  tending anotherass assessm essment ent (T2) (T2)to to start  treatmen  trea tment. t. After After treatmen treatment, t, the delayed delayed  treatmen  trea tmentt families att attended ended a posttreat posttreat-ment assessment assessment (T3) and a 6-month 6-month posttreatment assessment (T4).

󿬁

is unlikely that there will ever be suf  cien cientt trai traine ned d re reso sour urce cess to ad addr dres esss  the large large number number of case casess that exist exist.. To disseminate disseminate these trea treatmen tments ts to a greater grea ter prop proportion ortion of the popu populatio lation, n, alternative models of delivery must be developed. Guided self-h Guided self-help elp tre treatm atment ent inc includ ludes es off offerin ering g struct structurealongwith urealongwith a self-h self-help elp progr pro gram am to enhanc enhancee adhere adherence nce and impleme imp lementa ntatio tion n of the pro progra gram. m. The guidance offered is not therapy in its purestt sense, pures sense, but includes includes clarifying clarifying materials, helping familiesanswering remain onquestions, task, and modifying the program to  󿬁 t the individual family ’s needs. This form of guidance makes ma kes th thee dida didact ctic ic mate materi rial al more more readil rea dilyy access accessible ible to users users with with diverse levels of literacy or educational backgrounds. Ultimately, a guided selfhelp program could be adeptly administered by primary care practitioners or oth other er hea health lth care care pro provid viders ers with with minimal training. Thus, the purpose of this study was to assess the extent to which a guided self-help intervention, compared with a delayed delayed tre treatm atmentcontr entcontrol, ol, res result ulted ed in

METHODS Children aged 8 to 12 years who were overweight or obese (BMI percentile: 85th to 98th) and their parents were recruited through a number of methods, includ including ing newspaper newspaper adverti advertisesements, ment s, list serves, serves, pedia pediatrici trician an referrals referrals,, and direct mailing. We limited the upper end of BMI for children to the 98th

Treatment sessions were conducted at  the University of California, San Diego, an and d th thee stud studyy was was appr approv oved ed by th thee University of California, San Diego, Institutional Review Board. All treatment sessio ses sions ns wer weree led by gr gradu aduate ate stustudents in clinical psychology. All inter-

percentile because those with higher BMIss are signi󿬁can BMI cantly tly mor moree like likely ly to presen pre sentt with with obesit obesity-r y-rela elated ted hea health lth 7 comorbidities and require require mor moree in tensive treatment. Because these children dre n are not yet signi signi󿬁cant cantly ly obese,  they are more likely to respond to a minimal intervention such as GSH-PO and prevent additional development of  obesity. At least 1 parent or guardian particip part icipate ated d with the chi child. ld. Fa Famili milies es weree exclud wer excluded ed if either either the child or pa pare rent nt was was cu curr rren entl tlyy in invo volv lved ed in

ventionists attended a 4-hour training regarding behavioral intervention for  the study and were supervised by the 󿬁rst author on a weekly basis during  treatment.

any other psychological or weight-loss  treatment, was using medications that affected affect ed appetite or weight, weight, had a psychi chiatr atric ic condit condition ion,, or did not speak  speak  English. Englis h. Parents Parents provided written informed formed con consen sent, t, and chi childr ldren en comcompleted an assent. If a family responded to an advertisement, men t, and had a chi child ld tha thatt could could qualify qualify,,  they were invited for an assessment at whic which h their their heig height ht and and weigh weightt wou would ld be meas me asur ured ed and and wher wheree th they ey wo woul uld d complet com pletee sur survey veys. s. Fifty Fifty par parent ent-ch -child ild

clinics clini cs.. Famili amilies es rece receiv ived ed a pa pare rent nt manual, a child manual, and an activi ties manual. The activities manual was designed to provide activities and game gamess that that pa pare rent ntss and and chil childr dren en could do together to enhance program learnin lear ning g at home. home. The parent parent,, child, child, and activity manuals focused on the same  topics each week, week , with the exception of  parenting skills, and the information in  the child manuals was provided in ageapprop app ropriat riatee lan langua guage. ge. The manual manualss were designed by the project team to

pairs were randomly assignednumbers by using computer-generated computer-gener ated random  to a GSH-P GSH-PO O or a delayed delayed treatmen treatmentt

address addr essbehavior the themajorcompone majorcomponents ntsprograms of familyfamily based beha vioral al treatment treatment prog ramsfo forr ch chil ildh dhoo ood d ob obes esit ityy in a self self-h -hel elp p

GSH-PO

The GSH-PO GSH-PO int interv ervent ention ion inc includ luded ed 12 visits visi ts ove overr 5 months months.. The treatm treatment ent freque frequency ncy and time time for vis visits its (ev (every ery other week for 20 minutes) was deliberately liber ately chosen to develop develop a method method  that could be used in primary care

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manner.. Topics for the manner the manuals manuals included included  the caus causes es of childhood childhood obesity obesity,, the  traf 󿬁c lig light ht eat eating ing pla plan, n, sti stimul mulus us con contro trol,l, increasing physical activity, decreasing sedentary seden tary activity activity,, incr increasin easing g lifest lifestyle yle activity, motivation, teasing, body image, cognitive skills, social support, planning for hig high-r h-risk isk sit situat uation ions, s, and rel relaps apsee 8

prevention. Families were told to read  the assigned chapter in the parent and child manuals between visits, apply the skills, and complete any activities from  the activities activities manu manual al that were of in terestt to their family.  teres family. Meetings with the interv Meetings intervention entionists ists were amaximumof20minutesinlength,with  the exception of session 2, which was desi design gned ed to be 1 hour hour to allo allow w for for  time to discuss the dietary recommendat men dation ions. s. Visits Visits wer weree focuse focused d on monitoring weight of parent and child, 󿬂

re ectingonchildandparentbehaviors  that led to any weight changes (to improve self-regulation), answering any questions quest ions regarding regarding program program material, material, and problem solving any barriers to implementing program recommenda tions. Parents and children were given self-monitoring booklets and were told  to write down their food intake and physical activity daily in as much detail as possible. Interventionists also collec lecte ted d se selflf-mo moni nito torin ring g book bookss from from parents and children and praised them for any self-monitoring or other program efforts. Delayed Treatment Control

The delayed treatment group did not have any contact with the project team during the 5-month delay, and they received the GSH-PO intervention starting at T2.

Child Outcomes Child BMI 

The primary outcome measures in this  trial were child body size measures, including child BMI, BMI   z  score, and percentage perc entage overweight (%OW). Child height was measured by using a por table Schorr height hei ght board (Schorr Inc, Olney Oln ey,, MD) in dup duplica licate. te. Body Body weight weight was measured in duplicate on a Tanita digitall scale (model WB-110A digita WB-110A;; Tanita, Arlington, IL), and the average of the 2 values was used in analyses. analyses. Height and 2 weight were converted to BMI (kg/m ) and translated to BMI-for-age percen tile score by using the Centers for Disease Control and Prevention growth charts.9 Child %OW was calculated by usi using ng the follow following ing formul formula: a: %OW = 100*(BMI 2 M)/M, where M is the median BMI for gender and age according  to the Centers for Disease Control and Prevention growth chart data  󿬁 les. Dietary Intake 

Dietaryy intakeof Dietar intakeof thechild wasassessed wasassessed with three 24-hour dietary recalls with  the child (and with the parent present) at eac each h ass assess essmen mentt point point on 3 nonnonconsecutive days by telephone. Valida tion studies have provided support for  the use of this method of dietary assessment sessm ent for children. children.10–12 All of the inte interv rview iewss us used ed the the Nutr Nutrit ition ion Da Data ta

Physical Activity 

All measurements were completed by all pa parti rtici cipa pant ntss at T1 T1,, T2, T2, and and T3. T3. Measurements were completed at T4 by the delayed treatment group only. Demographic Demogr aphic char characteris acteristics tics were reported by the parents at T1.

activity intensities were determined from 14,15  th  the e Freed Freedson son age-ad age-adjus justed ted equ equati ation. on. Sede Sedent ntar aryy ti time me wa wass de dete term rmin ined ed as

PEDIATRICS Volume 131, Number 5, May 2013 May 2013

Parent Outcomes Parent BMI 

Parent height and weight were measured in the same manner as for the 2 child and translated to BMI (kg/m ). Parent Dietary Intake.

The Dietary History Questionnaire (DHQ) is a cognitiv cognitively ely based based foo food-fr d-freque equency ncy questio que stionna nnaire ire (FF (FFQ) Q) develop developed ed by the National Cancer Institute to assess dietary intake and nutrient consumption (http://www.riskfactor.cancer.gov/DHQ). http://www.riskfactor.cancer.gov/DHQ). Va Valida lidatio tion n stu studieshave dieshave rev reveale ealed d the DHQ  to be an improvement over the Block  FFQ and the Willett FFQ.16,17 The DHQ has been been widely widely use used d in normal normal-wei -weight ght,, overweight, and obese populations to assess dietary intake18–20 and change in dietary intakes during intervention  trials.21 Parent Physical Activity 

The Global Physical Activity Question22

Systems for Research nutrient calculation software and food content database (http://www.ncc.umn.edu/products/ (http://www.ncc.umn.edu/products/ ndsr.html). ndsr.html ).

Ph Phys ysic ical al acti activi vity ty of th thee ch chil ild d wa wass assess ass essed ed by usi using ng GT1M GT1M Actigr Actigraph aph acceleromet accele rometers ers (Actigraph (Actigraph,, Inc, PenPensacola, FL). Actigraph technology has been shown to be valid for quantifying quantifying activity activ ity levels in la labo borrat ator oryy an and d   󿬁eld 13 settings. Ligh Lightt and moderat moderate-to e-to-vigo -vigorous rous

Outcome Measures

accelerometer counts between 0 and 100. Activity categories were summed  to calculated minutes of valid days (.10 hours), and each category was reported as a percentage of total Actigraph wear-time to adjust for difference encess in the the am amou ount nt of tim imee the the children wore the accelerometers.

naire is aof16-item 16-i tem compr comprehen ehensiv sivee assessment health-related physical ac acti tivi vity ty an and d se sede dent ntar aryy beha behavi vior or in adults and captures a range of daily physical physic al activity activity habits: habits: occupationa occupational,l, active active trans transport portati ation, on, leisur leisure, e, and sedentary behavior. The Global Physical Act Activit ivityy Questio Questionna nnaire ire has been been validat vali dated ed agains againstt object objective ive and selfself22 report measures of activity. Acceptability and Liking Survey 

After treatment, children and parents completed a brief survey their acceptability and liking of about the GSH-PO program.

 

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Statistical Analysis

Initial tests of treatment group differen ence cess in ch child ild and and pare parent nt base baselin linee demogr dem ograph aphic ic cha charac racter terist istics ics were were 2 conducted with  x   tests for categorical variables variabl es and   t   tests for contin continuous uous variables varia bles.. Maxim Maximum um likelihood likelihood repeated repeated-measures models tested between-group between-group differences over time. Analyses were differences conducted by using all available data assumi ass uming ng dat data a wer weree missin missing g at ranrando dom. m. Mode Models ls were were sp spec ecii󿬁ed with with a between-subject factor of treatment group (0.5 = GSH-PO immediate treatment;   20.5 = delay delayed ed trea treatm tmen ent) t),, a wi with thin in-s -sub ubje ject ct fact factor or of time time (0 = ti time me 1 base baseli line ne,, 1 = time time 2 post post–immediate  treatmen  trea tment, t, 2 = 6 months months post post–immediate  treatme  tre atment) nt) and the trea treatmen tmentt   3   time interaction. In addition, the 2 treatment gr group oupss wer weree comb combine ined d in repea repeated ted-measures models to test for sustained  treatmentt effects  treatmen effects fro from m baseline baseline to 6 months posttreatment. All analyses were conducted by using SPSS SPS S 19 (SPSS (SPSS Inc Inc,, Chicag Chicago, o, IL) IL).. P values were not adjusted for multiple tests. All reported  P  values   values are for 2-sided tests with effects considered to be statistically signi󿬁cant at  P  , .05.

TABLE 1   Sample Demographic Characteristics by Study Group

Child Gender, % (n ) Girls Boys Age, mean 6 SD, y Ethnicity, % (n ) Asian African American Native Hawaiian/P Hawaiian/Paci aci󿬁c Islander Hispanic White Parent Gender, % (n ) Female Male Age, mean 6 SD, y Ethnicity, % (n ) Asian African American Hispanic White Marital status, % (n ) Married Never married or divorced Income, % (n ) ,$20,000–$60,000 .$60,000 Don’ t  t know Education, % (n ) Less than college degree College degree Master ’s or professional degree BMI, mean 6 SD Parents’  weight, % (n ) Normal weight Overweight Obese

Immediate (n  =   = 25)

Delayed (n  =   = 25)

60.0 (15) 40.0 (10) 10.3 6 1.3

64.0 (16) 36.0 (9) 10.5 6 1.4

4.0 (1) 8.0 (2) 4.0 (1) 12.0 (3) 72.0 (18)

12.0 (3) 4.0 (1) 0.0 16.0 (4) 68.0 (17)

84.0 (21) 16.0 (4) 42.9 6 5.7

82.6 (19) 17.4 (4) 43.2 6 4.8

8.0 (2) 12.0 (3) 4.0 (1) 76 (19)

17.4 (4) 0 8.7 (2) 73.9 (17)

88.0 (22) 12.0 (3)

78.3 (18) 21.7 (5)

8.0 (2) 84.0 (21) 8.0 (2)

21.7 (5) 69.6 (16) 8.7 (2)

40.0 (10) 36.0 (9) 24.0 (6) 27.5 6 6.1

26.0 (6) 17.4 (4) 56.5 (13) 27.9 6 6.1

48.0 (12) 20.0 (5) 32.0 (8)

36.0 (9) 36.0 (9) 28.0 (7)

RESULTS Recruitment and Completion

dyads in this study study.. Seventy-four Seventy-four fami-

Comparison of Immediate

Table able 1   shows samp sample le demog demograph raphic ic characteristics by group. No statistical diff differ eren ence cess we were re foun found d be betw twee een n groups on any of the child or parent demographic characteristics. At baseline, 64.0% of the immediate treatment group were obese and 68.0% of those in delayed delayed tre treatm atment ent gro group up wer weree obese obese [ x 2(1) = 0.089,  P  =  = .765]. At baseline, 5 of the GSH-PO GSH-PO immedia immediate te tre treatm atment ent parents were overweight and 8 were obese. In the delayed treatment group, 9 of the parents were overweight and 7 parents were obese.

lieswere schedu scheduled led for an ass assess essmen ment, t, and 50 were enrolled in the trial and were randomly assigned to the immediate treatment or delayed treatment arm. No parent-child pairs were lost in  the delayed treatment arm from T1 to T2. Twenty-󿬁ve parent-child pairs star ted treatment in both immediate (T1) and dela delayed yed tre treatm atment ent (T2 (T2)) tim timee poi points nts,, and 22 families   󿬁nished treatment in both both arms arms (12% (12% drop dropou outt to tota tal) l).. No parent-child pairs were lost between posttreatment and 6-month follow-up  time points.   Tabl Tablee 2   sho shows ws th thee obobserved body size (means and SD) at each assessment point.

Treatment and Delayed Treatment Control Groups (T1 to T2)

Figure 1 shows 1  shows the study recruitment and comple completion tion rate rate of par parent ent-ch -child ild

Table 2 shows 2  shows that from T1 to T2 child outcomes decreased in the immediate  treatment group but remained the sa same me or in incr crea ease sed d in th thee dela delayed yed  treatment control group. Table 3 shows 3 shows parameter estimates for the repeatedmeasures models. The intercept is the initial status of the sample at T1. The group gro up parame parameter ter is the dif differ ferenc encee between groups at T1. As expected, no differences were found because of ra rando ndom assign ass ignmen ment tonge group groups. s. The tim time e mpar parame ameter ter is tchange cha from T1 to T2 experienced by both groups.

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(P , .001). A similar differential change between groups was found for child BMI   z   score score (20.24) and child %OW (28.31) (P  , 0.001). In a mixed-model mixed-model including only those parents with a BMI .25 (n   = 29), the group   3   time in teraction was 20. 0.72 72 (S (SEE = 0.40; 0.40; P = .0 .08) 8),, sugges sug gestin ting g a change change in parent parent BMI  that did not reach statistical signi󿬁cance. Comparison of Maintenance of  GSH-PO for the Combined Immediate and Delayed Treatment Groups

We comb combin ined ed the the im imme medi diat atee and and delayed treatment groups by matching baseline, posttreatment, and 6-month follow-u foll ow-up p points(ie,T1, points(ie,T1, T2,and T3 for the immediate treatment group; T2, T3, and T4 for the delayed treatment treatment group). group). Table 2 shows 2 shows the pattern of means for

FIGURE 1 Study enrollment and retention.

The group   3   time interaction interaction is the differential change from T1 to T2 in the immediate treatment group compared with the del delayedtreatm ayedtreatment ent gro group up,, whi which ch represents repres ents the interv intervention ention treatm treatment ent effect. For child BMI, the group

3

 time

interaction indicated interaction indicated a statistica statistically lly signi󿬁cant treatment effect of a BMI point change of  21.39 (95% CI: 21.91  to 20.87) in the immediate treatment grou group p comp compar ared ed wit with h th thee dela delaye yed d  treatment control group from T1 to T2

TABLE 2  Observed Weight Data at Each Assessment Point

Child BMI Immediate Delayed Child BMI  z  score  score Immediate Delayed Child, %OW Immediate Delayed Parent BMI Immediate Delayed

T1

T2

T3

T4

24.07 6 1.92 24.40 6 2.55

23.34 6 2.11 25.17 6 2.79

24.03 6 2.64 24.48 6 3.01

 

1.71 6 0.25 1.71 6 0.28

1.49 6 0.32 1.74 6 0.30

1.50 6 0.37 1.56 6 0.34

 

39.35 6 9.27 40.21 6 11.09

32.75 6 10.65 42.37 6 12.37

34.05 6 12.71 36.04 6 12.47

27.53 6 6.11

26.79 6 6.43

27.15 6 6.46

27.90 6 6.05

28.01 6 6.22

27.46 6 5.91



1.55 6 0.39  



38.97 6 12.60 —

28.31 6 5.93

Data are means 6 SDs. Sample sizes for immediate group are as follows: T1,  n  =   = 25; T2,  n  =   = 22; T3,  n  =   = 22. Sample sizes for delayed group are as follows: T1,  n  = 25; T2,  n  =   = 25; T3,  n  =   = 22; T4,  n  =   = 22.

PEDIATRICS Volume 131, Number 5, May 2013 May 2013

some of their weight postintervention,  their normed weight change was still statistically different from baseline. No dif differ ferenc encee was found found for change change in parent BMI (20.17; SE = 0.22,  P  =  = .446) from baseline to the 6-month follow-up.



25.01 6 3.23

 

child and parent body size outcomes from baseline to the 6-month follow-up. Outcomes Outco mes gener generally ally decreased decreased from pre- to postinterve postintervention ntion and then increased from post- to 6-month followup.   TTab able le 4   shows shows the par parame ameter ter estimates estima tes for the repea repeated-me ted-measure asuress models mod els.. For child child outcom outcomes, es, cha change nge in BMI was not statistically signi 󿬁cant. However, the age- and gender-adjusted measur mea sures es of BMI z scor scoree (20. 0.10 10)) and and % OW (24.86) were signi󿬁cant, indicating  that although children did gain back 

Child and Parent Physical Activity  and Dietary Outcomes From T1 to T2

No between between-gr -group oup dif differ ferenc ences es were were fo u un n d f ro m T 1 t o T 2 f o r c h i lld d acceleromet accele rometer-meas er-measured ured sedentary sedentary,, light, or moderate-to-vigorous physical activity. No differences were found be tween groups for child total energy,

 

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Parameter arameter Estimates for Child and Parent Outcomes From T1 TABLE 3   Repeated-measures Model P  to T2 Outcome Child BMI BMI z   score %OW Parent a BMI

Intercept

Group

24.23 (0.31)** 1.71 (0.04)** 39.78 (1.42)**

Time

20.32

 

 

(0.62) 0.01 (0.07) 20.86 (2.83)

 

1.15 (2.03)

31.34 (1.01)**

Group 3 Time

 

0.06 (0.13) (0.02)** 21.99 (0.75)

 

(0.26)** (0.04)** 28.31 (0.75)**

 

20.20

 

20.73

(0.20)

21.39

 

20.09

 

20.24

(0.40)

Data are estimates (SE). Sample sizes for parents are as follows: T1,  n  =  = 13; T2,  n  =  = 11. Sample sizes for delayed group are as follows: T1,  n  = 16; T2,  n  = 16. **P  , .001. a Includes only overweight and obese parents.

percentage of energy from fat, or log transformed servings for fruits and vegetables per 1000 kcal. No difference was found for parent total metabolic equivalent task minutes per week of  moderate-to-vigorous physical activity. No between between-gr -group oup differe difference ncess were were found fou nd for par parent ent energy energy int intake ake and percentage of energy from fat. Acceptability and Liking of GSH-PO Intervention

All fam familie iliess (immed (immediat iatee and dela delayed yed  treatment) completed the acceptability and liking survey posttreatment. One hundred percent of parents said that  they liked the program, 74% liked the program   “a lot ”   or   “loved it.”   Ninety three percent of the children liked the program, 55% liked it   “a lot ”  or   “loved it.”   EightyEighty-thr three ee per percen centt of par parent entss would wou ld re reco comm mmen end d th thee prog progra ram m to other families, and 77% of the children  thought that other children their age would like the program.

TABLE 4   Repeated-measures Model Parameter Estimates for Child and Parent Outcomes From Baseline to 6 Months After Treatment Outcome Child BMI BMI z   sc scor oree %OW Parent BMI

Intercept

Time

24.61 (0.34)** 1.72 1.72 (0 (0.0 .04) 4)** ** 39.35 (1.82)**

   

-0.06 (0.12) (0.02)** 24.86 (1.90)*

31.37 (1.03)**

 

20.17

20.10

(0.22)

Baseline to 6-months after treatment was T1 to T3 for immediate treatment; and T2 to T4 for delayed treatment. *P  , .05, **P  , .001.

In reference to changing their lifestyle, 95% of the parents found the program helpful in changing the lifestyle of the child and family, 85% found the traf 󿬁c light light prog progra ram m helpf helpful ul,, and and 71% of  parents thought that the program helped their child to have more control over eating. Ninety-󿬁ve pe perc rcen entt of the the pare parent ntss reported reporte d that the interv intervention entionist ist feedback to questions was helpful ( “somewhat ” or  “ very”), and 90% thought that  the dietary advice and 90% thought the physic phy sical al act activit ivityy advice advice was hel helpfu pfull (“somewhat”   or   “very”). Ninety-three Ninety-three percen per centt of par parent entss rated rated the wee weekly kly we weig ighi hing ng he help lpfu full (“somewhat”   or and 90 90% % foun found d th thee posi positi tive ve “very ”), and parenting advice helpful (“somewhat” or   “very”). Finall Finallyy, 95% of pa pare rent ntss  thought that being accountable for  their child’s be beha havi vior or wa wass help helpfu full (“somewhat”  or   “very”).

DISCUSSION To our our kn know owled ledge, ge, this this is th thee   󿬁rst evaluation of a guided self-help treatment of overweight or obese children. The GSH-PO intervention showed a signi󿬁cant decrease in child BMI, BMI   z  sc scor ore, e, and and %OW im imme medi diat atel elyy af afte terr completing the 5-month treatment. In addition, addit ion, the intervention intervention resul resulted ted in decreases in child BMI   z  score   score and % OW tha thatt were were mai mainta ntained ined 6 months months after the intervention. It is inte intere rest stin ing g that that ther theree wer weree no differences in the other child or parent

measures in this study. Recent reviews report rep ort biases biases in self-r self-repo eported rted mea mea-sures of diet in children,23 but there should be less bias in the accelerometer measurements. Studies in adults show that changes in diet are necessary for weight loss, whereas physical activity is more important for weight maintenance.24,25 We believe believe that the changes in body size in the children were most likely related to changes in  their diets, but these were likely to be in inac accu cura rate tely ly repo reporte rted, d, a wellwellrecognized limitation of self-reported dietary data. Intermsofparentoutcomes,therewere no statistically statistically signi󿬁can cantt change changess in parent BMI, diet, or physical activity in  this study. study. We allowed parent parent weight sta status tus to var varyy in our recruitm recruitment ent for this study, resulting in a sample of normalweightt and overweig weigh overweight ht parents parents.. However, we evaluated parent weight loss in only the overweight parents and found decrease of nearly .75 points in BMI for  the immediate immediate treatment treatment compar compared ed with delayed treatment group but did not have adequate statistical power to detect this betweenbetween-group group difference. difference. Parent diet and physical activity were measur meas ured ed by self-rep self-report ort instrum instruments ents and are also subject to bias. The GSH-PO intervention has a number of stren strength gths. s. It is a low-int low-intens ensity ity in tervention, which could be easily  translated to primary care providers or otherhealth careproviders.The GSH-PO intervention interve ntion provides provides 4.5 ho hour urss of  direct contact over 5 months, as opposed to the 30 hours of clinic familybased treatment programs. It has the potential to be more cost-effective and represents a potential advancement in  the ef 󿬁ciency of current standards of  caree for ove car overwe rweigh ightt and obese obese chi chilldren. dre n. In additio addition, n, it can be adminis adminis- tered to families on an individual family basis, bas is, which which allows allows for   󿬂exib exibilit ilityy in scheduling.  



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ARTICLE

GSH-PO empha emphasizes sizes   “self-help ”   and places less signi󿬁cance on the role of   the interventionist by shifting the emphasis to the individual family as the primary agent of change. This shift in emphasis has the potential to provide greater great er self-ef 󿬁cac cacyy to chi childr ldren en and parent par ents. s. In additio addition n to pro provid viding ing the

population, including those who might not not norm normall allyy se seek ek mo more re in inte tens nsive ive interventions. In addition, GSH-PO may be mo more re ea easi sily ly inco incorp rpor orat ated ed in into to checkups and visits so that it can becomee a part of rou com routin tinee health health care. Becaus Bec ausee pri primar maryy car caree provid providers ers ini tially detect and screen for obesity,

families with speci󿬁c information and  tools for behavior change, this treatment model may also provide greater self-suf 󿬁ciency and self-ef 󿬁cacy to the parents and children that may make  the treatment effects more durable over time.

providing these skills in primary care of 󿬁ces could reduce any stigma associated with a weight-loss program.

program’s ef 󿬁ca cacy cy to th thee ra rand ndom omly ly assigned groups at the T1 and T2 only.

CONCLUSIONS This study revealed that the 5-month GSH-POinterventionresultsindecreases in BMI, BMI   z   score, and %OW in the  target child and maintenance of these losses at 6 months posttreatment. In addition, the intervention was well received by families, provides treatment in less time that that tradi traditio tional nal familyfamilybased treatment, and has the poten tial to be provided by health care providers in the future. The GSH-PO has  the potential to become the initial standard of care for overweight and obese children.

Primary care providers are often the gatewa gat ewayy to psych psycholog ologica icall treatm treatment ent because families typically do not seek  specia spe cialty lty psych psycholo ologic gical al servic services es as  their initial source of care. Because the GSH-PO is developed for dissemination

As in all studies, there are limitations  that need to be considered. This study incl includ uded ed a 6-m 6-mon onth th fo follo llow-u w-up p and and a mo mode dest st sa samp mple le si size ze,, and and la larg rger er studie stu diess are needed needed to provid providee addiaddi tional ef 󿬁cac cacyy dat data a and to trans translat latee  these methods to health care clinics. Our participants were also treatmentseeking and severely overweight children were excluded, limiting general-

in primar primaryy car caree settin settings, gs, it has the potential potent ial to int interv ervene ene with with pat patien ients ts earlier in the disease process as well as rea reach ch a larg larger er pro proport portion ion of the

izability. In addition, we did not include a control group that could be followed overr the length of the entir ove entiree stu study dy,, which whi ch limi limits ts our conclu conclusio sions ns on the

was instrumental in the data collection in this project. We also acknowledge all of the children and parents who participated in this study.

7. Weiss R, Dziur Dziura a J, Burgert TS, et al. Obes Obesity ity

5 A Day Power Plus progr program. am.   J Am Diet  Assoc . 1998;98(5):570–572

ACKNOWLEDGMENTS We acknowledge Hanaah Fannin, who

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(Continued from   󿬁 rst rst page)

PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275). Copyright © 2013 by the American Academy of Pediatrics FINANCIAL DISCLOSURE: DISCLOSURE: Dr  Dr Crowe has research grants from Shire, Alkermes, and Novartis; the other authors indicated they have no    󿬁 nancial nancial relationships  relevant to this article to disclose. FUNDING:   Supported by the National Institutes of Health (NIH) DK080266.

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Guided Self-Help for the Treatment of Pediatric Obesity Kerri N. Boutelle, Gregory J. Norman, Cheryl L. Rock, Kyung E. Rhee and Scott J. Crow Pediatrics 2013;131;e1435 ; originally published online April 1, 2013; DOI: 10.1542/peds.2012-2204 Updated Services Information &

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PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly publication, it has been published continuously since 1948. PEDIATRICS is owned, published, and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk  Grove Village, Illinois, 60007. Copyright © 2013 by the American Academy of Pediatrics. All rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.

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