Relationships examined: Parent and child readiness to change and sociodemographic characteristics in family based weight loss treatment.

BACKGROUND: Family based treatment is an effective, multipronged approach to address obesity as it plagues families. OBJECTIVE: To investigate the relationships among sociodemographic characteristics (e.g., education and income), body mass index (BMI) and race/ethnicity with readiness to change for parents enrolled in the Primary care pediatrics, Learning, Activity and Nutrition (PLAN) study. METHODS: Multivariate linear regressions tested two hypotheses: (1) White parents will have higher levels of baseline readiness to change, when compared to Black parents; (2) parents with higher income and education will have higher levels of readiness to change at baseline. RESULTS: A positive relationship exists between baseline parent BMI and readiness to change (Pearson correlation, 0.09, p < 0.05); statistically significant relationships exist between parent education level (-0.14, p < 0.05), income (0.04, p < 0.05) and readiness to change. Additionally, a statistically significant relationship exists, with both White (ß, -0.10, p < 0.05), and Other, non-Hispanic (-0.10, p < 0.05) parents exhibiting lower readiness to change than Black, non-Hispanic parents. Child data did not indicate significant relationships between race/ethnicity and readiness to change. CONCLUSIONS: Results demonstrate that investigators should consider sociodemographic characteristic factors and different levels of readiness to change in participants enrolling in obesity interventions.

Family-Based Behavioral Treatment for Childhood Obesity Implemented in Pediatric Primary Care: A Randomized Clinical Trial.

Importance: Intensive behavioral interventions for childhood overweight and obesity are recommended by national guidelines, but are currently offered primarily in specialty clinics. Evidence is lacking on their effectiveness in pediatric primary care settings. Objective: To evaluate the effects of family-based treatment for overweight or obesity implemented in pediatric primary care on children and their parents and siblings. Design, Setting, and Participants: This randomized clinical trial in 4 US settings enrolled 452 children aged 6 to 12 years with overweight or obesity, their parents, and 106 siblings. Participants were assigned to undergo family-based treatment or usual care and were followed up for 24 months. The trial was conducted from November 2017 through August 2021. Interventions: Family-based treatment used a variety of behavioral techniques to develop healthy eating, physical activity, and parenting behaviors within families. The treatment goal was 26 sessions over a 24-month period with a coach trained in behavior change methods; the number of sessions was individualized based on family progress. Main Outcomes and Measures: The primary outcome was the child's change from baseline to 24 months in the percentage above the median body mass index (BMI) in the general US population normalized for age and sex. Secondary outcomes were the changes in this measure for siblings and in BMI for parents. Results: Among 452 enrolled child-parent dyads, 226 were randomized to undergo family-based treatment and 226 to undergo usual care (child mean [SD] age, 9.8 [1.9] years; 53% female; mean percentage above median BMI, 59.4% [n = 27.0]; 153 [27.2%] were Black and 258 [57.1%] were White); 106 siblings were included. At 24 months, children receiving family-based treatment had better weight outcomes than those receiving usual care based on the difference in change in percentage above median BMI (-6.21% [95% CI, -10.14% to -2.29%]). Longitudinal growth models found that children, parents, and siblings undergoing family-based treatment all had outcomes superior to usual care that were evident at 6 months and maintained through 24 months (0- to 24-month changes in percentage above median BMI for family-based treatment and usual care were 0.00% [95% CI, -2.20% to 2.20%] vs 6.48% [95% CI, 4.35%-8.61%] for children; -1.05% [95% CI, -3.79% to 1.69%] vs 2.92% [95% CI, 0.58%-5.26%] for parents; and 0.03% [95% CI, -3.03% to 3.10%] vs 5.35% [95% CI, 2.70%-8.00%] for siblings). Conclusions and Relevance: Family-based treatment for childhood overweight and obesity was successfully implemented in pediatric primary care settings and led to improved weight outcomes over 24 months for children and parents. Siblings who were not directly treated also had improved weight outcomes, suggesting that this treatment may offer a novel approach for families with multiple children. Trial Registration: ClinicalTrials.gov Identifier: NCT02873715.

Implementing family-based behavioral treatment in the pediatric primary care setting: Design of the PLAN study.

Family-based behavioral treatment (FBT) is an evidence-based treatment for pediatric obesity. FBT has primarily been implemented in specialty clinics, with highly trained interventionists. The goal of this study is to assess effectiveness of FBT implemented in pediatric primary care settings using newly trained interventionists who might implement FBT in pediatric practices. The goal is to randomize 528 families with a child with overweight/obesity (≥85th BMI percentile) and parent with overweight/obesity (BMI ≥ 25) across four sites (Buffalo and Rochester, New York; Columbus, Ohio; St. Louis, Missouri) to FBT or usual care and obtain assessments at 6-month intervals over 24 months of treatment. FBT is implemented using a mastery model, which provides quantity of treatment tailored to family progress and following the United States Preventive Services Task Force recommendations for effective dose and duration of treatment. The primary outcome of the trial is change in relative weight for children, and secondarily, for parents and siblings who are overweight/obese. Between group differences in the tendency to prefer small immediate rewards over larger, delayed rewards (delay discounting) and how this is related to treatment outcome is also evaluated. Challenges in translation of group-based interventions to individualized treatments in primary care settings, and in study implementation that arose due to the COVID-19 pandemic are discussed. It is hypothesized that the FBT intervention will be associated with better changes in relative weight for children, parents, and siblings than usual care. The results of this study can inform future dissemination and implementation of FBT into primary care settings.

Do process simulations during episodic future thinking enhance the reduction of delay discounting for middle income participants and those living in poverty?

Two studies examined whether episodic future thinking (EFT; pre-experiencing future events) reduces discounting of future rewards (DD). No studies have investigated whether process simulations (i.e., simulating the process of executing a future event) amplify EFT's reduction of DD. Study 1 examined the effect of incorporating process simulations into EFT (N = 42, M age = 43.27; 91% female, family income = $75,976) using a 2 × 2 factorial design with type of episodic thinking (process, nonprocess/general) and temporal perspective (EFT, episodic recent thinking) as between-subjects factors. Study 2 replicated Study 1 in a sample of adults living in poverty (N = 36; M age = 38.44, 88% female; family income = $25,625). The results of both studies showed EFT reduced DD, but process-oriented EFT did not amplify the effect of EFT. Our findings suggest the key ingredient in EFT's effect on DD is self-projection into the future. This was also the first study to show EFT improves DD in a sample living in poverty.

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.

Reducing variety enhances effectiveness of family-based treatment for pediatric obesity.

Basic research has shown that increasing variety increases energy intake, and repeated consumption of the same food increases habituation to those foods and reduces consumption. Twenty-four families with overweight/obese 8-12 year-old children and overweight/obese parents were randomly assigned to 6months of usual family based treatment (FBT) or FBT plus reduced variety of high energy-dense foods (FBT+Variety). Intention to treat mixed model ANOVA showed between group differences in child percent overweight (FBT+Variety-15.4% vs. FBT-8.9%, p=0.017) and parent BMI (FBT+Variety-3.7kg/m(2) vs. FBT-2.3kg/m(2); p=0.017). Positive relationships were observed between child zBMI and parent BMI changes (r=0.51, p=0.018), and between reductions in food variety of high energy-dense foods and reductions in child zBMI (r=0.54, p=0.02) and parent BMI (r=0.45, p=0.08). These pilot data suggest that reducing the variety of high energy dense foods and repeating meals within the context of FBT resulted in improved child and parent weight changes at six months. This represents easy to implement changes that reduce choice and may reduce response burden on families. Reducing variety may be a complement to standard FBT that enhances weight loss. Long term studies are needed to assess maintenance of these changes.

Cost-effectiveness of family-based group treatment for child and parental obesity.

BACKGROUND: Obesity runs in families, and family-based behavioral treatment (FBT) is associated with weight loss in overweight/obese children and their overweight/obese parents. This study was designed to estimate the costs and cost-effectiveness of FBT compared to separate group treatments of the overweight/obese parent and child (PC). METHODS: Fifty overweight/obese 8- to 12-year-old children with overweight/obese parents were randomly assigned to 12 months of either FBT or PC treatment program. Assessment of societal costs (payer plus opportunity costs) were completed based on two assumptions: (1) programs for parent and child were available on separate days (PC-1) or (2) interventions for parent and child were available in the same location at sequential times on the same day (PC-2). Cost-effectiveness was calculated based on societal cost per unit of change using percent overBMI for children and weight for parents. RESULTS: The average societal cost per family was $1,448 for FBT and $2,260 for PC-1 (p < 0.001) and $2,124 for PC-2 (p < 0.001). Child cost-effectiveness for FBT was $209.17/percent overBMI, compared to $1,036.50/percent overBMI for PC-1 and $973.98/percent overBMI for PC-2. Parent cost-effectiveness was $132.97/pound (lb) for FBT and $373.53/lb (PC-1) or $351.00/lb (PC-2). CONCLUSIONS: For families with overweight/obese children and parents, FBT presents a lower cost per unit of weight loss for parents and children than treating the parent and child separately. Given the high rates of pediatric and adult obesity, FBT may provide a unique cost-effective platform for obesity intervention that alters weight in overweight/obese parents and their overweight/obese children.

Heart disease, overweight, and cigarette smoking are associated with increased prevalence of extra-cranial venous abnormalities.

OBJECTIVES: Most of the extra-cranial venous abnormalities have been previously described as truncular venous malformations. In this hypothesis-driven study, we evaluated possible association of risk/protective factors with the presence of truncular and functional venous abnormalities in internal jugular veins (IJVs) in a large cohort of volunteers without known central nervous system (CNS) pathology. METHODS: The study included 240 controls who underwent physical and Doppler sonography (DS) examinations for the presence of intra- and extra-luminal structural and functional abnormalities of the IJVs, and were assessed with a physical examination and structured environmental questionnaire for demographic characteristics, presence of autoimmune and other concomitant diseases, vascular risk factors, environmental factors, and habits. Logistic regression analysis was used to test which risk/protective factors were associated with the presence and number of extra-cranial venous abnormalities. RESULTS: Subjects with heart disease (P<0·001), overweight (P = 0·005), and smoking (P = 0·016) had a significantly increased number of intra-luminal structural venous abnormalities. Presence of heart disease increased the risk of a malformed valve 12·9 times (95% CI: 5·4-31·3, P<0·001), while smoking increased it 2·21 times (95% CI: 1-4·9, P = 0·033). Being overweight (P = 0·003), a history of mononucleosis (P = 0·012) and smoking (P = 0·042) increased risk for presence of a flap. No association was found between the investigated risk factors and extra-luminal or functional venous abnormalities. However, use of dietary and herbal supplements had a protective role for the presence of functional venous abnormalities. CONCLUSIONS: There is a close association between intra-luminal, structural, extra-cranial, venous system pathology and the presence of heart disease, overweight, and smoking.

Patterns of dietary and herbal supplement use by multiple sclerosis patients.

To assess the patterns of dietary (DS) and herbal supplement (HS) use in MS patients, compare use between MS patients and healthy controls and to identify potential interactions with drugs used to treat MS. This study included 279 MS subjects and 161 controls from a study of risk factors in MS. All patients received a neurological examination. All subjects provided responses to a standardized questionnaire administered during an in-person interview. A larger proportion of MS patients (82.1%) compared to controls (60.1%) used one or more DS regularly for at least 3 months (p < 0.001). There was a trend toward a higher proportion of MS patients (26.6%) versus controls (17.8%) who used HSs for more than 1 month (p = 0.038). The most common DS used after MS onset was a multivitamin (78.1%), followed by vitamin D (65.8%). Use of the majority of specific DSs increased significantly after MS onset compared to before. The proportion of controls and MS patients after MS onset who reported using an individual HS was generally similar. The most commonly used HS in patients after MS was evening primrose oil (40.4%) followed by cranberry fruit extract (35.2%). There was no evidence for associations with progressive disease course or with choice of disease-modifying treatment. Dietary supplements are used more frequently by MS patients than controls. Use tends to increase after MS onset compared to before, especially for DS. The use of HS by MS patients is only modestly greater than by controls.

Risk factors for chronic cerebrospinal venous insufficiency (CCSVI) in a large cohort of volunteers.

BACKGROUND: The role of intra- and extra-cranial venous system impairment in the pathogenesis of various vascular, inflammatory and neurodegenerative neurological disorders, as well as in aging, has not been studied in detail. Nor have risk factors been determined for increased susceptibility of venous pathology in the intra-cranial and extra-cranial veins. The aim of this study was to investigate the association between presence of a newly proposed vascular condition called chronic cerebrospinal venous insufficiency (CCSVI) and environmental factors in a large volunteer control group without known central nervous system pathology. METHODS AND FINDINGS: The data were collected in a prospective study from 252 subjects who were screened for medical history as part of the entry criteria and participated in the case-control study of CCSVI prevalence in multiple sclerosis (MS) patients, and then were analyzed post-hoc. All participants underwent physical and Doppler sonography examinations, and were assessed with a structured environmental questionnaire. Fullfilment of ≥ 2 positive venous hemodynamic (VH) criteria on Doppler sonography was considered indicative of CCSVI diagnosis. Risk and protective factors associated with CCSVI were analyzed using logistic regression analysis. Seventy (27.8%) subjects presented with CCSVI diagnosis and 153 (60.7%) presented with one or more VH criteria. The presence of heart disease (p = .001), especially heart murmurs (p = .007), a history of infectious mononucleosis (p = .002), and irritable bowel syndrome (p = .005) were associated with more frequent CCSVI diagnosis. Current or previous smoking (p = .029) showed a trend for association with more frequent CCSVI diagnosis, while use of dietary supplements (p = .018) showed a trend for association with less frequent CCSVI diagnosis. CONCLUSIONS: Risk factors for CCSVI differ from established risk factors for peripheral venous diseases. Vascular, infectious and inflammatory factors were associated with higher CCSVI frequency.

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.