Families Improving Together (FIT) for weight loss: a resource for translation of a positive climate-based intervention into community settings

We provide strategies and resources from the Families Improving Together for Weight Loss Program to create a warm, supportive climate characterized by positive communication within the parent-child relationship.

Abstract

Climate-based weight loss interventions, or those that foster a nurturing family environment, address important ecological influences typically ignored by the traditional biomedical treatments. Promoting a climate characterized by positive communication, autonomy support, and parental warmth supports adolescents in making healthy behavioral changes. In addition, encouraging these skills within the family may have additional benefits of improved family functioning and other mental and physical health outcomes. Although several programs have identified essential elements and established the evidence base for the efficacy of these interventions, few have offered resources for the translation of these constructs from theoretical concepts to tangible practice. This paper provides strategies and resources utilized in the Families Improving Together (FIT) for weight loss randomized controlled trial to create a warm, supportive climate characterized by positive communication within the parent–child relationship. Detailed descriptions of how Project FIT emphasized these constructs through facilitator training, intervention curriculum, and process evaluation are provided as a resource for clinical and community interventions. Researchers are encouraged to provide resources to promote translation of evidence-based interventions for programs aiming to utilize a positive climate-based family approach for lifestyle modification.

Implications.

Practice: Climate-based family interventions promoting positive parent–child communication and appropriate autonomy can be effectively translated into community settings to target adolescent health behaviors.

Policy: Policymakers who aim to improve youth health behaviors and related chronic diseases later in life should support implementation of health promotion programs that are theoretically based and supported by research.

Research: Health promotion intervention research teams should consider providing implementation resources including facilitator training guides, program curriculum, and process evaluation protocols to increase access to evidence-based programs for community settings that can be implemented with fidelity.

INTRODUCTION

The prevalence of obesity among adolescents, especially within minority groups, is staggering [1]. Traditional weight loss treatments informed by the biomedical model ignore important ecological considerations that influence diet and physical activity (PA) behaviors [2]. A multitude of systems affect weight-related behaviors including the home environment and social relationships. A nurturing environment, characterized by supportive relationships and appropriate monitoring, has been identified as critical to promoting health and well-being in youth [3]. Establishing a climate that reinforces a developmentally appropriate level of autonomy and models skills required for healthy development contributes to self-regulation and psychological flexibility which may in turn have effects on a variety of outcomes, including obesity [3]. Based on this perspective, evidence-based approaches for addressing youth obesity that create nurturing environments across the ecological framework have been identified [4]. Essential elements of these interventions, largely informed by behavioral theories such as Self-Determination Theory [5], Social Cognitive Theory [6], and Family Systems Theory [7], include the promotion of positive parenting, autonomous motivation, and behavioral skills to facilitate health behavior changes.

The family environment has been shown to positively influence youth health behaviors by providing a warm and supportive setting for learning, growth, and development [8]. Positive parent–child communication provides a foundation for parents to be change agents in promoting healthy behaviors. Although there is evidence that peers are an increasingly important influence for behavior of adolescents, in cultures with strong-family ties, there is evidence that parents play an equally important, unique role in promoting weight-related behaviors [9]. Family climate is positively associated with adolescent health behaviors and weight status [4, 10, 11]. For example, Berge et al. [12] found higher levels of family functioning (defined as communication, joint problem-solving, closeness, and appropriate behavioral control) were related to healthier body mass index scores, nutrition, and PA in adolescents. Similar results were found by Haines et al. [13] who showed relationships between higher family functioning, lower obesity risk, and less sedentary behavior. Furthermore, there is evidence that improving family climates in interventions mitigates deleterious effects of unsupportive parenting on youth weight-related outcomes nearly 15 years later [14].

Providing autonomy support is a relevant skill for parents as adolescents engage in increasingly independent decision-making into young adulthood [15]. Engaging in shared decision-making (i.e., allowing input into discussions around and offering choice in health behaviors) encourages motivation for and enjoyment of behaviors [15]. This is evidenced by associations between parental autonomy support and adolescent intrinsic motivation to improve health behaviors and adherence to weight-loss treatment [16]. Parents can also use this strategy to model problem-solving and troubleshooting of barriers to engaging in healthy behaviors by involving their adolescent in these conversations.

A growing evidence base has shown that these approaches are efficacious for improving health behaviors in youth and adults [4, 11, 17, 18]. However, a gap between research and practice exists that limits implementation of evidence-based interventions outside of research programs. This is largely a result of limited transparency in publications as programs have seldom provided adequate information on how to effectively promote these constructs within clinical or community-based settings. This paper bridges this gap by providing a detailed guide on how to train staff and implement climate-based programs that can be used in group-based or individual interventions to manage obesity, diabetes, or other chronic diseases. Detailed curriculum information, participant worksheets, and training guides are available as Supplementary Material for clinical and community use with the goal of increasing reach and fidelity.

The current paper details strategies utilized in the Families Improving Together (FIT) for weight loss randomized controlled trial [19], which consisted of 8 weekly group sessions attended by parents and adolescents led by two trained facilitators targeting diet, PA, and sedentary behavior. Families also met individually with facilitators each week for feedback on their progress and to problem-solve potential barriers to change. The program was developed based on a qualitative needs assessment within the African American community to reduce weight-related stigma in intervention programs and was thus framed as a family-based diabetes prevention program focused on improving overall family health. Project FIT aimed to facilitate positive weight-related behavioral changes (see Supplementary Material and also [19] for full intervention essential elements and curriculum including behavioral skills and motivational interviewing techniques) by encouraging a warm family climate, positive parent-child communication, and increased parental autonomy support. These goals were salient in training facilitators for groups and individualized feedback, designing intervention curriculum, and developing process evaluation protocols to ensure fidelity.

TRAINING FACILITATORS TO MODEL POSITIVE COMMUNICATION

The training of facilitators on autonomy supportive communication was a critical component of maintaining a positive social climate within the group. Prior to working with families, FIT facilitators participated in 3 days (9 total hours) of training which was supplemented with at-home reading materials and a video on family communication styles related to health behaviors (see Supplementary Material for training curriculum). The principal investigator, co-investigator, and graduate students who had previously facilitated the intervention conducted trainings in a small group format that employed training slides, hands on activities, role-plays, and group discussion. Facilitators had a background in psychology or community health and held a bachelor’s degree at minimum.

Trainers provided information on the intervention curriculum with a strong emphasis on behavioral and motivational theories (Self-Determination Theory, Social Cognitive Theory, and Family-Systems Theory) used to develop the FIT intervention. A key message reinforced was the importance of motivational interviewing strategies (e.g., eliciting change talk, collaborative goal-setting, and reflective listening) and providing autonomy support in each component of intervention delivery. For example, facilitators were trained to model autonomy supportive practices and motivational interviewing in the group intervention and to use these strategies during the individualized feedback sessions with parents and adolescents. Constructs such as creating a sense of belonging, encouraging parents to provide autonomy support, and allowing participants to develop their own personalized goals were central tenets of training and were reinforced with several hands-on activities and role plays. Individuals were also required to co-facilitate prior to becoming a lead facilitator to see a facilitator model these skills in the group setting.

FIT CURRICULUM TO ENCOURAGE POSITIVE FAMILY CLIMATE

Prior to teaching positive family communication skills, FIT facilitators presented positive family communication as a foundation for health behavior change, noting that positive family relationships and social support would be critical to success. The focus on positive communication also reduced the likelihood of weight-related stigma comments within the family and group climate. To capitalize on existing strengths of families while encouraging their openness to practicing new skills, facilitators challenged families to take advantage of the group-based delivery format to share what worked for them and to keep an open mind for new skills.

The key family communication skills covered throughout the FIT curriculum include listening to connect, using “pull” rather than “push” language, using “I” statements, focusing on “how” as much as “what” of communication, and using effective nonverbal cues (Table 1). Facilitators taught these skills using four different types of intervention activities described below: (a) between- and within-family discussions, (b) setting and enforcing group ground rules, (c) in-session practice exercises, and (d) out-of-session family bonding activities (see Supplementary Material for workbook materials).

Table 1.

Project FIT family communication skills

Skill	Definition	Examples
Listening to connect	Using “reflective” or “active” listening statements to communicate an understanding of the adolescents’ thoughts and feelings Using open-ended questions to obtain additional details or clarifications	“What you are saying is that…” “It sounds like you feel…” “Would you say a little more about that? I want to make sure I understand.”
Using “pull” rather than “push” language	Encouraging adolescents to make decisions for themselves with parents’ strategic guidance	Pull language: • “You might …” • “In what ways is this important?” • “You have the answer …” • “Let us help you find your way…” • “Why might you consider…?” • “How might you possibly go about…?” Push language: • “You must …” • “It’s important because …” • “We have the answer …” • “Let us tell you …” • “You should because …” • “Here’s how to change …”
Using “I” statements	Using statements that focus on the feelings and experiences of the parent, rather than on what the adolescent had done or failed to do	“I feel … when … happens” rather than “You never listen to me.”
Focusing on the “how” as much as the “what” of communication	Maintaining composure using a calm/neutral volume, pitch, and tone of voice	Talking using a neutral tone of voice
Using effective nonverbal cues	Demonstrating interest and an understanding of what the adolescent is saying without using words	Maintaining consistent eye contact Leaning in towards the adolescent

BETWEEN- AND WITHIN-FAMILY DISCUSSIONS

Facilitators led group discussion on family communication using a series of open-ended prompts (e.g., “When and where does your family usually talk? What do you think is working well? Or may need some improvement? Does anyone else do that? How does that work for you?”) to acknowledge and reinforce participants’ ideas and to encourage sharing between families. Facilitators then prompted parent–adolescent dyads to discuss and distinguish between positive and negative communication skills by completing a worksheet together. This worksheet (see Supplementary Material, workbook page 1) showed positive communication skills and provided spaces for families to fill in negative communication skills together. Facilitators asked families to share their responses with the group, and these discussions served to prepare families for setting group “ground rules” for positive communication.

SETTING AND ENFORCING GROUP GROUND RULES

The purpose of setting group “ground rules” was to model and reinforce positive communication within group sessions to foster a positive social climate and mutual respect among family members. Facilitators asked families to refer back to the positive communication strategies and to agree on five ground rules. Facilitators encouraged parents and adolescents to make their wording behaviorally based (e.g., if they say, “we will respect one another”, ask “how will you respect one another?”). If parents or adolescents framed their wording for ground rules negatively, facilitators reviewed a positive parenting concept known as the “positive opposite.” Focusing on the positive opposite of negative behaviors encourages parents to acknowledge, describe, and reinforce what they would like their child to do rather than what they would not like them to do. Examples of group ground rules included, “Make encouraging comments” and “Let everyone have a chance to talk.” Once the ground rules had been established, facilitators elicited suggestions from families for how best to enforce the ground rules within sessions. At the beginning of each session, facilitators reminded families that the ground rules were displayed and that they would be enforcing them throughout the session using the agreed upon enforcement technique.

IN-SESSION PRACTICE EXERCISES

Facilitators led various in-session activities that allowed parents and adolescents to learn and practice positive communication skills. To teach the skills of “listening to connect,” and “using ‘pull’ rather than ‘push’ language,” parents and adolescents were separated into different subgroups. In the parent subgroup, facilitators asked parents to share examples of how they showed they were listening to their adolescents. As parents shared their suggestions, facilitators reviewed strategies for engaging in active listening (i.e., make eye contact, lean in towards your adolescent, reflect back what you are hearing, ask for additional details with open-ended questions, and summarize adolescents’ thoughts before sharing your own). Facilitators additionally asked parents to consider their interactions with friends, bosses, parents, and partners and reflect on their response to being told they “must” do something. Facilitators highlighted the point that getting others to make their own decisions increases their motivation. They then reviewed the examples of “pull” versus “push” language. Parents engaged in two role-play activities discussing tracking and reaching calorie goals using reflective listening and “pull” language as if they were the parent or the adolescent. At the end of the parent subgroup, facilitators challenged parents to identify three ways they would practice active listening and/or pull language throughout the week as it related to their adolescents’ calorie goals. During the corresponding adolescent subgroup session, facilitators challenged adolescents to practice their interviewing and listening skills. Facilitators divided adolescents into pairs and tasked them with asking one another questions and problem-solving related to their goals (i.e., “What are you doing to track your PA?” “What has gotten in the way of your tracking?”).

Immediately following the subgroup sessions, facilitators brought parents and adolescents back together. One parent and one adolescent volunteer engaged in a role reversal role play exercise in front of the group wherein the parent took on the role of the adolescent and the adolescent took on the role of the parent. During the first part of the role reversal role play, the “parent” asked the “adolescent” the following question: “What has gotten in the way of you tracking your health behaviors or calories?” The parent and adolescent volunteers next played themselves, and facilitators tasked them to work together to set one family rule around a health behavior of their choice (“What will this rule be? How will you make sure your family follows this rule?”). At the end of the role reversal role play, facilitators asked parents and adolescents to share what differences they noticed between the two role plays and to provide the volunteers with feedback on their interaction.

OUT-OF-SESSION FAMILY BONDING ACTIVITIES

At the end of each weekly group session, facilitators assigned a “family bonding activity,” or a take-home activity to reinforce both communication and behavioral skills covered during group sessions. Family bonding activities included: use a self-monitoring tool of your choice to track lifestyle behaviors and check in with one another on monitoring progress (Week 1); set a family-related goal and discuss progress towards the goal together (Week 2); discuss how to support your family member in meeting calorie goals (Week 3); prepare a healthy family meal together (Week 4); plan a family PA (Week 5); come up with a family television time budget (Week 6); and have a family meeting and set 1–2 rules together (Week 7).

PROCESS EVALUATION AS MEANS TO MAINTAIN POSITIVE CLIMATE

Process evaluation methods were utilized to assess implementation of the FIT intervention and to ensure positive group climate (see [20] for full description). Trained and certified staff members conducted formal (summative) process evaluation to monitor fidelity (extent to which the intervention is consistent with theoretical elements), content (components of the intervention that may influence implementation such as facilitator attitude or group climate), and dose (amount of key intervention elements covered in session) while sitting in group sessions and individualized feedback sessions. Additionally, each week facilitators conducted less formal (formative) process evaluation where they met to discuss issues related to family and group climate and ways to adjust instruction to address these concerns.

Although each cohort and family presented with unique issues, common problems were identified through the evaluation process. One reoccurring issue involved conflict between the adolescent and parent due to differing goals for the child’s weight loss. The team strategized that a facilitator could model autonomy support for the parent by discussing what goals the adolescent found important or fun during individualized feedback sessions. Additionally, facilitators found it useful to reinforce positive communication skills between parent and adolescent, such as listening to connect and using “pull” rather than “push” language. Minimal weight loss or weight gain during the intervention was another common issue. Facilitators concluded that maintaining a positive group climate was essential to addressing this possible setback and enforced group ground rules to promote a supportive environment. Due to this model of continuous process evaluation, facilitators were able to flexibly meet the families’ needs while maintaining fidelity to intervention curriculum and essential elements.

IMPLICATIONS FOR INTERVENTIONS AND POLICY

Leading health behavior theories support the use of a climate-based approach to prevent and treat adolescent obesity and other health behaviors through promoting positive communication, autonomy support, and parental warmth [5, 7]. Interventions that utilize this approach not only model for parents how to be positive change agents in their family’s health but provide both parent and child with skills for a healthier relationship with each other. We urge interventionists to consider not only the behavioral skills necessary to enact change but also the context in which behavior change occurs. Because physical, mental, and social behaviors cluster in youth, interventions informed by this perspective may have positive impacts in additional domains because they target key elements underlying behavior change and motivation [3, 21]. This may lead to added physical, social, and psychological benefits resulting from the intervention, increasing the return on investment of these programs.

We also encourage other health behavior change interventions to provide tangible resources for implementation in clinical and community settings. Access to these resources may be especially important for clinicians who have limited institutional supports while working with underserved populations. Although the current intervention was implemented with African American families in an urban nonmedical setting, skills and strategies utilized within the FIT program described here are translatable in any intervention setting that seeks to promote positive climate and health behavior changes. Thoughtfully developed, evidenced-based intervention strategies are effective, yet will have limited reach and impact when detailed descriptions of how to implement them broadly are not available. To facilitate translation of effective interventions into broader settings, investigators should consider dissemination of detailed information related to training of staff, curriculum, and process evaluation methods in addition to trial results.

Compliance with ethical standards

Authors’ Contributions: L.H.L. coordinated the preparation of the full manuscript and supplemental materials. D.K.W., S.M.S., H.K. and C.J.K. all contributed to writing and providing comments on early drafts of the paper. D.K.W. conceptualized the FIT trial and intervention as Principal Investigator. D.K.W. and H.K. contributed to overall study design. L.H.L., D.K.W., S.M.S., H.K., and C.J.K. contributed to intervention development, process evaluation development, and implementation and the FIT intervention.

Funding: This research was supported by the National Institute of Child Health and Human Development (R01HD072153 to D. K. Wilson), the National Institute of General Medical Sciences (T32GM081740), and the University of South Carolina (Advanced Support Program for Integration of Research Excellence-II Grant to L. H. Law).

Conflict of Interest: The authors declare that they have no conflict of interest.

Ethical Approval: All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. This article does not contain any studies with animals performed by any of the authors.

Informed Consent: Informed consent was obtained from all individual participants included in the study.