Web-Based and Mobile Delivery of an Episodic Future Thinking Intervention for Overweight and Obese Families: A Feasibility Study.

BACKGROUND: The bias toward immediate gratification is associated with maladaptive eating behaviors and has been cross-sectionally and prospectively related to obesity. Engaging in episodic future thinking, which involves mental self-projection to pre-experience future events, reduces this bias and energy intake in overweight/obese adults and children. To examine how episodic future thinking can be incorporated into clinical interventions, a Web-based system was created to provide training for adults and children in their everyday lives. OBJECTIVE: Our study examined the technical feasibility, usability, and acceptability of a Web-based system that is accessible by mobile devices and adapts episodic future thinking for delivery in family-based obesity interventions. METHODS: We recruited 20 parent-child dyads (N=40) from the surrounding community and randomized to episodic future thinking versus a nutritional information thinking control to test the feasibility of a 4-week Web-based intervention. Parents were 44.1 (SD 7.8) years of age with BMI of 34.2 (SD 6.8) kg/m(2). Children were 11.0 (SD 1.3) years of age with BMI percentile of 96.0 (SD 1.8). Families met weekly with a case manager for 4 weeks and used the system daily. Adherence was collected through the Web-based system, and perceived acceptance of the Web-based system was assessed postintervention. Measurements of body composition and dietary intake were collected at baseline and after the 4 weeks of intervention. RESULTS: All 20 families completed the intervention and attended all sessions. Results showed parents and children had high adherence to the Web-based system and perceived it to be easy to use, useful, and helpful. No differences between conditions were found in adherence for parents (P=.65) or children (P=.27). In addition, results suggest that basic nutrition information along with episodic future thinking delivered through our Web-based system may reduce energy intake and weight. CONCLUSIONS: We showed that our Web-based system is an accepted technology and a feasible utility. Furthermore, results provide initial evidence that our system can be incorporated into family-based treatments targeting behaviors related to weight control. These results show promising utility in using our Web-based system in interventions.

The challenge of identifying behavioral alternatives to food: clinic and field studies.

BACKGROUND: One of the basic principles of behavioral economics interventions is identification of alternative behaviors to compete with the reinforcing value of a highly rewarding commodity. PURPOSE: Two experiments that attempt to increase alternatives to eating in obese youth are presented. METHODS: A randomized, controlled trial was used in Study 1 to compare a comprehensive family-based behavioral treatment program or an experimental treatment that incorporated reinforcing children for engaging in alternative behaviors to eating for 41 overweight 8- to 12-year-old children. Study 2 used a within-subject design with baseline, enriched environment and a second baseline phase to determine the influence of providing activities that compete with eating for 13 overweight 8- to 12-year-old children. Measurements included body mass index (BMI) change, alternatives to eating, eating, and physical activity. RESULTS: In Study 1 both treatments were associated with significant (p < .05) and maintained reductions in z-BMI over the 24 months of observation. The experimental group showed a significantly (p < .05) greater increase in alternatives to eating, and both groups showed significant (p < .05) increases in physical activity. In Study 2 alternative behaviors to eating were increased by almost 1 hr/day (p < .001) but were not associated with significant changes in energy intake or physical activity. CONCLUSION: These results suggest that using the methods studied, increasing behaviors that could compete with eating did not influence relative weight in a clinical outcome study or energy intake in a controlled field study.

The influence of parenting change on pediatric weight control.

OBJECTIVE: Parenting style was examined as a predictor of weight loss maintenance in behavioral family-based pediatric obesity treatment. RESEARCH METHODS AND PROCEDURES: Fifty obese children who participated in a behavioral family-based pediatric obesity treatment were studied. Hierarchical regression tested the incremental effect of baseline parenting and parenting during treatment on children's percentage overweight change over 12 months, beyond demographics and adherence to targeted behaviors. RESULTS: Children's percentage overweight significantly decreased at 6 (-16.3) and 12 (-11.1) months. Adherence to program goals significantly increased variance accounted for in the regression model by 10.8%, whereas adding baseline father acceptance and change in father acceptance accounted for another 20.5%. The overall model accounted for 40.6% of the variance in pediatric weight control. ANOVA showed significantly greater percentage overweight decrease from baseline for youth with fathers who increased their acceptance vs. those who decreased acceptance at 6 (-19.8 vs. -14.6) and 12 (-17.4 vs. -8.1) months. DISCUSSION: Youth who perceive an increase in father acceptance after treatment had better changes in percentage overweight over 12 months than youth with lower ratings of father acceptance. Future directions include examining how other parenting dimensions impact pediatric obesity treatment outcome and how parental acceptance can be enhanced to improve child weight control.

The effect of reinforcement or stimulus control to reduce sedentary behavior in the treatment of pediatric obesity.

Obese children were randomly assigned to a family-based behavioral treatment that included either stimulus control or reinforcement to reduce sedentary behaviors. Significant and equivalent decreases in sedentary behavior and high energy density foods, increases in physical activity and fruits and vegetables, and decreases in standardized body mass index (z-BMI) were observed. Children who substituted active for sedentary behaviors had significantly greater z-BMI changes at 6 (-1.21 vs. -0.76) and 12 (-1.05 vs. -0.51) months, respectively. Substitution of physically active for sedentary behaviors and changes in activity level predicted 6- and 12-month z-BMI changes. Results suggest stimulus control and reinforcing reduced sedentary behaviors are equivalent ways to decrease sedentary behaviors, and behavioral economic relationships in eating and activity may mediate the effects of treatment.

A cost-analysis of adopting a healthful diet in a family-based obesity treatment program.

OBJECTIVE: To assess dietary costs during a family-based pediatric obesity intervention. DESIGN: Families were randomized to one of two groups. Dietary and cost data were collected from a parent or child using three 24-hour recalls: at baseline, 6 months, and 12 months. SUBJECTS: Thirty-one families with an obese 8- to 12-year-old child entered treatment, with complete dietary data provided from 20 families. INTERVENTION: The 20-week behavior modification intervention emphasized increasing diet nutrient-density. Families attended group and individual sessions or group sessions. MAIN OUTCOME MEASURES: Energy intake; percent of energy from protein, fat, and carbohydrate; servings and percent servings from food groups classified by nutrient density; and daily food costs. STATISTICAL ANALYSES PERFORMED: Mixed analyses of variance, with group as the between-subject factor, and time as the within-subject factor. RESULTS: No significant effect of group was found in any analyses. Significant decreases in percent overweight were observed at 6 and 12 months for children (-10.0+/-8.7 and -8.0+/-10.3, respectively) (mean+/-standard deviation) and parents (-6.7+/-10.3 and -5.3+/-14.1). Energy intake for parents and children combined significantly decreased from baseline (1,881+/-462) to 6 months (1,412+/-284), and 1 year (1,338+/-444). Servings from low-nutrient-dense foods significantly decreased from baseline (34.7+/-16.2) to 6 months (16.0+/-8.6) and 1 year (18.6+/-9.2), causing a significant increase in diet nutrient density. Dietary cost did not change at 6 months, but significantly decreased from baseline to 1 year ($6.77+/-2.41 to $5.04+/-1.80). Cost per 1,000 kcal did not significantly change. APPLICATIONS/CONCLUSIONS: Adopting a lower-energy, nutrient-dense diet did not increase dietary costs over time. Consequently, cost should not be a barrier in the adoption of a healthful diet.