Childhood Obesity: a Study of Group Treatment Targeting Parents Behaviour
Childhood Obesity: a 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.
Inclusion Criteria:

 -  Age 7-12 years

 -  Body Mass Index > 2SDS (age adjusted BMI)

 -  no known medical cause of obesity

 Exclusion Criteria:

 -  pervasive developmental disorders

 -  serious psychopathology

 -  parental drug abuse