Keywords

Introduction

The childhood obesity epidemic is a pressing public health concern, with approximately 31.8% of children with either overweight or obesity [1]. Childhood obesity represents a considerable cost to society through increased health-care burden and associated spending [2]. It has many negative health consequences, including both medical (e.g., increased risk of diabetes, hypertension) and psychosocial comorbidities (e.g., bullying, weight-based teasing, and stigmatization that leads to a reduced quality of life) [3]. Given that 82% of children with obesity become adults with obesity [4], these health-care costs and physical and psychological comorbidities will persist into adulthood if the obesity is not treated effectively.

Fortunately, when obesity is treated at an early age, due to potential for height growth, relatively small weight losses can have a significant impact [5]. Children ages 8–9 years old with a BMI at or above the 97th percentile for age and sex need to lose only 1.8 (girls) to 2.1 (boys) kg over 1 year to achieve a healthy weight, which is in contrast to the 5.5 (boys) to 7.6 (girls) kg weight loss necessary for a 12–13-year-old to reach a healthy weight. Furthermore, maintaining weight and preventing weight gain improve cardiovascular risk factors in children but not adolescents [6], further emphasizing the importance of early intervention. Intervention early in childhood also allows healthy eating and physical activity habits to be established before children become entrenched in obesogenic patterns. Thus, early intervention is critical to promote a healthy weight and cardiovascular health in adulthood. In this chapter we will (1) present current treatment recommendations for childhood obesity and provide a brief review of the literature in support of childhood obesity treatment, (2) describe the components of family-based behavioral treatments for childhood obesity, and (3) explore future directions for FBT research.

Current Treatment Recommendations for Childhood Obesity

The United States Preventive Services Task Force (USPSTF) recommends that clinicians start tracking BMI percentiles at 2 years of age to screen children aged 6 years and older for obesity and, if diagnosed with obesity, offer them or refer them to a comprehensive, behavioral intervention of ≥26 hours over a period of up to 12 months to improve weight status [7]. These recommendations are based upon the results of a rigorous, scientific review that demonstrated the efficacy of interventions of 26 or more hours of contact that include dietary, physical activity, and behavioral counseling components [8].

Underpinning these recommendations and guidelines is a significant body of research demonstrating the potency of intensive, multicomponent lifestyle interventions in inducing weight loss in children and in reducing medical and psychological comorbidities associated with obesity, as compared to no-treatment controls, education-only, or single-component conditions. The amount, or duration of treatment contact, has also been found to be a consistent predictor of long-term weight outcomes in children [9]. Furthermore, the inclusion of parents or caregivers in the treatment of childhood obesity improves weight loss outcomes in comparison with interventions that only target the child. In fact, interventions with a family-based component result in a 6% greater mean reduction in percent overweight compared to those without this component [10].

Family-Based Behavioral Weight Loss Treatment

Family-based behavioral weight loss treatment (FBT) is a multicomponent behavioral weight control intervention developed and refined by Leonard Epstein, Denise Wilfley, and colleagues [11, 12]. FBT targets both children and parents and is considered a first-line treatment for children with overweight and obesity [13]. FBT is effective at improving weight status in both the short and long term [12, 14] and has been shown to improve other obesity-related comorbidities such as cardiometabolic risk factors and improvements in psychological well-being [15, 16]. Although the majority of studies have been conducted with children in middle childhood [11], FBT has also been successfully adapted for use with both preschoolers [17] and adolescents [18].

Sustainable behavior change is associated with early treatment response; specifically, recent work highlights that children who lose weight by week 8 of a weight loss intervention have the greatest likelihood of sustained success [19]. It is important for providers to encourage weight loss early in the intervention to maximize the potential for long-term success.

To improve a child’s weight status, FBT targets modification of energy balance behaviors (i.e., decreasing energy intake and increasing energy expenditure) through the use of behavior change strategies and the active involvement of a parent or caregiver. In FBT, the parent or caregiver, who often also has overweight or obesity, is charged with both changing his or her own energy balance behaviors and supporting the child in these endeavors. Furthermore, the parent or caregiver is encouraged to engineer the home environment so that it promotes these behaviors for the entire family. To facilitate long-term weight loss maintenance, treatment contact is extended to allow for the continued practice of behavioral change skills and the development of family and social networks in support of weight loss maintenance behaviors [12]. The components of FBT are described below.

Key Components of Family-Based Behavioral Weight Loss Treatment

Dietary Modification

There are three primary dietary modification goals in FBT: (1) decrease energy intake, (2) improve nutritional quality, and (3) shift food preferences toward more nutrient-dense choices. To facilitate a decrease in energy intake while improving nutritional quality, FBT uses a family-friendly method of categorizing foods according to traffic light colors shown in Table 32.1 [20]. In addition, families learn to gradually adopt healthier eating habits through decreasing portion sizes; reducing intake of energy-dense, low-nutrient-dense foods (red foods); increasing intake of lower-calorie, more nutritious foods (green foods); and regularly consuming three meals a day. To shift taste preferences from less nutritious to more nutritious food options, families are discouraged from swapping energy-dense foods with non- or low-calorie or fat substitutes (e.g., swapping out ice cream with frozen yogurt) because these latter foods are typically processed to taste the same as their high-calorie alternative.

Table 32.1 Traffic light classification of foods/beverages and activities
Full size table

Other dietary goals include reducing portion sizes of yellow and red foods, which have been shown to reduce intake [21], and reducing food intake away from home, which helps increase overall diet quality and has been shown to be associated with reductions in both child BMI and percent body fat during FBT [22]. FBT has also been shown to decrease food fussiness (i.e., the frequent rejection of both familiar and unfamiliar foods), which increases diet quality, and thus increases relative weight loss [23]. Following sufficient weight loss, children and parents are instructed to increase their caloric intake to a level appropriate for weight maintenance. Other dietary goals for weight maintenance are similar to the dietary goals during weight loss treatment. In fact, continued reduced red food intake predicts weight loss maintenance in both children and their parents [24], indicating that dietary factors that help influence weight loss during FBT are also important for sustained weight maintenance.

Energy Expenditure Modification

The primary energy expenditure goals in FBT are to increase moderate-to-vigorous physical activity and to decrease sedentary behaviors (e.g., nonschool or work-related screen time). Shown in Table 32.1, the colors of the traffic light are also used to help families identify which activities to increase (green, moderate-to-vigorous physical activity) and to decrease (red, sedentary behaviors). Families are also encouraged to increase lifestyle activities such as using stairs instead of elevators or walking or riding a bike to school rather than taking a car. Eating is a complementary behavior to sedentary behavior for many people (i.e., they both increase or decrease in the same direction); thus, decreasing time spent engaging in sedentary behaviors not only creates opportunities for greater time spent being physically active but also decreases opportunities for eating [25]. Increasing physical activity not only facilitates weight change in the short term but is also crucial for weight maintenance following FBT; physical activity level is also predictive of sustained weight change 10 years after participation in FBT [14].

Behavior Change Strategies

Components of behavior therapy and behavior change are vital to family-based behavioral weight loss interventions; interventions that incorporate behavior change strategies are more successful at achieving weight loss and the prevention of excess weight gain than education alone [26]. Standard behavior change strategies include goal setting, self-monitoring, family-based reward systems, and stimulus control strategies.

Goal setting is the process of creating specific, measurable, and realistic targets (i.e., goals) for behavior change. Sample goals include consuming less than 15 servings of red foods per week, engaging in 60 min of activity per day, reducing time spent in sedentary behavior by 50%, or achieving projected weight loss or weight maintenance. The frequency of goal setting is associated with sustained behavior change, and continued, frequent goal setting is an important component of weight maintenance [27]. All children and parents are given weight loss goals, but other goals are individualized to focus on specific behaviors most needing improvement. As the intervention progresses, goals change to accommodate participant progress.

Goals are accompanied by self-monitoring, which allows one to monitor progress and to determine which goals are being met. Those who participate in frequent self-monitoring are more aware of their energy balance behaviors and have more successful weight outcomes [28]. In FBT, both the parent and child are encouraged to participate in regular self-monitoring of weight-related behaviors by weighing at home and recording the weights, on a weekly basis, and parents are encouraged to help their child master this skill.

In FBT, reward systems are used to help reinforce behaviors. To develop a reward-based incentive system, parents and children work together to determine appropriate and appealing rewards. Children earn points for achieving their goals and can exchange their points for rewards. Ideal rewards are those that increase social support and reinforce the targeted behaviors (e.g., park visit with friends); it is strongly recommended that parents do not use food as a reward and instead try to increase the reinforcing value of physical activity or peer interactions.

Stimulus control is defined as using environmental enrichment to restructure the environment to increase the likelihood of engaging in desired behaviors and is a critical component of behavior change interventions for obesity [10]. Within a behavioral economic framework, people’s choices to obtain commodities are influenced by the constraints placed on those commodities. As the constraints on the commodities change, so do choices. As such, stimulus control works by placing constraints on undesirable choices (i.e., red foods and activities) to help someone make the best choice thus making the healthy choice the easy choice. In FBT, it is necessary for parents to remove prompts for unhealthy foods and sedentary behaviors (e.g., removing chips and cookies from the home, keeping videogame equipment on a high shelf in the closet) and increase the prompts for healthy foods and physical activity (e.g., placing fruits in a basket on the kitchen counter, keeping sneakers by the door) in the home.

Family Involvement and Support

Given that greater degree of parental involvement leads to greater child weight loss and that targeting the parent and child together is more effective than targeting the child alone [29], family involvement is a critical component of FBT. In FBT, participating parents and caregivers are also taught to systematically use behavioral principles and positive parenting approaches to help shape and support their child’s weight change efforts. Children’s weight-related behaviors exist in the context of their home and family environment. The goal of including parents in their child’s treatment is to capitalize on this parental influence to promote healthier behavior choices and maximize health outcomes for both parent and child. Parents are encouraged to create a healthy home environment and model healthy behaviors by purchasing healthier foods, planning healthier meals, developing a family-based reward system to reinforce healthy choices, participating in and encouraging increased physical activity, and using praise to reinforce healthy behaviors while simultaneously minimizing attention to unhealthy behaviors [30]. While parents are tasked with helping their child reduce their consumption of energy-dense foods, it is critical to do so without using overly restrictive feeding practices or using excessive control over when and how much food a child eats. Thus, as a part of the emphasis on parenting skills in FBT, parents are taught how to use limit setting to help create structure and routines around eating (and activity and sleep) behaviors to avoid conceptualizing certain foods as forbidden. As such, FBT has been shown to decrease restrictive parent feeding practices, which is associated with reductions in child relative weight during treatment [31].

Parents participating in FBT are encouraged to actively work toward changing their own weight status in addition to supporting their child’s efforts. By including parents as active treatment targets, they can model the healthier eating and physical activity behavior critical for weight loss success. According to social learning theory, modeling is a critical way for parents to socialize their children’s behavior [32]. When children are learning a new behavior, observing a key socialization agent (i.e., a parent) engaged in this behavior reinforces it. In fact, children with overweight or obesity may be particularly sensitive to adult influence in the transmission of health behaviors [33], underscoring the importance of active parental involvement in FBT. As such, parent weight loss is a positive predictor of child weight loss in FBT [34].

Importance of Intervening Across Time and Contexts

While weight loss during family-based behavioral interventions has been clearly demonstrated, weight regain after lifestyle change is a common phenomenon among adults and is a challenge for children as well [35]. A child’s weight-related dietary and physical activity behaviors are not just developed and maintained in the context of the family home but also the broader community within which children and their families live, work, and play. Thus, interventions that utilize a socioenvironmental approach are efficacious for weight loss because they extend the focus of behavior change beyond the individual to encompass the home, peer, and community contexts [36]. Bouton’s work on context-specific extinction shows that when new weight control behaviors are acquired during the course of FBT, these new behaviors do not replace the old behaviors associated with weight gain but rather coexist with them [37]. Unfortunately, new behaviors are not very generalizable outside of the setting in which they were learned, and old behaviors are easily activated across the different contexts of our obesogenic world. Therefore, concerted efforts must be made to ensure that new learning is practiced across most or all relevant contexts, that appropriate support and cues for healthful behaviors are in place, and that there is sufficient time devoted to the mastery and practice of these strategies. As a result of this contextual influence on the acquisition and practice of energy balance behaviors, FBT takes a socioenvironmental or multilevel approach to behavior change to improve maintenance of weight losses over time [38]. To address challenges to the maintenance of these new behaviors, FBT teaches families to plan for the different constraints or barriers to maintaining a healthy energy balance across these different levels of influence, e.g., learn how to identify and capitalize on facilitators for healthy living within peer networks and the community.

Peer Level

The overarching goal of the peer component in FBT is to increase the number of peers that are supportive of a healthier lifestyle rather than to change the attitudes and behaviors of everyone within the social network. Peer interactions are naturally reinforcing to children, and good peer relationships have a positive influence on overall quality of life. When peers are supportive of healthy energy balance behaviors, weight loss maintenance efforts are enhanced [39]. Conversely, a lack of peer support for physical activity and healthy eating contributes to weight gain [12]. In FBT, heightened social problems (e.g., loneliness, jealousy, susceptibility to teasing) predict greater weight regain after FBT [40], and children with higher levels of social problems evidence poorer weight loss maintenance [12]. These findings may be partially explained by the fact that youth who experience social problems or rejection may be more likely to use food as a coping mechanism [41] and less likely to engage in physical activity [42]. These findings highlight the need to include training in pro-social techniques as part of treatment. Therefore, in FBT, families are encouraged to establish healthy peer networks and to disentangle socializing from unhealthy activities (e.g., encourage active playdates and birthday parties). In an effort to improve children’s confidence in their ability to relate positively to peers, FBT also includes training in pro-social techniques for dealing with teasing and cognitive behavioral techniques to improve body image and self-esteem.

Community Level

At the community level , aspects of the built environment may affect an individual’s choice to engage in energy balance behaviors. Environmental features of one’s neighborhood are associated with rates of obesity and physical activity in children [43]. Important environmental factors include access to healthy foods (i.e., proximity of grocery stores), proximity to fast-food restaurants, relative cost of healthy and unhealthy foods, perceived safety and neighborhood walkability, and access to community recreation facilities and local parks [44]. For example, the built environment influences children’s weight loss success in FBT; access to parks and open spaces predicted greater weight loss success at a 2-year follow-up, whereas reduced access to parks and greater access to supermarkets and convenience stores predicted poorer outcome [45]. In FBT, families engage in a number of activities to help increase their familiarity with how their built environment can both help and interfere with the establishment of healthy habits over the long term. It is also important that families learn to create a lifestyle that capitalizes on healthful environmental opportunities (e.g., local parks) while limiting access to obesity-promoting aspects of the environment (e.g., fast-food restaurants). Problem-solving, goal setting, and stimulus control are techniques that families can use in FBT to better work around or with their built environments. In addition, families are encouraged to become advocates for increased access to healthy foods and activity choices in their schools, their work places, and other community settings. Families are encouraged to build a culture of health in their homes, in their relationships, and in their communities to provide support for the difficult challenge of healthy weight maintenance in our obesogenic world.

Future Directions in the Behavioral Treatment of Obesity

Although FBT is a very effective treatment for childhood obesity, transdisciplinary research is needed to facilitate our understanding of individual, modifiable factors that can affect treatment response and to contribute to the development of even more potent, personalized, and efficient forms of FBT.

Personalized and Adaptive Treatment Designs

Previous work has identified predictors of FBT treatment success [46]; predictors of better child relative weight loss at the end of FBT included lower child baseline zBMI and age, higher baseline parent-reported self-efficacy at reducing calories, and greater parent BMI reductions across treatment [46]. Additionally, it has been shown that a child’s weight loss by the eighth week of FBT predicts long-term treatment success [19]. Given this knowledge, advances in educational and systems sciences [47, 48] could be brought to bear to assist in the development of mastery learning models [49] or adaptive treatment algorithms [50] that would allow the intensity or direction of FBT to adjust to the needs or characteristics of individual families, thus conserving resources and improving treatment outcomes.

The varying intervention needs of individuals may not be met by uniform intervention dose, content, or frequency; thus, adaptive interventions deploy intervention content depending on specific individual needs [51]. For example, adaptive interventions can change or enhance treatment dose for non-responders, reintroduce treatment for those who experience relapse, and decrease or alter dose for those who are early responders. Sequential, multiple assignment, randomized trials (SMARTs) allow one to simultaneously test multiple adaptive interventions [52]. Specifically, a SMART framework has been proposed for weight loss research [53]. SMARTs use decision roles for deciding when to adapt treatment [51]. For example, weight loss at week 8 of FBT could be used to adapt treatment; those who have not achieved their weight loss goal by week 8 could have their treatment frequency increased or enhanced to identify whether this potentiates treatment response.

Another option to enhance outcomes may be to tailor treatment using a mastery approach, which calibrates content and dose to the needs of the individual and has been shown to enhance weight loss outcomes [49]. Like many protocol-based interventions, FBT is designed to ensure that all participants receive the same dose of treatment. This ensures standardization of the protocol but may not ideally allocate treatment resources to meet participant’s needs. An alternative approach, based on education research [54], is to use mastery teaching that takes into account different learning rates and does not present new information until patients master previous information. To examine whether a mastery-based learning approach to FBT improved treatment outcomes relative to standardization of FBT, families were randomized to mastery or usual FBT. The same information was presented to both groups, but the mastery group had to demonstrate mastery of information and mastery of behavioral goals. Results showed significantly better changes for the mastery group at 1 year in comparison with usual FBT [49]. While the terms “personalized” or “precision” medicine have traditionally been associated with medical treatments [55, 56], the use of mastery-based FBT for treating childhood obesity may serve as a model to efficiently and effectively match treatment “dose” or intensity to patient progress across a wide variety of behavioral health problems.

Co-location Within Primary Care Settings

Currently, FBT is typically only offered in specialty clinics or as part of research studies. One way to increase the availability of FBT while preserving its potency would be to conduct FBT with individual families within primary care settings. Co-location is a model of coordinated health care that places a behavioral health-care provider within the same location as the primary care physician. Primary care offers an optimal setting for timely, continuous delivery of evidence-based obesity treatment by capitalizing on the established and ongoing relationship between primary care providers and families [57] and reducing fragmented care that can occur through multiple providers and offices. As such, integrated care has been associated with improved treatment outcomes and patient satisfaction with treatment for other diseases [58]. Preliminary research suggests that FBT interventionists can be successfully co-located within pediatric primary care practices and achieve both child and parent weight losses [59]. However, this study used an abbreviated form of FBT in terms of both treatment content and intensity. Although further research is needed to test the efficacy of full-dose FBT in primary care, the co-location of a behavioral health interventionist within primary care would allow pediatricians to more easily refer appropriate families to comprehensive behavioral treatment for weight loss while still retaining them within the familiar practice setting. Furthermore, co-location would also allow for easier coordination of care, which is important given the comorbidities associated with obesity.

Need for Centers for Excellence

While FBT has proven to be effective for treatment of childhood obesity, access to care remains a challenge. Barriers include time and cost of training providers in FBT delivery, lack of reimbursement for treatment, and limited specialty clinics to which providers can refer their patients [60]. As insurers and medical service delivery systems shift toward a health-care market that incentivizes prevention and the effective management of complex, multilevel diseases such as obesity, interventions such as FBT will be in demand to meet this need. In anticipation of this shift in the health-care system, it will be necessary to determine how best to scale up FBT for broader implementation without losing its potency. To achieve the broadest reach, professionals must be equipped to deliver FBT across multiple settings. One proposed approach to address this gap is creating regional centers of excellence in which FBT experts train center leaders to deliver FBT and supervise delivery. Such centers would have the potential to bridge the gap between treatment experts and interventionists to ensure proper delivery of FBT on a large scale [60].

Influence of FBT on the Microbiome

The gut microbiome , the set of genes accompanying the microbiota in the human gut, provides important metabolic capabilities and offers a promising new avenue for childhood obesity research. Seminal work in mice demonstrated that the microbiome in mice with obesity is more efficient at harvesting energy than the microbiome of mice without obesity [61], and human twin data support that the microbiome impacts host energetics [62]. Diet plays a large role in shaping the gut microbiome. Promising research in mice has shown that the diet affects the microbiome; switching from a low-fat, high-fat diet to a “Western” diet (i.e., high fat, high sugar) changed the metabolic pathways and shifted the structure of the mouse microbiome relatively quickly [63], indicating that the microbiome is responsive to changes in the diet. A recent meta-analysis highlights the importance of a diet higher in fruits, vegetables, and fiber for microbial health, integrity, and richness [64]. Given that FBT targets changes in the diet so that the diet is higher in fiber-containing foods such as fruits and vegetables, it follows that FBT would favorably alter the microbiome. As such, if FBT alters the microbiome, this may bolster and reinforce the weight loss seen in treatment. However, the impact of behavioral treatment for obesity on the gut microbiome has yet to be tested and remains an important next step in FBT research.

FBT with Comorbid Psychiatric Conditions

Rates of low self-esteem, anxiety, and depression are higher among children with overweight and obesity than among the general population [3]. Moreover, children with psychiatric conditions may be particularly vulnerable to the development of obesity and comorbid conditions [65], and this risk is exacerbated by the use of antipsychotic medications, many of which have the side effect of weight gain [66]; see also Chap. 37 by Drs. Reeves and Sikich. Notably, children with psychiatric conditions are twice as likely to develop obesity-related conditions such as diabetes or hypertension than children in the general population [67]. In many of these children, the use of antipsychotics cannot be discontinued as they are necessary to stabilize the psychiatric disorder, and thus obesity treatment is necessary to mitigate weight gain. Behavioral weight loss treatments among this high-risk population have been promising in adults, with more participants in the treatment group achieving clinically significant weight loss (i.e., ≥5% initial body weight) than participants in the control group [68]. While this is a nascent area in childhood obesity treatment research, a pilot FBT trial with three children with overweight or obesity taking antipsychotic medications was promising, showing that FBT is feasible among this population [69]. Additional research with larger samples is needed to confirm this finding.

Conclusions

Evidence supports early intervention for obesity during childhood as robust, and sustainable changes can be made at this time. FBT for childhood obesity, a multicomponent treatment that intervenes across several socioenvironmental contexts, has demonstrated effectiveness in reducing weight and improving physiological and psychosocial outcomes in children and their parents. Given its reach beyond the target child, FBT may be a very cost-effective way to treat obesity across multiple generations [70].