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Systematic Review and Meta-Analysis of Comprehensive Behavioral

Family Lifestyle Interventions Addressing Pediatric Obesity


David M. Janicke,1 PHD, Ric G. Steele,2 PHD, Laurie A. Gayes,2 MS, Crystal S. Lim,1 PHD, Lisa
M. Clifford,1 PHD, Elizabeth M. Schneider,1 PHD, Julia K. Carmody,1 MS, and Sarah Westen1 MS
1
Department of Clinical and Health Psychology, University of Florida and 2Clinical Child Psychology Program,
University of Kansas

All correspondence concerning this article should be addressed to David M. Janicke, PHD, Department of
Clinical and Health Psychology, University of Florida, PO Box 100165, Gainesville, FL 32610, USA.
E-mail: djanicke@phhp.ufl.edu
Received January 16, 2014; revisions received March 29, 2014; accepted April 7, 2014

Purpose To conduct a meta-analysis of randomized controlled trials examining the efficacy of comprehen-
sive behavioral family lifestyle interventions (CBFLI) for pediatric obesity. Method Common research
databases were searched for articles through April 1, 2013. 20 different studies (42 effect sizes and 1,671
participants) met inclusion criteria. Risk of bias assessment and rating of quality of the evidence were
conducted. Results The overall effect size for CBFLIs as compared with passive control groups over all
time points was statistically significant (Hedges g 0.473, 95% confidence interval [.362, .584]) and sugges-
tive of a small effect size. Duration of treatment, number of treatment sessions, the amount of time in treat-
ment, child age, format of therapy (individual vs. group), form of contact, and study use of intent to treat
analysis were all statistically significant moderators of effect size. Conclusion CBFLIs demonstrated effi-
cacy for improving weight outcomes in youths who are overweight or obese.

Key words children; intervention outcome; meta-analysis; obesity.

Childhood obesity is a significant public health concern, evidence-based pediatric obesity interventions to treat in-
with roughly 32% of children considered overweight or creased weight status in children and adolescents.
obese (Ogden, Carroll, Kit, & Flegal, 2012). The sequelae Research to elucidate factors contributing to the con-
of pediatric obesity include comorbid medical complica- tinual rise in rates of pediatric obesity provides evidence of
tions, such as high blood pressure, abnormal lipid pro- environment by gene interactions contributing to child and
teins, liver disease, sleep disordered breathing, and type adolescent weight status. Studies have also shown that en-
2 diabetes (Daniels, 2006). Overweight and obese children vironmental factors can alter genetic factors associated with
face increased risks for poor self-esteem and body image, weight (Koletzko, Brands, Poston, Godfrey, &
peer victimization, weight stigmatization, depressive symp- Demmelmair, 2012). Potential environmental factors in-
toms, and other psychological difficulties (Daniels, 2006; clude consuming large portions of high-calorie nutrient-
Puhl, Luedicke, & Heuer, 2011). Obesity in childhood also poor foods, decreased engagement in physical activity,
leads to increased risks of being obese in adulthood (Singh, and increased time spent in sedentary behaviors (Lioret,
Mulder, Twisk, van Mechelen, & Chinapaw, 2008). Volatier, Lafay, Touvier, & Maire, 2009; Spear et al.,
Pediatric interventions that lead to weight reductions 2007). One of the strongest predictors of child weight is
have been associated with improvements in metabolic fac- parent weight status (Whitaker, Wright, Pepe, Seidel, &
tors (Ebbeling, Leidig, Sinclair, Hangen, & Ludwig, 2003) Dietz, 1997). Given that parents play a significant role in
and self-esteem (Janicke et al., 2008). There is a need for establishing patterns of eating and physical activity

Journal of Pediatric Psychology 39(8) pp. 809825, 2014


doi:10.1093/jpepsy/jsu023
Advance Access publication May 13, 2014
Journal of Pediatric Psychology vol. 39 no. 8 The Author 2014. Published by Oxford University Press on behalf of the Society of Pediatric Psychology.
All rights reserved. For permissions, please e-mail: journals.permissions@oup.com

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810 Janicke et al.

throughout childhood (Spear et al., 2007), behavioral comprehensive, in that they address all three intervention
family lifestyle interventions have been developed that components. For the purposes of this review, interventions
focus on modifying the obesogenic family environment to that included content addressing all three areas (i.e., die-
address weight management in children and adolescents. tary intake, physical activity, and behavior strategies) are
Generally, behavioral family lifestyle interventions referred to hereafter as comprehensive behavioral family
focus on encouraging overweight and obese children and lifestyle interventions (CBFLIs). Owing to the increase in
their parents to modify the familys dietary intake, physical outcome research examining treatments for pediatric obe-
activity habits, or both. Dietary modifications generally sity, there is a need to understand the current efficacy of
target reducing the consumption of high-fat/high-calorie these interventions, as well as to identify moderators of
foods and increasing consumption of fruits and vegetables, treatment success to inform future clinical practice and
as well as dietary monitoring through classifications treatment outcome research.
systems such as the Stoplight diet (Epstein, 1993). Jelalian and Saelens (1999) conducted a review of pe-
Activity targets commonly include increasing the intensity diatric obesity treatments in the empirically supported
and duration of physical activity (i.e., play, family activities, treatment series published in the Journal of Pediatric
organized sports, or structured exercise program) and Psychology over a decade ago. They concluded that be-
reducing time spent in sedentary activities (e.g., television havioral lifestyle interventions could be considered well-
viewing). Behavioral strategies to support the adoption of established treatments and that there was strong evidence
healthier lifestyle behaviors are central to these programs. for their short- and long-term efficacy (e.g., 5 and 10 years
Specific strategies may include the following: parent model- posttreatment) in reducing weight in school-age children.
ing; monitoring of dietary intake and physical activity; goal The evidence of behavioral lifestyle interventions for ado-
setting; problem solving; gradual shaping; child behavior lescents was only considered promising owing to the
management strategies including differential attention and limited number of treatment outcome studies in adoles-
contingency management; and stimulus control.
cents at that time. However, there was no requirement
Parents are often considered a critical agent of change
that the treatments reviewed by Jelalian and Saelens
in behavioral lifestyle interventions, as they exercise signif-
(1999) be CBFLIs.
icant control over childrens eating and physical environ-
Not surprisingly, since the Jelalian and Saelens review,
ment and, ultimately, behaviors. As such, one or both
a number of systemic reviews and meta-analyses of pediat-
parents are typically included in treatment. Parents are
ric obesity interventions have been published (Kitzmann
often encouraged, if not specifically targeted, to also
et al., 2010; McGovern et al., 2008; Oude-Luttikhuis
follow healthy lifestyle treatment recommendations. The
et al., 2009; Seo et al., 2010; Whitlock, OConnor,
format of behavioral family lifestyle interventions varies
Williams, Beil, & Lutz, 2010; Wilfley et al., 2007). The
from group based (multiple families participate at one
general consensus from these published reports is that pe-
time) and individual family based (family meets one-
diatric obesity interventions result in small to moderate
on-one with interventionist), to a combination of these
formats. The extent to which children and adolescents short-term improvements in adiposity in children and ad-
are directly involved in treatment also varies across olescents. However, a thorough examination of this litera-
interventions. While the vast majority of interventions ture finds mixed methodology and results across meta-
require children or adolescents to regularly attend interven- analyses, with great variety in the number of studies in-
tion sessions with their parents, some recent interventions cluded in different meta-analyses, largely owing to differing
have adopted a parent-only model, in which only the foci and study inclusion and exclusion criteria (i.e., intent-
participating parent(s) attend intervention sessions during to-treat [ITT] analysis, different intervention components,
which they are taught strategies to support their child or duration of treatment or follow-up analysis, randomization
adolescent in modifying weight-related lifestyle behaviors of treatment participants, minimum sample size require-
(Golan, Kaufman, & Shahar, 2006; Janicke et al., 2008). ments, adequate control condition). Moreover, a number
The number of content components also varies across of meta-analyses use broad inclusion criteria that allow for
lifestyle interventions. Some interventions may include lifestyle interventions with diverse treatment components
only two components. For example, an intervention may (two or three component programs) or interventions deliv-
address dietary intake using behavior strategies but not ered in different settings (e.g., community, clinic, research,
address physical activity. Others may address physical and school; Kitzmann et al., 2010). While informative, one
activity and dietary intake but not use behavior strategies. disadvantage to this broader approach is that such clinical
Finally, there are those interventions that are heterogeneity precludes a meaningful answer as to the

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Meta-Analysis of Family Interventions for Obesity 811

intervention type to which an effect can be generalized lifestyle interventions produce larger effects at posttreat-
(Cohen, Thombs, & Hagedoorn, 2010). ment. Relative to Oude-Luttikhus et al. (2009) who re-
Although a number of meta-analyses include interven- quired intent-to-treatment analysis for study inclusion,
tion studies with behavioral family components, many do Young and colleagues did not include intent-to-treatment
not provide explicit examination of interventions with a analysis as an inclusion criteria. This may in part account
behavioral family component or adequately define behav- for the larger number of interventions included and the
ioral components (Kitzmann et al., 2010; McGovern et al., large effect size reported by Young et al.
2008; Seo et al., 2010; Wilfley et al., 2007). To our knowl- While these three meta-analyses provide essential
edge only three meta-analyses have explicitly examined the information on the relative efficacy of behavioral family
efficacy of pediatric lifestyle interventions that require the lifestyle interventions, the most recent review was of inter-
inclusion of a behavioral family component (Oude- ventions published only through May 2008. Additionally,
Luttikhuis et al., 2009; Whitlock et al., 2010; Young, the target of past meta-analyses of behavioral family life-
Northern, Lister, Drummond, & OBrien, 2007). style interventions has been on change in weight status,
However, even these three reviews do not require the use and therefore, more information is needed on the impact of
of all three common lifestyle intervention components (i.e., these interventions on key secondary outcomes such as
dietary intake, physical activity, and behavioral strategies) dietary intake and physical activity, as well as potential
for study inclusion in the meta-analytic reviews. moderators of treatment effects. Finally, none of these
Whitlock and colleagues identified 11 fair- or good- past reviews explicitly required that interventions were
quality behavioral family lifestyle intervention trials pub- CBFLIs, meaning they did not require interventions to
lished between 2005 and 2008 addressing weight loss in include all three treatment components to be included
overweight and obese children and adolescents 19 years (i.e., dietary intake physical activity and behavioral
of age (Whitlock et al., 2010). Results revealed that behav- strategies). Thus, the primary objective of this review is
ioral family lifestyle interventions of medium to high inten- to evaluate the efficacy of CBFLIs in reducing or stabilizing
sity (i.e., 26 hr of treatment contact) had moderate to child adiposity in overweight and obese youth. A secondary
large effects on weight outcomes compared with very low objective of this review is to evaluate the impact of CBFLIs
intensity interventions (e.g., <10 hr) in the short term, on key secondary outcomes including child caloric intake,
with intervention effectiveness tending to increase with physical activity, sedentary behavior, and parent use of
more intensive interventions. The authors also concluded behavior management strategies. A final secondary objec-
that there was insufficient evidence to draw conclusions on tive of this meta-analysis is to evaluate potential modera-
outcomes >12 months after treatment. tors of treatment outcome including (1) child age; (2) child
The Cochrane Collaborative published a review that sex; (3) duration and intensity of treatment; (4) length of
included 54 randomized controlled trials (RCTs) published time from baseline to outcome assessment; (5) whether the
through May 2008 and focused on lifestyle interventions parent(s) is targeted for health behavior or weight change;
(i.e., dietary, physical activity, and/or behavioral oriented (6) type of comparison control condition; (7) methodolog-
treatment) for children and adolescents (mean age <18 ical rigor of studies; and (8) other study characteristics
years at posttreatment) (Oude-Luttikhus et al., 2009). (i.e., ITT analysis used, manualized intervention, exclusion
However, they only identified eight behavioral family life- of children over the 99th percentile for body mass index
style interventions that qualified for a separate meta-anal- (BMI), form of therapy [individual vs. group vs. both], and
ysis examining both short- and long-term outcomes in form of contact [in-person, in-person plus internet,
elementary-age and adolescent youth. While noting many phone]). These moderating variables were selected based
limitations in the literature and the lack of quality data to on findings from previous published studies, as well as
adequately ascertain treatment efficacy, the authors con- reviews and recommendations for treating pediatric obesity
cluded that behavioral family lifestyle interventions result (Faith et al., 2012; Jelalian & Saelens, 1999; Spear et al.,
in significant and clinically meaningful changes in weight 2007; Wilfley et al., 2007), and represent potential
status for children and adolescents compared with stan- important directions for future intervention research.
dard care and self-help, both in the short and long term. The proposed methods will draw heavily from the
Finally, Young and colleagues (2007) identified 44 Cochrane Collaboration and represent current best practice
pediatric obesity interventions across 16 studies for chil- in systematic review methodology. This review will add to
dren aged 512 years. Of these 44 interventions, 31 were the literature by examining only those studies that include
behavioral lifestyle interventions. Results indicated that rel- behavioral lifestyle interventions that are comprehensive in
ative to alternative treatment interventions, behavioral nature (intervention explicitly addresses dietary intake and

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812 Janicke et al.

physical activity, and uses behavioral change strategies), primary objectives of the intervention were to produce
examining a greater variety of possible moderators of treat- weight loss or prevent further weight gain in children or
ment outcomes, including studies published up to April adolescents who were already obese or overweight at base-
2013, and by including standardized methods to evaluate line, and (3) interventions were conducted in outpatient or
trial quality of included studies and rate the level of evi- community settings. Studies were excluded if the active
dence for our findings. intervention being evaluated (1) involved a curriculum-
based school weight management program and (2) child
weight was based on subjective methods of measurement
Methods (e.g., self-reported, parent-reported, interviewer estimated).
Criteria for Considering Studies for This Review Active interventions in which only parents attended treat-
Types of Studies ment sessions, but child weight or adiposity was the pri-
RCTs comparing an active CBFLI for overweight or obesity mary outcome, were eligible for inclusion in this analysis.
in children or adolescents with an attention/educational Studies reporting only previously reported data and studies
control, other active treatment, or wait list control were in which medication was part of treatment were also
considered for this review. Studies meeting the following excluded.
criteria were included: Interventions that were considered to include a dietary
component must have included education, presentation,
 RCTs published in full in peer-reviewed journals, or discussion of healthy eating, dietary guidelines, or
unpublished dissertations, and brief reports that in- food preparation strategies. Interventions that were consid-
clude sufficient methodological details to allow (1) crit- ered to address physical activity must have included one of
ical appraisal of study quality and (2) calculation of the following: (1) education on the importance of adequate
effect sizes.
physical activity, (2) encouragement to increase physical
 Primary aim of the trial was to evaluate the efficacy or
effectiveness of an active CBFLI for overweight or obe- activity, (3) guidelines for recommended levels of physical
sity in children or adolescents with change in weight as activity for children, or (4) structured physical activity time
the primary outcome. for children during intervention sessions. Finally, for an
 Both the treatment and the control arms of the study intervention to have been considered behavioral, the de-
must have a minimum sample size of 10 at the scription of the active treatment must have included one of
posttreatment assessment. the following terms: self-monitoring, stimulus control, goal
setting, positive reinforcement, differential or contingency
Types of Participants management, behavioral parent training, or problem solv-
Children and adolescents, 19 years of age at baseline, ing. Moreover, these terms must have described efforts to
who are classified as overweight or obese based on age help families makes changes to child dietary intake or phys-
and gender norms (Kuczmarski et al., 2000), were in- ical activity. Only studies that included sufficient informa-
cluded in this review. Studies were excluded if (1) partic- tion to determine whether they met these inclusion criteria
ipants were from special populations, such as children or were eligible for review.
adolescents with developmental disabilities, developmental
delays, or cognitive impairment, (2) child or adolescent
participants were diagnosed with a chronic illness that in- Type of Outcome Measures
hibits typical growth and development (e.g., cystic fibrosis) Change in child weight at posttreatment was the primary
or bulimia nervosa, (3) any of the child participants were outcome targeted in this meta-analysis. For inclusion, mea-
classified as normal weight in any of the treatment arms at sures of child weight must have been objective, adjusted
baseline assessment, or (4) children or adolescents with an for child age and sex, and reported as one of the following:
underlying diagnosis that predisposes children to obesity BMI, BMI z-score, BMI percentile, percent overweight, or
or greater than normal weight gain (e.g., Prader-Willi adiposity. Data were analyzed at pretreatment and
Syndrome, Thyroid disease). posttreatment. When available, data were also analyzed at
the first follow-up visit that occurred at least 6 months
Types of Interventions postbaseline. Change in child weight must have been re-
Interventions were included if (1) the active treatment ported or was able to be calculated from the inclusion of
included dietary, physical activity, and behavioral compo- pretreatment and posttreatment weight values. In addition,
nents that focused on change in weight and weight-related child weight must have been assessed at the same time
health behaviors (for explicit criteria see below), (2) the points across all randomized conditions.

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Meta-Analysis of Family Interventions for Obesity 813

Search Methods for Identification of Studies of two reviewers who each independently assessed the full
text of the remaining articles to determine eligibility for
A two-phase search strategy was used to identify studies for
inclusion in the analysis. When an inclusion or exclusion
this review. First, five electronic databases (the Cochrane
decision could not be reached by the two reviewers, the full
Central Register of Controlled Trials [CENTRAL]; ProQuest
team of reviewers discussed the concerns to yield a con-
Dissertations and Theses Full Text; PsycINFO via EBSCO;
sensus. The reviewers were not blind to the names of study
PubMed; and Web of Science) were systematically searched
authors, institutions, or journals. Of the 298 full-text arti-
by one member of the research team using the following
cles reviewed, 278 were excluded (see Figure 1 for reasons
truncated key terms to identify studies for review: (child
for exclusions). The two-phase process resulted in 20 stud-
OR adolescent OR family OR parent) AND (intervention
ies eligible for inclusion in the current meta-analysis.
OR treatment) AND (overweight OR obesity). While the
integrity of the search terms was not significantly altered,
some changes in search strategies were necessary based on Data Extraction
the requirements of the particular database used (i.e., use A coding document was developed for data extraction pro-
of MeSH terms for PubMed). Systematic searches of these cedures. This included critical study information such as
databases occurred in February 2013 and again in April references, details of participants and their demographics,
2013 to allow for identification of studies published up aspects of the intervention or therapy, characteristics of the
through April 1, 2013. The search was limited to articles treatment team, the setting of the intervention, outcome
that were available in English. measures, and statistical outcomes. Both members from
A total of 7,734 articles were identified through the each review team carried out data extraction from studies
initial searches across databases, while an additional 12 that were identified for inclusion. All intervention and out-
articles were identified from examination of published come data were compared for consistency and resolved to
meta-analyses and systematic reviews reporting on inter- 100% agreement with the assistance of the first author as
ventions addressing pediatric obesity (see Figure 1 for the needed.
PRISMA Flow diagram). Of these 7,746 studies, 192 were
removed as they represented duplicates across one or more
databases, 9 studies were removed as no full-text article of Assessment of Study Rigor
the study was available, and 7,149 were excluded based on Study rigor was assessed on an 18-point scale developed by
an initial screening of the title and abstract. Study exclu- Lundahl et al. (2010) and based on criteria from existing
sion criteria for the abstract review were as follows: assessment instruments and approaches, such as the
Cochrane system. Each study was rated by the first
1. Participants author based on criteria such as number of participants,
attrition, quality control, inclusion of the assessment of
a. Youth >19 years of age.
treatment fidelity, objectivity of measurements, and report-
b. Less than 10 participants in any condition at
ing of follow-up data. Higher scores indicate higher study
posttreatment.
quality.
2. Intervention
a. At least one arm of the intervention is not a
primarily behavioral intervention.
Assessment of Risk of Bias
b. Nonrandomized controlled trial. Available information about the included trials was used to
c. Child weight was not a primary outcome of the assess risk of bias in five domains: random sequence gener-
intervention. ation (failure to use a specified randomization process),
3. Comparison groups allocation concealment (failure to blind investigators for
future randomization assignments), blinding of outcome as-
a. Study did not include at least one of the fol-
sessment (failure to conceal outcome assessors from partic-
lowing control conditions: (i) no treatment con-
ipant intervention group assignment), incomplete outcome
trol, (ii) waitlist control, (iii) education control,
data (failure to report complete outcome data from all ran-
or (iv) treatment as usual control.
domized participants), and selective reporting (failure to
report results for all planned outcome data). Guidelines
During the second phase of the search, the remaining from the Cochrane Handbook were followed for this as-
298 articles were assigned to one of three teams composed sessment (Higgins & Green, 2011).

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814 Janicke et al.

Identification
Studies identified through initial Studies identified through
database searches other sources
(n = 8025) (n = 12)

Study Abstracts Screened for Eligibility


(n = 8037)
Screening

Duplicate Studies/Records
Removed (n = 1672)

Studies Excluded based on


Abstract Review
(n = 6067)
Eligibility

Full Text Manuscript


Assessed for Eligibility Studies excluded after full text review
(n = 298) (n = 278)

a) All participants 19 years and above = 2


b) Not all children overweight/obese = 52
c) Curriculum-based school program = 23
d) Lack of appropriate control = 54
e) Medication intervention = 1
Included

f) Lack of data to calculate effect size = 11


g) Follow-up data from another paper = 2
h) Duplicate data from another paper = 10
i) Methods paper only = 5
j) Not a randomized controlled trial = 45
k) Intervention does not include dietary,
physical & behavioral components = 36
Studies eligible and l) Primary outcome is not objectively
included in qualitative adiposity-based variable = 10
synthesis (n = 20) m) Sample size < 10 in one condition = 15
n) Child-only intervention = 12

Figure 1. PRISMA participant flow diagram.

Rating the Quality of Evidence and Strength of each outcome across studies falls into one of four catego-
Recommendations ries ranging from high to very low.
The Grading of Recommendations Assessment,
Development and Evaluation (GRADE) system was used Data Analysis
to evaluate the quality of evidence in this review. With The primary objective of this meta-analysis was to evaluate
the GRADE system, evidence for specific outcomes is the efficacy of CBFLIs on adiposity in children and adoles-
rated across studies, rather than within individual studies. cents. To control for change in weight status due to the
In this approach, RCTs are initially considered to provide intervention, the effect size calculated was constructed as a
high-quality evidence and observational studies are comparison of the change in weight status in the control
considered to provide low-quality evidence for estimates condition as compared with the intervention condition.
of intervention effects. Five factors may lead to rating Independent effect sizes were calculated for the primary
down the quality of evidence (risk of bias, inconsistency, outcome variable (adiposity) in each identified study. To
indirectness, imprecision, and publication bias) and three minimize the distortion of standard error estimates
factors may lead to rating up (large effect size, dose resulting from nonindependent effect size estimates
response relationship exists, and consideration of all plau- (Card, 2012), multiple outcomes derived from the same
sible confounding variables). The quality of evidence for sample were aggregated such that each study (or group

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Meta-Analysis of Family Interventions for Obesity 815

of studies using the same sample) contributed only one weighted regression analyses, with studies with lower stan-
overall effect size at each assessment point for the primary dard error contributing more weight in the regression equa-
outcome variable. For studies reporting multiple outcome tion. Categorical variables (e.g., gender, setting) were
measures assessing the same general construct (e.g., BMI, analyzed using analysis of variance techniques to assess
zBMI, percent overweight), an overall effect size was differences between groups of interest. It is recommended
created by averaging the individual effect sizes. If studies that 20 studies per group be included to achieve optimal
reported multiple analyses using subsets of the same power to detect group differences (Card, 2012). Therefore,
sample, the analysis most directly assessing change in lack of significant differences between groups found in
childrens weight or adiposity was used. these analyses may be due to insufficient power, as this
Effect sizes were calculated following the aforemen- study only contained 20 studies in total. For this reason,
tioned rules (e.g., one effect size per variable per study, secondary analyses of interactions between moderating var-
etc.). iables were not assessed.
Hedges g (Hedges & Olkin, 1985) was used as the To evaluate the degree to which publication bias (i.e.,
index of standard mean difference between treatment con- file-drawer problem; Rosenthal, 1979) inflated the result-
ditions in the current meta-analysis. Hedges g is preferred ing effect sizes of this meta-analysis an effect size fail-safe N
as an index of mean difference when the preponderance of was calculated (Card, 2012). An effect size fail-safe N in-
studies in the sample use relatively small sample sizes, with dicates the number of unidentified studies with an average
correspondingly greater standard errors (Card, 2012). In effect size that would be necessary to reduce the obtained
studies where efficacy of treatment is represented via mean effect size to the smallest meaningful effect size
other statistics (e.g., F, t, X), these values were converted (ESmin). Following Rosenthal (1979), the smallest meaning-
into Hedges g using standard conversion procedures. ful effect size was set to 0.1.
Cohen (1969) provided guidelines for interpreting the d
effect size: small, 0.200.49; medium, 0.500.79; and
large, 0.80. Mean effect sizes based on Hedges g follow Results
these same conventions. All effect sizes were expressed in Description of Studies
terms of 95% confidence intervals (CIs). Confidence bands The literature search returned 20 studies that were eligible
that did not include zero were considered statistically sig- for inclusion based on the inclusion and exclusion criteria
nificant, while those with confidence bands including zero (see PRISMA diagram). Across these studies, 42 effect sizes
were considered nonsignificant. were calculated to account for multiple time points and
Before calculating mean effect sizes, individual effect multiple outcomes. To prevent violations of independence,
sizes were weighted to reflect the degree to which the stan- effect sizes from a single study were averaged to create an
dard error approximates population parameters (Card, overall average effect size for each study, which was then
2012). Specifically, a weighted mean effect size was calcu- used to calculate the overall effect size across all studies.
lated by computing the product of each studys effect size Descriptions of study characteristics are presented in
by its weight, calculating the sum of each individual Table I.
weighted effect size, and dividing this sum by the sum of The majority of the studies were published in the past
weights. 10 years, although one study was published in 1985. Of
To examine the homogeneity of effect sizes for the the 20 studies presented here, eight did not provide zBMI
primary outcome variable, the Q statistic was used. A sig- data. In these cases, BMI, % body fat, or % overweight data
nificant Q statistic indicates that within-group variability were used and averaged to yield a single estimate of weight
among effect sizes is greater than sampling error alone change for the study. For length of study period, studies
would predict. This is presumed to signal systematic dif- ranged from no data after measurements to follow-up 2
ferences between studies in the sample, perhaps suggesting years after baseline. Study rigor was measured using an
the presence of moderator variables (Card, 2012). To pre- 18-point scale assessing methodological quality derived
serve statistical power for the planned moderation analyses from Lundahl et al. (2010). This scale was used because
described below, a fixed effect model was used when esti- it yielded the most comprehensive assessment of study
mating heterogeneity among the sample of studies (Card, rigor identified. The average total score on this scale was
2012). 12.3, and scores ranged from 9 to 16. The average num-
Continuous and categorical moderators were assessed ber of participants per study was 86.28, with a range of
using differing methodologies. Continuous variables (e.g., 22108. The total number of child participants across
age, duration), modeled separately, were analyzed using studies was 1,671.

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816 Janicke et al.

Table I. Study Characteristics

Parent
Child Duration targeted for Outcome
Type of Sample age Percent Country where Race/ of Tx lifestyle assessment Outcome
Study authors study size range female study conducted ethnicity (month) change time point(s) assessment

Boudreau, Kurowski, 2-arm RCT 26 912 51.2% United States L 100% 6 No 6 BMI z-score
Gonzalez, Dimond, &
Oreskovic (2013)
Bocca, Corpeleijn, Stolk, 2-arm RCT 75 35 72.0% The Netherlands N.R. 4 Yes 4, 12 BMI z-score
& Sauer (2012)
Debar et al. (2012) 2-arm RCT 208 1217 100% United States W 72% 5 No 6, 12 BMI z-score
Diaz, Esparza-Romero, 2-arm RCT 43 917 51.2% Mexico N.R. 6 No 6, 12 BMI z-score
Moya-Camarena,
Robles-Sardin, &
Valencia (2010)
Golley et al. (2007) 2-arm RCT 74 69 63.52% Australia W 98% 5 Yes 12 BMI z-score
Janicke et al. (2008) 3-arm RCT 71 814 60.6% United States W 73% 4 Yes 4, 10 BMI z-score
AA 10%
H 9%
O 8%
Jiang et al. (2005) 2-arm RCT 68 1215 39.7% China N.R. 24 Yes 24 BMI
Kalarchian et al. (2009) 2-arm RCT 192 812 57.0% United States W 74% 12 No 6, 12, 18 %overweight
AA 26%
Kalavainen, Korppi, & 2-arm RCT 70 79 65.7% Finland F 98.5% 6 Yes 6, 12 BMI z-score
Nuutinen (2007)
Nemet et al. (2005) 2-arm RCT 46 616 43.5% Isreal N.R. 3 No 3, 12 BMI, BMI %
body fat
Nemet, Barzilay-Teeni, & 2-arm RCT 22 811 63.6% Isreal N.R. 3 No 3 BMI %, body
Eliakim (2008) fat %
Reinehr et al. (2010) 2-arm RCT 66 816 60.6% Germany N.R. 6 N.R. 6 BMI z-score
Sacher et al. (2008) 2-arm RCT 116 812 54.3% United Kingdom W 50% 12 No 6 BMI z-score
Savoye et al. (2007) 2-arm RCT 174 816 60.3% United States W 37%. 12 No 6, 12, 24 Body fat
AA 39%
H 24%
Senediak & Spence 3-arm RCT 33 613 N.R. United States N.R. 1 No 1 %overweight
(1985)
Shelton et al. (2007) 2-arm RCT 43 310 53.5% Australia N.R. 1 Yes 3 BMI and WC
Vos, Huisman, Houdijk, 2-arm RCT 79 817 53.2% The Netherlands N.R. 3 No 3, 12 BMI z-score
Pijl, & Wit (2012)
Wafa et al. (2011) 2-arm RCT 107 711 53.5% Malaysia N.R. 6 No 6 BMI z-score
West, Sanders, Cleghorn, 2-arm RCT 101 411 67.3% Australia W 87% 3 No 6 BMI z-score
& Davies (2010) M 6%
A 4%
I 3%
Williamson et al. (2005) 2-arm RCT 57 1115 100% United States AA 100% 6 Yes 6, 24 BMI, body fat
Note. AA African American; A Asian; F Finnish; H Hispanic; I Indigenous; L Latina; M Mediterranean; O other; W White WC waist circumference;
N.R. not reported; RCT randomized controlled trial.

Overall Weight Outcome Effect Size Only one study yielded a negative effect size (Kalarchian
The overall effect size for change in zBMI in CBFLIs as et al., 2009), indicating that the rest of the studies yielded
compared with that in passive control groups over all improved outcomes as compared with the control group.
time points was statistically significant (g 0.473, 95% The effect size of each individual study, as well as each
CI [.362, .584]). This finding is consistent with Cohens studys contribution to the overall effect size, is depicted
classification of a small effect size (Cohen, 1969). in Figure 2.

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Meta-Analysis of Family Interventions for Obesity 817

Figure 2. Forest plot depicting overall effect size of each study included in the meta-analysis. The overall effect size is delineated as a dotted
vertical line. The size of the dot represents the weight of the study in contributing to the overall effect size. The error bars represent the 95%
confidence interval.

Overall Effect Sizes for Secondary Outcomes (posttreatment) and outcomes at later follow-up assess-
Eight studies provided useable information on child caloric ments. Based on 20 studies, the effect size for CBFLIs at
intake. The overall effect size for change in caloric intake in posttreatment as compared with control groups was statis-
CBFLIs as compared with that in passive control groups tically significant (g 0.416, 95% CI [.307, .526]).
over all time points was not statistically significant Furthermore, based on 11 studies, the effect size for
(g 0.086, 95% CI [.090, .263]). CBFLIs at follow-up assessment as compared with control
There was an insufficient number of studies (e.g., less groups was also statistically significant (g 0.386, 95% CI
than two) meeting inclusion and exclusion criteria for this [.248, .524]. Both of these meet criteria for a small effect
review that reported on physical activity, sedentary behav- size (Cohen, 1969). The difference between the effect size
ior, and parent use of behavioral management strategies to for posttreatment assessments and follow-up assessments
allow for the calculation of an effect size based on the was not statistically significant.
Cochrane review guidelines.
Moderator Analyses
Posttreatment and Follow-up Assessment Weight A test of heterogeneity was then conducted to determine
Outcome Effect Size the appropriateness of testing for moderating variables. The
Secondary analysis separately examined weight outcomes Q test of heterogeneity was statistically significant (84.446,
directly following completion of the intervention p < .001), indicating that these studies are heterogeneous

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818 Janicke et al.

and that study variables are significantly moderating the Effect Size Fail-Safe N Calculation
study effect sizes. Therefore, analyses, with each moderator A fail-safe N was calculated to help evaluate the likelihood
variable modeled separately, were conducted to assess of our overall effect size being an overly positive represen-
study characteristics that may be influencing effect size tation of the true effect size. This calculation assesses the
outcomes. Moderating variables were included based on number of studies with an effect size of zero that would
reviews and recommendations for treating pediatric obe- have to be included before the overall effect size would
sity, previous research, and their potential of representing shrink to the smallest meaningful effect size. Our calcula-
important directions for future intervention research (Faith tions indicated that 75 studies with an effect size of zero
et al., 2012; Jelalian & Saelens, 1999; Spear et al., 2007; would have to be added to this meta-analysis to bring
Wilfley et al., 2007). Continuous moderator variables ex- down the overall effect size to 0.1.
amined in this meta-analysis included time between base-
line and posttreatment assessment, duration of treatment, Risk of Bias
number of sessions, child age, child sex (i.e., % female), Each study was assessed on five dimensions for risk of bias.
methodological rigor of study, and amount of time in treat- The summary risk of bias findings across all studies are
ment for both child and parent. Duration of treatment, presented in Figure 3. Overall the 20 studies included in
number of sessions, child age, and the amount of time this review exhibit relatively low risk of bias for random
that the child spent in treatment were all statistically sig- sequence generation and selective reporting. Over half of
nificant moderators. Specifically, larger effect sizes were the studies examined were judged to exhibit unclear or
associated with longer treatment (duration in weeks), high risk of bias for blinding of outcome assessment. In ad-
more treatment sessions, a greater total amount of time dition, over half to the studies reviewed reported insuffi-
(over the course of treatment) that the child spent in treat- cient methodological details and outcome data to
ment, and greater child age. The results of continuous determine if there was low or high risk of bias for incom-
moderating analyses are presented in Table II. plete outcome data and thus were classified as unclear risk
Categorical moderators analyzed in this meta-analysis of bias. Finally, over half of the studies examined exhibited
included whether the study sample used ITT analysis, type high risk of bias for allocation concealment.
of control group, use of a manualized treatment, BMI
greater than the 99th percentile as an exclusionary criteria, GRADE Rating
if the parents were targeted for their own health behavior A rating of moderate (3 on a scale of 14) was assigned
change, format for therapy, and form of contact with par- to the quality of evidence for improvements in BMI Z-score
ticipants. Results from these analyses are presented in based on the GRADE system. As all trials were RCTs, our
Table III. Use of ITT analysis, format of therapy, and review assumed a starting point of high-quality evidence (a
form of contact were significant moderating variables, rating of 4). However, the quality of evidence was incon-
such that individual and in-person CBFLIs were associated sistent and there are some potential concerns with risk for
with larger effect sizes. bias (see previous section), which lowered the overall rating
from high quality to moderate quality. A rating of low
quality (2 on a scale of 14) was assigned to the quality
of evidence for changes in caloric intake based on the
Table II. Continuous Moderator Analyses
GRADE system. As all trials were RCTs, our review as-
Moderator variables R2 value p value Beta
sumed a starting point of high-quality evidence (a rating
Time between baseline and .043 .198 0.208 of 4). However, owing to the potential concerns for risk of
assessment bias and the fact that the measurement of dietary intake
Duration of intervention .374 .004 0.612
was viewed as imprecise, the GRADE rating was reduced
Number of intervention sessions .264 .020 0.514
from high quality to low quality. See Table IV for a display
Percentage of females participants in .068 .281 0.234
of the Summary of Findings Table.
intervention
Age of child participants .305 .014 0.169
Methodological rigor of study .003 .831 0.193
Amount of minutes child in .795 .000 0.892
Discussion
treatment Previous reviews examining studies published before 2008
Amount of minutes parent in .017 .603 0.131 have reported that lifestyle interventions addressing pedi-
treatment atric obesity are associated with improvements in weight

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Meta-Analysis of Family Interventions for Obesity 819

outcomes (Jelalian & Saelens, 1999; Kitzmann et al., 2010; overweight or obese. Specifically, our inclusion criteria re-
Oude-Luttikhuis et al., 2009; Whitlock et al., 2010; quired that intervention programs address three compo-
Wilfley et al., 2007). While very informative, these reviews nents, improvements in dietary intake, increases in
included heterogeneous groups of studies with varied types physical activity, and the use of behavioral strategies to
of lifestyle intervention programs. The current meta-analy- achieve improvements in these two areas. The overall
sis extends the literature by examining studies published in effect size of 0.47 for change in BMi z-score, although
2013 and being the first to examine only multi-component small, was approaching Cohens requirement of 0.5 for a
CBFLIs to treat obesity in children and adolescents who are medium effect size. This finding is consistent with similar
past reviews (Whitlock et al., 2010; Wilfley et al., 2007)
Table III. Categorical Moderator Analyses
and suggests that multi-component CBFLIs are efficacious
in improving weight outcomes in children who are over-
Moderator
variables Categories N Effect size
weight or obese. Follow-up analysis found that effect sizes
a
did not significantly differ between results at posttreatment
Intent to treat Yes (1) 7 0.658 (0.491, 0.824)
and follow-up assessments, providing evidence that im-
No (2) 13 0.290 (0.141, 0.440)
provements in weight outcomes are maintained at follow-
Type of control Standard care 10 0.430 (0.280, 0.572)
up. The length of follow-up assessments ranged from 10 to
group Waitlist 9 0.470 (0.290, 0.650)
24 months after baseline, with a majority (8 of 10 studies)
Use of Yes 5 0.546 (0.314, 0.747)
including 12-month follow-up assessment. The analyses of
manualized No 7 0.360 (0.115, 0.605)
effect sizes examining maintenance of outcomes at follow-
treatment Not reported 8 0.437 (0.279, 0.596)
up assessments were based on a relatively small number of
BMI > 99th as Yes (1) 4 0.352 (0.279, 0.596)
studies. Thus, results should be interpreted with caution.
exclusion No (2) 11 0.392 (0.239, 0.546)
Exploratory analyses were also conducted to examine
Not reported 5 0.812 (0.546, 1.075)
potential moderators of treatment outcome. Most notably
Parent targeted Yes (1) 6 0.268 (0.049, 0.486)
dose of treatment, as measured by the number of interven-
for change No (2) 12 0.502 (0.366, 0.638)
tion sessions and the number of minutes children spent in
Not reported 2 0.689 (0.265, 1.113)
treatment sessions, was positively related to effect size.
Form of therapya Individual 2 1.291 (0.889, 1.693)
This is consistent with previous reviews (Whitlock et al.,
Group 13 0.372 (0.240, 0.504)
2010; Wilfley et al., 2007). Our results, in combination
Both 5 0.426 (0.240, 0.665)
with these previous reviews, provide support for the notion
Form of contacta In person 14 0.642 (0.498, 0.786)
that greater intervention duration and intensity are associ-
Phone only 1 0.219 (0.363, 0.801)
ated with better weight outcomes, which is similar to find-
In personOther 5 0.176 (0.007, 0.359)
ings reported in the adult obesity literature (Middleton,
Timing of Post-Treatment 20b 0.416 (0.307, 0.526)
Patidar, & Perri, 2012). However, more research
measurement Follow-up 11b 0.386 (0.248, 0.524)
specifically examining doseresponse relationships of
Note. aIndicates statistically significant moderating variable.
b
Due to multiple measurements taken within the same study, this number does CBFLIs to weight and behavioral outcomes is needed
not represent studies, instead representing measurements taken within a study. before definitive conclusions can be drawn.

Figure 3. Risk of bias.

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820 Janicke et al.

Table IV. Summary of Findings for Multi-Component Behavioral Family Interventions to Treat Obesity in Children and Adolescents

Patient or population: Overweight and obese children and adolescents

Outcomes Illustrative comparative risks (95% CI) Relative effect No of partici- Quality of the Comments
Assumed risk Corresponding risk (95% confi- pants evidence
Control Behavior Family Therapy dence interval) (studies) (GRADE)

BMI z-score (overall) The overall mean decrease in - 1671 (20  Results were statisti-
Investigators used BMI z-score in the inter- studies) moderate cally significant. As
objective measurement vention groups was 0.47 a rule of thumb,
of anthropometric standard deviations more 0.2 SD represents a
variables. than the control groups small, 0.5 a moder-
(0.360.58 lower) ate, and 0.8 a large
difference.
Caloric Intake The overall mean decrease in - 542 (8  low Results were not sta-
Investigators used objec- caloric intake in the inter- studies) quality tistically significant.
tive measurement of ca- vention groups was 0.09
loric intake (i.e., 24-hr standard deviations more
recalls, food frequency than the control groups
questionnaires). (0.090.26 lower)
Note. GRADE Working Group grades of evidence.
High quality (): Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality (): Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality (): Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality (): We are very uncertain about the estimate.

The level of parent involvement relative to weight out- Oude-Luttikhuis (2009) who found larger effects for stud-
comes in pediatric lifestyle interventions has received grow- ies with children 12 years of age compared with studies
ing attention in the literature in recent years. Neither the with children <12 years of age. Weight outcomes were
amount of time parents spent in treatment nor whether the moderated by form of therapy (individual vs. group) and
parents were targeted for their own lifestyle behavior form of contact (in person vs. phone only vs. in-person
change was related to child weight outcomes in this anal- plus other), such that therapy with individual families
ysis. This is consistent with a review by Faith and col- and therapy delivered via in-person contacts related to
leagues (2012) who found limited support for the notion larger effect sizes. However, the number of studies in-
that greater parental involvement in treatment leads to cluded in this moderator analyses were heavily skewed
better child weight outcomes. However, Faith and col- toward group and in-person contacts that these findings
leagues did find that greater parent adherence to core be- must be viewed as preliminary. The current review also
havioral strategies was related to greater child weight status found that studies that used ITT analysis (k 7) were as-
outcomes. It may be that the actual application of behav- sociated with better weight outcomes than studies that did
ioral strategies to address lifestyle issues within the home not use ITT analysis. While one could speculate that stud-
leads to better child weight outcomes, which was not as- ies including ITT analysis are methodologically stronger
sessed in our analysis. As noted by Faith et al. (2012), only than those studies that do not include ITT analysis, our
a few studies have reported on this important relationship moderator analysis examining methodological rigor of in-
(Epstein, 1993; Wrotniak, Epstein, Paluch, & Roemmich, cluded studies was not significant and thus did not sup-
2005). Future intervention trials should include data col- port this conclusion.
lection to examine if parent use of behavioral strategies Data from eight studies found that CBFLIs do not have
mediates the relationship between treatment participation significant effects on change in caloric intake. This is sur-
and key outcomes such as changes in dietary intake, phys- prising given the effects that CBFLIs were found to have on
ical activity, and weight status. weight change. It is likely that the imprecise nature of as-
A number of other potential moderators of effect size sessing caloric intake at least partially impacted these re-
outcomes were examined in this review. Age was a mod- sults (Schoeller, 1995), as it seems unlikely that the weight
erator, such that larger effect sizes for weight outcomes changes observed were entirely due to increases in energy
were positively associated with the mean age of child expenditure. These findings highlight the need for innova-
participants. This is consistent with a review by tive future research designs to examine the specific

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Meta-Analysis of Family Interventions for Obesity 821

mechanisms by which the interventions exert their influ- (Klesges, Dzewaltowski, & Glasgow, 2008). We echo this
ence. One such example may be the use of sequential, call and also encourage researchers to more clearly opera-
multiple assignment, randomized trials (SMART Designs) tionally define and describe both the active intervention
that provide data to enable assessment of optimal compo- and control condition on which the intervention is tested
nent sequencing that can facilitate the development of against. Second, the overall GRADE rating for this analysis
high-quality adaptive interventions (Almirall, Compton, was negatively impacted by the high risk of bias in a
Gunlicks-Stoessel, Duan, & Murphy, 2012). number of areas. To reduce this risk of potential bias and
Consistent with the other systematic reviews in this increase our confidence in the efficacy of CBFLIs, it is also
special issue, the GRADE system (Guyatt et al., 2011) important for future studies to ensure proper concealment
was used to assess the strength and quality of the evidence of randomization and treatment condition assignment to
of our findings. Evidence for changes in BMI z-score from investigators and assessment staff. With regards to data
the reviewed studies was assigned a moderate GRADE analysis, future studies should conduct ITT analyses
rating, indicating that further research is likely to have an when examining primary and secondary outcomes, and
important impact on our confidence in the estimate of should clearly document why data are missing and what
effect and may change the estimate. However, evidence strategies and assumptions used for handling missing data.
for our finding on caloric intake was assigned a low qual- There are some important additional limitations of the
ity rating, indicating that further research is likely to have current analysis that have implications for future research.
an important impact on our confidence in the estimate of The clinical significance of weight outcomes associated
effect and is likely to change the estimate. Characteristics of with CBFLIs is an on-going question. Few studies in this
the studies included in this meta-analysis that strength- review reported on metabolic parameters associated with
ened the GRADE rating for weight outcomes included weight changes. While these data are admittedly difficult to
the use of RCTs, evidence of a doseresponse relationship gather with children, it will be critical to document
between weight and treatment (e.g., better weight out- improvements not only in weight outcomes but also
comes were associated with greater treatment duration metabolic parameters. Similarly, only eight studies in the
and intensity), and an overall small effect size approaching literature contained sufficient information to examine
a medium effect. There were, however, also some change in dietary intake. Moreover, there were not
weaknesses in this literature, which precluded a stronger enough articles identified to calculate effect sizes for both
GRADE rating for each outcome. For example, 75% of physical activity and sedentary behavior. Future studies of
studies were rated as having unclear or high risk of bias lifestyle interventions for obesity should include sufficient
of incomplete reporting of outcome data due to large objective information to allow effect sizes to be calculated
amounts of missing data, insufficient details regarding rea- for dietary intake, physical activity, and sedentary behavior,
sons for missing data, or the use of inadequate methods for as these effect sizes likely moderate overall effect sizes for
managing missing data, which diminishes confidences in lifestyle interventions. Admittedly, reliable and valid assess-
estimation of treatment effects. Moreover, half the studies ment of dietary intake is an ongoing challenge. Repeated
included in this analysis were rated high on risk of bias for 24-hr recalls offer the best combination of feasibility and
allocation concealment (i.e., investigators were not blind to strong psychometric properties, but are expensive,
randomized assignment of participants). In addition, effect time-consuming, and still subject to self-reporting bias.
sizes across studies for weight outcomes were somewhat Strategies to reduce reporting bias and further improve
inconsistent. Finally, as noted previously, the imprecise the reliability and validity of assessing dietary intake are
nature of assessing caloric intake negatively impacted our sorely needed. In addition, compared with other meta-
Grade rating for changes in caloric intake. analyses, only a relatively small number of studies and
There are a variety of steps that can be taken by future participants were included in this meta-analysis. As such,
research to address these methodological limitations and findings from our analysis of moderators should be viewed
improve the scientific rigor in this area. First, many studies with caution. Finally, there is the risk of publication bias in
were excluded from the meta-analysis owing to failure to any meta-analysis; the discovery of additional studies of
provide sufficient information to allow for calculation of CBFLIs might have affected the results obtained here.
effect size, or properly classify the study intervention or However, the fail-safe calculation indicated that 75 stud-
methodology. Similar concerns have been noted by ies with an effect size of 0 would need to be added to this
Klesges and colleagues, who called for researchers to meta-analysis to result in an effect size of 0.1.
improve the reporting of contextual and generalizability The potential for adverse events is important to con-
elements central to translational research sider when evaluating interventions to address childhood

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822 Janicke et al.

obesity, not only in terms of the potential for delayed linear of families in community settings, and that are feasible
growth but also for negative outcomes such as the devel- for both families and providers. Telehealth, technology-
opment of disordered eating behaviors and reductions in aided, and internet-based social media interventions are
self-esteem (Satter, 2005). Eight of the 20 studies included areas that hold promise and are deservedly garnering
in this analysis reported on adverse events. Only four of more attention (Davis, Sampilo, Gallagher, Landrum, &
these reported on potential changes in problematic eating Malone, 2013). Finally, developing broader multi-layered
attitudes and behaviors or self-esteem (DeBar et al., 2012; intervention efforts that include CBFLIs within larger com-
Janicke et al., 2008; Jiang, Xia, Greiner, Lian, & munity change efforts, such as by Rogers and colleagues
Rosenqvist, 2005; Williamson et al., 2005). One study (Rogers et al., 2013), can build awareness, as well as envi-
specifically assessed for slowed linear growth (Golley, ronmental and social supports that have the potential to
Magarey, Baur, Steinbeck, & Daniels, 2007), while three facilitate long-term behavior change that can reach larger
other studies reported on generic adverse events (Nemet numbers of children and families.
et al., 2005; Reihner et al., 2010; Sacher et al., 2010).
Across these eight studies there was no data suggestive of
an increase in negative outcomes or adverse events subse- Conclusion
quent to participating in CBFLIs. This is consistent with
The current study provides evidence that CBFLIs address-
the findings from previous reviews (Carter & Bulik, 2008;
ing pediatric obesity lead to improvements in child weight
Oude-Luttikhuis et al., 2009; Whitlock et al., 2010). While
outcomes. While the overall effect size was small, it ap-
testing the efficacy or effectiveness of CBFLIs on reducing
proached the medium range. There was no difference in
or slowing weight gain in youth has important public
effect sizes for weight outcomes at posttreatment relative to
health implications, it is equally important that families
long-term follow-up. Greater duration and intensity of
participating in these interventions are not exposed to ad-
treatment, as well as greater child age, were all related to
ditional causes of harm. Therefore, researchers should
better weight outcomes. Future research is needed to better
place a high priority on reporting information on the
document changes in caloric intake, physical activity, and
number and types of adverse events associated with
metabolic parameters associated with participation in
tested interventions.
CBFLIs. Future research is also needed to develop innova-
Given the lack of interventions addressing obesity in
young children, as well as recent findings showing that tive strategies for feasibly implementing CBFLIs in real-
children who are overweight at 5 years of age are four world settings while preserving the core components of
times more likely to be obese between 5 and 14 years of treatment with established efficacy.
age compared with children who are normal weight
Conflicts of interest: None declared.
(Cunningham, Kramer, & Narayan, 2014), there is great
need for more prevention and intervention research focus-
ing on the impact of behavioral family interventions in
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