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Original Investigation
October 30, 2017

Dose, Content, and Mediators of Family-Based Treatment for Childhood ObesityA Multisite Randomized Clinical Trial

Author Affiliations
  • 1Department of Psychiatry, Washington University School of Medicine, St Louis, Missouri
  • 2Department of Pediatrics, University of Washington, Seattle
  • 3Seattle Children's Research Institute, Seattle, Washington
  • 4Department of Medicine, Washington University School of Medicine, St Louis, Missouri
  • 5Department of Physical Therapy, University of British Columbia, Vancouver, British Columbia, Canada
  • 6Djavad Mowafaghian Center for Brain Health, University of British Columbia, Vancouver, British Columbia, Canada
  • 7Center for Hip Health and Mobility, Vancouver, British Columbia, Canada
  • 8Department of Psychiatry, University of Pittsburgh, Pittsburgh, Pennsylvania
  • 9Division of Biostatistics, Washington University, St Louis, Missouri
  • 10Department of Psychology, Washington University, St Louis, Missouri
  • 11Department of Clinical and Health Psychology, University of Florida, Gainesville
  • 12Department of Pediatrics, University at Buffalo, Buffalo, New York
JAMA Pediatr. Published online October 30, 2017. doi:10.1001/jamapediatrics.2017.2960
Key Points

Question  Does treatment designed to strengthen healthy dietary and physical activity habits (enhanced social facilitation maintenance) in children produce better weight loss outcomes than a control condition, and does a higher dose of this treatment provide additional benefits?

Findings  In this randomized clinical trial, 172 parent-child dyads were assigned to 1 of 3 32-week interventions following 16 weeks of family-based behavioral weight loss treatment. The 32-week sessions of enhanced social facilitation maintenance demonstrated better weight outcomes than 16 sessions of enhanced social facilitation maintenance and the control condition.

Meaning  This study provides empirical support that higher-dose and specialized treatment content designed to help families maintain weight-control behaviors following family-based behavioral weight loss treatment enhances weight outcomes.


Importance  Elucidation of optimal dosing and treatment content is critical for health care providers, payers, and policy makers, as well as mechanisms of change to inform intervention delivery and training initiatives for childhood obesity.

Objectives  To evaluate effects, following a 4-month family-based behavioral weight loss treatment (FBT), of 2 doses (HIGH or LOW) of a weight-control intervention (enhanced social facilitation maintenance [SFM+]) vs a weight-control education condition (CONTROL; matched for dose with LOW), on child anthropometrics, and to explore putative mediators of weight loss outcomes.

Design, Setting, and Participants  For this parallel-group randomized clinical trial conducted at 2 US academic medical centers from December 2009 to March 2013, 172 parent-child dyads completed FBT and were then randomized to 8 months of SFM+ (HIGH, n = 59; LOW, n = 56) or CONTROL (n = 57). Children (aged 7-11 years) with overweight and obesity (body mass index [BMI; calculated as weight in kilograms divided by height in meters squared] ≥85th percentile) with at least 1 parent with overweight and obesity (BMI ≥25) were recruited.

Interventions  HIGH SFM+ vs LOW SFM+ (CONTROL matched the dose of LOW).

Main Outcomes and Measures  Intention-to-treat analysis using mixed-effects models estimated change in child percentage overweight (percentage above the median BMI for a child's age and sex) for the FBT period (0-4 months) and the SFM+ period (4-12 months), and proportion of children achieving a clinically significant change in percentage overweight (≥9-unit decrease; months 0-12). Theory-based outcome mediators were also evaluated.

Results  This study recruited 172 parent-child dyads (mean [SD] age: parents 42.3 [6.4] years; children, 9.4 [1.3] years). The omnibus treatment × time interaction for child percentage overweight was significant (F8, 618.9 = 2.89; P = .004). Planned pairwise comparisons revealed that from months 4 to 12, LOW had better outcomes than CONTROL (difference, −3.34; 95% CI, −6.21 to −0.47; d = −0.40; P = .02). HIGH had better outcomes than LOW (difference, −3.37; 95% CI, −6.15 to −0.59; d = −0.38; P = .02) and CONTROL (difference, −6.71; 95% CI, −9.57 to −3.84; d = −0.77; P < .001). A greater proportion of children in HIGH (45 [82%]) vs LOW (34 [64%]) (difference, 18.00; 95% CI, 1.00-34.00; P = .03; number needed to treat = 5.56) and CONTROL (25 [48%]) (difference, 34.00; 95% CI, 16.00-51.00; P < .001; number needed to treat = 2.94) had clinically significant percentage overweight reductions. Food and activity monitoring and goal setting mediated the effect of LOW vs CONTROL (50%). Monitoring and goal setting, family and home environment, and healthy behaviors with peers mediated the effect of HIGH vs CONTROL (25%-42%).

Conclusions and Relevance  Following FBT, specialized intervention content (SFM+) enhanced children’s weight outcomes and outperformed a credible control condition, with high dose delivery yielding the best outcomes. Sustained monitoring and goal setting, support from the family and home environment, and healthy peer interactions explained outcome differences, highlighting key treatment targets.

Trial Registration  clinicaltrials.gov Identifier: NCT00759746.