Intervention in Overweight Children Improves BMI and Physical Activity

Abstract

Background

Childhood obesity is a growing epidemic in family medicine with few clinical treatment options. We implemented and evaluated a group office-visit intervention by family physicians emphasizing nutrition and physical activity within a resiliency psychosocial model, for overweight children and their parents.

Methods

The intervention lasted for 3 months, with half of the children crossing over to intervention after 6 months on study. Participants included 35 children who met eligibility criteria of being in third through fifth grades and having a body mass index above the 85th percentile. The 3-month twelve-session intervention, “Choices”, included topics on nutrition, physical activity, and resiliency. The sessions were developed for delivery by a family physician, and a nutritionist, who all received training in positive psychology and resilience skills. Main outcome measures were body mass index (BMI) z-scores for age-and-gender, and weight-for-age-and-gender z-scores, as well as qualitative interviews to understand individual and family processes.

Results

The intervention resulted in a significant effect on one primary outcome, BMI z-score (-0.138 per 9 months (p =0.017) and a trend toward significance on the other, weight for age z-score (-0.87 per 9 months (p=0.09). The net shift of activity from the low METS to the high METS had an intervention effect of 2.84 METS (p = 0.037). Families reported lasting changes in behaviors and attitudes.

Discussion

The innovative approach used in this study demonstrated modest efficacy in reducing BMI z-score, changing physical activity levels, and possibly shifting family dynamics.

INTRODUCTION

Childhood obesity is an emerging epidemic; two-third of adults¹ and nearly one-third of children are overweight or obese.² Obese children are more likely to become obese adults.^3,4 Adult obesity is associated with a number of serious health conditions including heart disease, diabetes, and some cancers.⁵ Research on the mediators of familial patterns of overweight children and obesity suggests that overweight parents tend to create environments that promote overweight among their children.⁶

Several public health initiatives have been launched to address this problem.⁷ However, family physicians have an important role in timely identification of overweight and obese children during periodic health examinations. They also have a role in promoting preventive measures, encouraging positive changes in behavior, as well as identifying and treating obesity-related comorbidities.⁸ They are uniquely situated to counsel both children and their parents.

Highly controlling and restrictive parental feeding strategies contribute to positive energy balance and higher body mass index by interfering with children’s ability to self-regulate energy intake.^9,10 Because parents provide the child’s contextual environment, they should be viewed as key players and central agents of change in the prevention and treatment of weight-related problems, and therefore provided with appropriate training.¹¹ Practical advice for parents includes how to foster children’s preferences for healthy foods and how to promote acceptance of new foods by children.

Reviews of childhood obesity prevention studies largely focus on school-based programs, many of which do not include a parent component.^12,13 Our literature review performed on PubMed in 2010, identified 88 publications which dealt with childhood obesity interventions. Few of these interventions involved both parent and child.^14,15 No studies combined motivational interviewing or similar interventions with structured physical activity and/or nutritional education.

In designing this intervention, we reviewed the literature on prior proven effective strategies for weight loss in children. Based on the review, we selected approaches that empowered participants to make informed “choices” related to nutrition, TV viewing, sugar - sweetened beverages, fast food and physical activity. To improve coping skills and increase the likelihood of success in making lifestyle changes, we enhanced the concept of “choices” by providing an innovative approach to problem-solving skills designed to strengthen resiliency. We developed a group office curriculum and conducted an early phase trial to test the efficacy of the program using a lagged intervention/control design.

METHODS

The University of Arizona Human Subjects Protection Program approved all procedures. Parents provided written consent, and children provided written assent for the intervention and data collection.

Design

The intervention lasted for 3 months, with half of the children crossing over to intervention after 6 months on study. In this 3-month lagged intervention design, the cohort periods were March-May 2006, and September-November, 2006. Both cohorts had data collection at months 0, 3, 6, 9, 12, and 15. Cohort 1 began the intervention at study month 0, continued the intervention until month 3, and had post-intervention data collection time points at months 6, 9, 12 and 15. Cohort 2 was the lagged control and began the intervention in study month 6, completed in month 9, and had data collection in months 12 and 15. Allocation was done using design-adaptive allocation that minimizes the differences between groups as participants enter the study. Balancing factors were gender, age, and BMI.¹⁶

Target population and recruitment

The intervention targeted children in 3^rd –5^th grades (ages 8–11 years, BMI above the 85^th percentile) and their parents. Recruitment methods included posters and flyers in Family Medicine, Pediatric, and community clinics, university email list-serves, campus-wide notices, newspaper advertisements, and news stories between December 2005 and February 2006 (see consort diagram -Figure 1).

Figure 1.

Consort Diagram

Intervention

Overview

The Choices model incorporated the inclusion of a parent and built on the above described literature review and motivational interviewing/enhancement philosophy. ¹⁷ Rather than requiring participants to follow a regiment, “one size fits all” approach, Choices allowed participants to individually modify their lifestyle in relationship to their goals. The facilitators consistently avoided labeling choices as good or bad, or healthy or unhealthy. The intervention encouraged choices based on factual knowledge (Table 1).

Table 1.

Choices Classes Intervention Topics

Class	Content and objectives	Physical activity
#1	Get acquainted; learn about program, why and what; pedometers Orientation to importance for children’s health; need for whole family to be involved	Pedometers – using, logging; family activity guide
#2	How active am I? What’s fun? How can I do more? Why is it important? Barriers and facilitators to family PA, child’s PA; enhancing PA for all; pedometer goals	Pedometer challenge
#3	What are the connections between cognition and emotion and behavior? Between what I think and what I feel and do? How does this work for children? Adults?	Chalk—hopscotch & sidewalk games
#4	Why is it important to drink water for thirst? How much sugar is in beverages?	Jump ropes
#5	How can I challenge my thinking habits that don’t help me? Recognize inaccurate thinking and change it? Ways to support children & family.	Nerf soccer
#6	How much food is enough? Portion sizes	Frisbee
#7	Television: when more isn’t better; the TV turn-off challenge	TV turn-off
#8	Time in the park – family games and review	Yoga cards
#9	Fast-foods – the truth about fat in food	Dance video
#10	Fast foods -- making other choices for the long term	Juggling scarves
#11	Making active choices: living my life	TaiBo video
#12	Choosing food and beverage that fits my lifestyle – putting it all together
CELEBRATION/GRADUATION

The 12-week group office visit intervention was developed to be compatible within a fee- for-service family medicine environment. Groups met weekly from 5:30 – 7:00 pm and were organized into three 20–30 minute increments: individual and group check-in; class content; and physical activity. Standardized participant handouts and leader manuals were developed covering the entire intervention so that both cohorts received the same intervention. Parents met with the family physician attending and the nutritionist, while the boys and girls met separately with the family medicine residents for the specific topic of the week and then met together for the physical activity. Both parents and their children received age appropriate information on the same topics. The family medicine residents presented the nutrition and activity material in an engaging, interactive manner to encourage the children’s participation. The children’s groups met separately to meet their age-appropriate developmental and gender issues. After the final session, each group had reunions 3–4 and 6–8 months post-intervention.

Physical activity and nutrition

In session one, children and a parent received pedometers, and instructions on their use. They reported steps in the second session, and set goals to increase their total steps. Physical activities promoted individual and group participation with small toys, such as a soft soccer ball, a dance video, and children’s yoga cards. As sessions progressed, children became conditioned and activities became more vigorous.

The program adapted a TV turn-off concept from Robinson et al. ¹⁸ Over several sessions, children observed their TV behavior and then committed to a TV turn-off challenge; parents committed to support them. Children who met their goals received a certificate of accomplishment.

The nutrition content was developed by the authors and nutritionist and focused on: benefits of water consumption; decreasing sugar- sweetened beverages; understanding satiety and portion sizes; familiarity with fat content in foods and choices for lower fat fast foods.

Resiliency and self-talk

The psychosocial goal was to empower children and parents to recognize their choices. Doctor Andrew Shatte, a psychologist, with expertise in the concept of resiliency provided a two day training session for the group facilitators. He taught the following concepts: 1) our thoughts about problems impact our feelings; and 2) changing our thoughts about situations can change our emotional and behavioral response. We developed teaching materials and training manuals for two resilience-focused sessions and educated the family medicine residents on this topic as well as the topics for the other sessions.

“Resilience” was the psychological framework for fostering flexibility and accuracy in making new choices. The greatest obstacle to resilience is inaccurate thoughts and beliefs about oneself, one’s world, and one’s future. People tend to fall into predictable thinking traps, limiting their problem solving abilities. By analyzing traps and providing steps to circumvent them, participants gain accuracy in their thinking, and increase resilience.¹⁷ Dr Shatte has applied this approach previously to treat and prevent depression. The model was adapted here because of its relevance to children’s beliefs about obesity and their behaviors, and themselves in relation to peers.

Quality assurance measures

All classes and reunions were audio-recorded and reviewed weekly to refine the model and language used by all the intervention staff. The leaders and investigators debriefed after each session to discuss how to improve future sessions. We systematically gathered participant feedback to modify the intervention process and contribute to process evaluation in upcoming sessions.

Measures

Quantitative measures

Outcome measures were collected at baseline and every 3 months up to 15 months. The main outcome quantitative measures were BMI- and weight- for age z-scores, as well as percent body fat. Height was measured using a wall-mounted stadiometer; the average of 3 measurements was used. Weight and percent body fat were measured on an electronic scale with built-in bioelectric impedance (Tanita TM); two measurements were taken, and if inconsistent a third was obtained. CDC reference population data were used for z-scores.¹⁹

Physical activity

Data collection sessions occurred 5:30 – 7:30 pm on Tuesday – Thursday. At each data collection visit, the children were given a validated physical activity recall focused on recalling activities before, during, and after school of the current and prior day. A MET (metabolic equivalent unit describing the energy expenditure of a specific activity) was assigned to each activity. Examples include watching TV or playing video games (MET = 1) and running (MET = 10) according to the validated measurement protocol. Although self-reports have the potential for bias, this type of recall is appropriate to the age group has been used and validated in a multi-site school-based obesity intervention study for this age group.²⁰ We chose it over pedometers to lower the ongoing participant study burden. Pedometers were used as an intervention tool, and did not contribute to the outcome measures.

Qualitative interviews

All parents and their children were contacted for 30-minute qualitative interviews 12–18 months and again at 18–24 months post-intervention. Gender-matched interviewers met the children individually. Initial questions were open-ended regarding recall of the intervention; probes on the easiest, most difficult, and continuing lifestyle changes followed. Parents were queried on project content (Choices model, thinking patterns), changes in children’s behavior, and durability of those changes. Interviews were digitally recorded.

Data analysis

Quantitative measures

All outcome variables were analyzed using the same statistical model, a generalized linear regression with a 1-period stationary autoregressive structure within person (xtgee procedure of Stata). The explanatory factors were: (1) count of the number of measurement periods since the start of intervention, to measure the cumulative intervention effect and set to zero for the last two measurements in cohort 1 and the first two in cohort 2, (2) count of the total number of three-month (measurement) periods on study, to account for physical growth, and (3) baseline value of the outcome measure. Analyses were adjusted for two of the factors used in the dynamic allocation, gender and BMI at baseline; the omitted variables were ethnicity (due to lack of variability) and age at baseline (due to inter-correlation with baseline weight, BMI, or height). Thus, the intervention effects were assessed from the start of the intervention (month 0 in cohort 1, month 6 in cohort 2) over the subsequent 9 months. The analyses were supplemented with graphical analysis to avoid regression artifacts. Missing data for weight and height were imputed by linearly interpolating for any missing data in visits 2–5 (4 missing visits out of 128 possible (2.3%)), and linearly extrapolated based on standardized growth curves if visit 6 was missing (5 missing out of 32 total (15.6%)). All values were rechecked before analysis. A time trend variable was included to control for normal growth. P-values for weight and BMI endpoints were one-sided, due to the research hypotheses of improvement, not worsening, but the height p-values were two-sided due to absence of a one-sided research hypothesis.

The original planned sample size was 40 with 80% power to detect an effect size of 0.7–0.8 using a simple conditional change model. The sample size reported here is 32, but with more measurement visits per person than in the original power calculations. The observed effect sizes were 0.47 for the target 4kg/yr weight effect and 0.52 for the target 0.75kg/m²/yr BMI effect.

Qualitative data analysis

All recordings were transcribed and coded using Atlas.ti. Codes included those pre-specified based on interview questions, and open codes developed on emerging themes. Pre-specified codes included: attitudes toward the Choices concept, reported changes in food and physical activity behaviors, empowerment of children and parents, children’s self esteem, and implementation of resiliency concepts. Emergent themes included family responses and issues for multi-household families.

RESULTS

Recruitment and study population

Recruitment occurred from mid-December 2005 through February 2006 through a mix of community outreach efforts (flyers, posters, newspaper ads, newspaper articles) encouraging interested families to contact us. Seventy five families responded to our outreach, contacting our office or leaving phone messages and 35 were subsequently consented and randomized to the study. Two families were unable to attend sessions, but the children received nearly all the measurements and are included in all analyses. The remaining 30 children attended 75% of class sessions on average. The data completion rate was 95%. Details are provided in Figure 1.

The baseline characteristics of the study population are shown in Table 2. The groups were balanced on most characteristics. The group size for Cohort 1 was 15 boys and girls and for cohort 2 was 17 boys and girls.

Table 2. Baseline anthropometrics and demographics.

Mean ± SD age, height, weight, BMI, % body fat; number of children in each group by gender, parental income, ethnicity, parental education

Characteristic	March-boys	March-girls	Sept-boys	Sept-girls	Total
Sample size	7	8	9	8	32
Age (yrs)	9.7 ± 0.4	9.7 ± 0.8	9.6 ± 0.6	9.3 ± 0.6	9.6 ± 0.6
Weight (kg)	56.0 ± 9.1	53.1 ± 8.8	56.8 ± 15.6	58.8 ± 15.9	56.2 ± 12.6
Wt/age Z**	2.35 ± 0.44	2.10 ± 0.58	2.31 ± 0.70	2.46 ± 0.71	2.31 ± 0.61
Height (cm)	144.1 ± 4.1	143.4 ± 5.7	146.4 ± 8.0	146.0 ± 10.1	145.1 ± 7.2
Ht/age Z**	1.07 ± 0.62	1.03 ± 0.69	1.50 ± 0.04	1.67 ± 0.06
BMI (kg/m2)	26.9 ± 3.6	25.8 ± 4.0	26.3 ± 6.2	27.5 ± 6.8	26.6 ± 5.2
BMI/age Z**	2.19 ± 0.33	2.00 ± 0.45	2.07 ± 0.42	2.11 ± 0.53	2.09 ± 0.43
Body fat (%)*	41.3 ± 14.3	36.9 ± 5.3	35.4 ± 9.5	39.4 ± 8.8	38.1 ± 9.6
	March		September
Mother’s Education
High school/GED	3		0		3
Some college or voc. training	4		5		9
College degree	5		2		7
> College	2		5		7
Father’s Education
<High school/GED	4		3		7
Some college or voc. training	5		4		9
College degree	3		2		5
> College	2		3		5
Family income
<$50,000	6		4		10
50,000–100,000	4		4		8
>100,000	3		4		7
Ethnicity
AI/AN	0		1		1
Asian/Pacific Islander	2		1		3
Hispanic	4		3		7
White non-Hispanic	9		12		21

^*Tanita

^**CDC

Growth and questionnaire outcomes

Growth data analyses are shown in Table 3, and in Figures 2–3. The intervention effects are shown as regression coefficients, where the outcome was measured at the end of a 3 month interval (as shown in Figures 2 and 3), and the explanatory variable was time on intervention (in 3-month units). The primary outcome BMI z-score showed a significant beneficial intervention effect of (-0.046 (p=0.017) per 3-month interval), and weight z-score was (-0.29 (p=0.09) per 3-month interval). Again in terms of 3-month changes, the intervention effect was estimated to be −0.34 kg/m²(p=0.025) for BMI, in the light of a natural growth rate of 0.51 kg/m², and −0.64 kg (p=).053)for weight relative to natural growth of 2.30 kg.

Figure 2.

BMI and BMI Z -score

In the upper panel, the light dashed line represents the predicted BMI increase if the children were to continue at the same CDC z-score (percentile). The lower panel shows the BMI age-specific z-score. In both panels, the heavy dashed line represents the intervention periods, and the darker dots are the three measurements points after the intervention for each group.

Figure 3.

Weight and Weight for age Z-score

In the upper panel, the dashed line represents the predicted weight increase if the children were to continue at the same CDC z-score (percentile). The lower panel shows the weight age-specific z-score. In both panels, the heavy dashed line represents the intervention periods, and the darker dots are the three measurement points after the intervention.

Additionally, height also showed an intervention effect of +0.59cm/3mo (2.36cm/yr) (graph not shown, p=0.06). The intervention effect on % Body fat (Tanita) was generally consistent with the other results but did not achieve statistical significance. The declines in weight and BMI were clearly associated with the lagged intervention design (Figures 2–3). The graphical results suggest that the intervention effects lasted for at least 6 months beyond the end of the intervention; in wave 1 with extended follow-up, the intervention effects are seen to last for 12 months.

For physical activity, there was a large positive estimated intervention effect for increasing high METS activities, and similarly a large reduction effect for low METS activities, with medium METS activities remaining essentially unchanged. While none of these activity group changes was statistically significant alone, the net shift of activity from the low METS group to the high METS group had an intervention effect of 2.84 (SDE = 1.36, p = 0.037). The time-trend effects for high and low METS did not approach significance.

Interview Results

Interviews 12–18 months beyond the intervention suggest that many behavior changes were lasting. Children were queried about specific ongoing changes in food choices. Table 4 presents their most frequent answers. Children who avoided vegetables were willingly eating them. Many children who primarily drank soda at baseline now predominantly drank water. Some children who were sedentary now enjoyed physical activity and participated regularly in organized activities. Parents reported girls were growing into lower BMIs. Although parents acknowledged struggling with Choices topics, they felt their roles were more clearly defined. Parents reported being enthusiastic about making changes; one year after the intervention, they requested a booster session for additional support. Interviews 18–24 months post-intervention, revealed that over half the families maintained some new behaviors and about half the children were reported to be on different growth and physical activity trajectories.

Table 4.

Counts of children’s spontaneous comments about changes in food choices

Food-related choices	N
Smaller portions	9
Drinking more water	7
Eating healthier in general	6
Drinking less soda	4
Eating less fast food	4
Making better choices when eating out	3
Trying new fruits and vegetables	3
Snacking less between meals, and improving snack choices	3

Table 5 provides quotations from the qualitative interviews. The quotations in Table 5A illustrate how the information from the Choices sessions was woven into families’ daily routines. The children’s quotes suggest their sense of self-efficacy, around food and activity. Similarly, the parents’ comments show how the Choices experience shifted family dynamics. Parent 10 illustrates how parents also benefited from the resilience approach, by having a forum for sharing beliefs, and support to try new approaches. Their involvement provided tools to enhance their parenting skills.

Table 5.

Representative Quotations from Qualitative Interviews

5.A. Implementation of the Choices model:

Parent 1: “They said, “This is not what you have to do, this is the way it is. If you choose to do this, it leads to some ramifications. Do you want this or not? It’s up to you.” … it was constantly stressed that we’re not telling you what to do, …we’re just showing you, giving you bits of information so that you can make choices. … as a parent, that’s exactly what I try and do with [my daughter]. “

Parent 2: “…when [child’s name] will say to me, ‘Can I have this or that?’ what I try and say is it’s your body, it’s your choice what you put into your body, you are in control or what goes into your body, you know, and so I try and evoke…I think that the name Choices for the program is a great name.”

[Parent 3: “ I thought Choices was great… good life style information that everyone can benefit from, not just people that are struggling with weight issues…”]

I: So you like going outside a lot--and you got into the program to learn about that?

[Child 1]: Yeah, and to learn how I can get fit, just be more confident with who I am, and just make better choices..

[Child 2]: [Making better food choices] made me…feel better, like, on the holidays, that I don’t eat as much. And that I’m watching over myself, instead of just my parents watching over me. And it has made me feel good that I have gotten more active and stuff like that.

[Parent 4]: “…before I came to Choices classes I had all those problems, a lot of the conflicts for food, [child] wants some bad foods, as a parent I try to be nice and then…sometimes I get angry, and behave angry, all those…we have family conflicts, and then when I came to Choices classes and talked to other parents, I realized it’s not only my problem, it’s everyone’s problem. We feel like friends, even though we only met a couple of times, we already feel the same way.”

5.B. Resilience

Parent 5: “My wife was very very supportive, she liked us coming to the Choices project, because she’s also concerned about [child]’s health, and she knows that all those pamphlets, all those information, that I bring from the Choices project, she takes a look at the reading materials”

Parent 6: “everyday in the beginning when we would come to the class, she [nutritionist] would have some kind of low calorie snack, which was good, …now I’m putting more vegetables in his lunch.”

Parent 7: ‘Her mother tends to like chicken nuggets and Easy Macs, or, but I know she took information back, and I noticed because Monday she packs a lunch for [child’s name], [whispering] so I always check, and there actually gets to some fresh fruit in there and vegetables now.’

Parent 8: ‘…when I am with [child’s name] I always try and encourage her you know, watch her portions, think about what you are putting in your body, drink more water, and I don’t think that a lot of that is happening when she is with her mom. … “

Parent 9: “…some kids had been teasing her at school before we got here, and so she was very self-conscious … And then, the other thing is that I think the class gave her a little more confidence…”

Parent 10: “I think seeing other kids heavy helped him accept that it’s okay to be heavier, because [before,] he would wear sweatshirts in May when it was like 95 degrees outside, …And he doesn’t do that anymore, this year he is not wearing his hoodie.”

Table 5B exemplifies the integration of the resilience component. As families increased knowledge about nutrition and activity, they enhanced their flexibility to change in these areas. Several enrolled families experienced separation or divorce. The Choices sessions provided time for expression and processing of family conflicts. In some divorced families, the information was used by both parents, as illustrated in quotes 6 and 7. For other families, the project was unable to function across family conflicts. Components of the resilience models were designed to ease the overweight stigma by teaching children that they could respond differently in challenging situations. Examples in the lessons were drawn from daily life as well as from food and activity situations. The reports from Parents 8 and 9 suggest that this was successful for the children.

DISCUSSION

This intervention, utilizing a resilience approach, showed that children who participated became less sedentary and decreased their BMI. The intervention model was well accepted by parents and children, and post-intervention interviews demonstrated sustained changes.

Overweight children are less physically active than their non-overweight peers²¹, and this tracks into adulthood.²² Our physical activity intervention (i.e., TV turnoff, pedometers, activity passport, toys) was successful in decreasing sedentary activities and possibly increasing high intensity activities. The 9-month duration of the effect beyond the intervention is consistent with a recent systematic review of childhood physical activity interventions.²³

Unlike interventions that utilize natural social groups such as clubs or schools, the Choices project brought together children sharing common issues who had never met. Children were among others with similar body habitus and struggling with similar issues of self-esteem.

The parent quotes suggest the Choices model intervention follows an approach suggested by Ludwig, in that a key parenting practice applicable to all ages is to create a protective environment in the home that applies equally to everyone to avoid stigmatizing obese children and support the health of the whole family. ²⁴ The model was adaptable, recognizing that not all members of families were overweight. The program focused on building life skills appropriate to all family members.

The foundation of the model empowered parents and children by providing a nonjudgmental framework to make lifelong changes. The model acknowledged children as important agents for change and allowed them to make educated choices not driven by rebellion or conflict. It built upon Epstein’s observations^25–29 that children with the most control over their physical activity in the intervention were the most active years later, and carried that thread forward about food and beverage choices. Prior obesity interventions have restricted one macronutrient or provided food rules or mnemonics, without empowering children explicitly. For example, a study by Kalarchian introduced a “Stoplight Eating plan” where foods were assigned red, yellow or green for unhealthy; not necessary for health; and healthy foods, respectively.³⁰ The control group also received this model, but didn’t receive the repeated counseling visits. Although weight loss was seen initially in the study group, these losses weren’t maintained beyond 12 months post intervention. In contrast, Choices avoided judgmental food-labeling. The post-intervention qualitative data suggest that many families continued to maintain some of the changes. It is possible that the empowerment approach coupled with simple lifestyle changes, contributed to long-term endurance of some of the effects. The children enthusiastically attended the sessions and were often the catalyst motivating their parents to be punctual for the sessions, to be diligent about wearing their pedometers, and to be compliant in turning off the TV during TV turn-off week.

In contrast to an ongoing study involving only parents of overweight children,³¹ our intervention targeted both parents and children. While we were concerned that empowering children might challenge parental control, the qualitative data, support that the model instead clarifies the parental role as controlling the food supply and providing opportunities for physical activity, and the child’s role as making informed choices in a supportive environment.

The resilience model was an excellent match for this empowerment perspective. Parents and children beginning the program found themselves locked in difficult situations, feeling they had tried everything, without success. The voluminous literature on the pessimistic explanatory style has shown it to be a precursor to helplessness, hopelessness, and depression, since it constricts the pessimist’s ability to generate creative solutions to old problems.^32–35 The resilience components worked to circumvent pessimism in two ways. First, explicit techniques to avoid pessimistic explanatory styles were learned and reinforced. Second, offering creative lifestyle “choices” modeled the generation of new problem-solving possibilities that would otherwise be difficult for the pessimist to generate. The model gave participants permission to become flexible, and to change their response to their child’s behavior around eating and activity. Even the most authoritarian parents began to relinquish unnecessary levels of control by week 8, as they witnessed their children making reasonable choices.

Limitations

Given the need for rapid recruitment to fulfill research goals, a majority of families were recruited from the community rather than clinical sites. This may indicate obstacles unique to our clinical sites, but may point to more general issues for recruitment within clinic populations. Possible issues include 1) healthy children are seen infrequently, 2) other issues often take precedence over discussion of overweight, 3) hectic family lives, 4) delayed wait times for beginning groups, and 5) lack of understanding that overweight is a health problem for children. In addition many of the subjects in the study were from white, non-Hispanic backgrounds. This along with the small study size limits the generalization of the conclusions.

More objective outcome measures could have been collected, including data on step counts derived from pedometers. We recognize the bias inherent in the use of self -reported nutrition and activity assessment tools.

Clinical Implications

This “proof of concept” study was designed to test the efficacy of the group office visit model in reducing children’s weight and increasing physical activity. Since we conducted the study at a family medicine residency training site, we included family medicine residents to facilitate the children’s groups. However, replication in a community setting needs further exploration. Groups could be conducted with one physician and one to two medical assistants/nurses or boys/parents groups could be scheduled at different time than girls/parents groups to reduce the number of facilitators required.

Another consideration is provider compensation. In this model physicians see a similar number of patients per hour compared to routine office visits; this makes it economically feasible and cost neutral at the clinic level. Additionally the national emphasis on childhood obesity may provide new incentives for intervention programs targeting overweight children.

Conclusion

Our study offers a novel approach for family physicians to empower parents and children in a group office setting. The visits incorporate the concepts of “choices” and “resiliency”, nutrition and physical activity messages emphasizing that energy balance is a lifelong issue. The Choices model produced positive changes in participants’ lifestyles that endured beyond the time frame of the intervention. The long-term relationship between patients and family physicians may provide the optimal venue for continuing support of families challenged by issues of obesity and maintenance of healthy lifestyle changes, and these results suggest that this intervention warrants a larger clinical trial in a clinical setting.

Table 3.

Regression Effects^a of CHOICES Intervention

Outcomeb	Intervention effectc (SDE)d	P-valuee
BMI (z-score)	−0.046 (0.022)	0.017
Weight (z-score)	−0.029 (0.022)	0.090
BMI (kg/m2)	−0.34 (0.17)	0.025
Weight (kg)	−0.64 (0.39)	0.053
Height (cm)	0.59 (0.21)	0.006
Height (z-score)	0.041 (0.027)	0.127
Low METSg	−1.04 (0.60)	0.084
Medium METS	0.13 (1.08)	0.904
High METS f	1.82 (1.42)	0.197

^aThe other variables in the equation were baseline value, male indicator, and growth trend.

^bn = 32 for Weight, BMI, Height; n = 22 for physical activity

^cPer 3-month period post intervention

^dStandard Deviation of the Estimate (sometimes called SE)

^eOne-sided for Weight and BMI, two-sided for all other variables

^fShift from low METS to high METS significant at p=0.037; see text for details.