Key Primary Studies Contributing to the Evidence Base for Family Based Programmes

The evidence base for family-based programmes to treat childhood obesity (aged 7 to 11), with parents as the main agents of change, has come mainly from the USA (Epstein et al 1990, Israel et al 1985) and Israel (Golan 2004a,b, 2006a).

2.8.2.1 Family-Based Behavioural Therapy (Epstein)

Fifteen of the studies in the NICE guidance (NICE 2006a) and 12 of the studies in the Cochrane review (Oude Luttikhuis et al 2009) were from Epstein’s group from the University of Buffalo, New York, USA, thus contributing considerably to the evidence base. This group have evaluated ‘Family-Based Behavioural Therapy’, examining different lifestyle combinations, behaviour management approaches and/or target groups, delivered to groups over 8-12 weeks (Epstein et al 1994). Their programme used the Traffic Light Diet, which is a calorie- based food exchange system, with foods colour coded with green for ‘go’; yellow for ‘eat with care’; and red for ‘stop’. In a ten-year follow-up of ‘Family- Based Behavioural Therapy’ in 77 families comprising obese parents and their obese 6 to 12 year olds, long-term changes in weight were best if the parent and child were targeted together (-11.2% at 5 years, -7.5% at 10 years). This is compared with targeting the child alone (+2.7% at 5 years, +4.5% at 10 years) and a group where neither child or parent were specifically targeted (+7.9%, +14.3%) (Epstein et al 1990). Their programme provides evidence that parents should be involved in the therapy process in order to sustain change.

2.8.2.2 Golan

A second group of researchers making a significant contribution to the evidence for family-based interventions are headed up by Professor Moria Golan from the Hebrew University of Jerusalem, Israel. Golan and Crow (2004b) reported a 7 year follow-up of a randomised controlled trial of 60 obese children (6-11 years) in which parents or children were targeted as the exclusive agents of change. Parents attended 14 one-hour group sessions including eating and activity behaviour modification, decreasing stimulus exposure, parental modelling, and parents were encouraged to practice ‘authoritative’ parenting. The focus favoured parenting over lifestyle components (personal communication with Golan). The children attended group sessions, were prescribed a diet, and discussions included physical activity, eating behaviour modification and self- monitoring. The mean reduction in percentage overweight was superior for the parent group (29%) compared with the child group (20%) (p<0.05).

Golan et al (2006a) have carried out a further study in 32 families with obese children aged 6-11 years who were randomised either to treatment of parents exclusivelyortreatment of parents with the obese child. Both groups received a 6-month educational and behavioural programme for a healthy lifestyle. Only the intervention group which treated parents exclusively resulted in a significant reduction in percentage overweight, suggesting that interventions delivered to parents alone may be more effective and that the obese child could be omitted from active participation. Golan (2006b) also reported the preliminary results of

complete data the BMI of the children reduced significantly at the end of the 3- month programme. Longer term follow-up is required to establish the effectiveness of the programme now that it has bridged the gap from research to practice.

2.8.2.3 Israel

In the USA, Israel et al (1985) carried out an RCT with 33 ‘overweight’ children (8-12 years) and their parents, assigning them to one of three interventions:- a multi-component behavioural weight reduction programme, with and without an added parent-training course in child management skills, and a waiting-list control. At the end of the 9 week programme, both treatments groups were better than control for reducing body weight (p<0.001) and percent overweight (p<0.001), albeit the two treatment groups did not differ from each other. At one-year follow-up, the parent training group showed superior maintenance of the improvement in percentage overweight compared with the group that just received the weight reduction programme, indicating that parenting skills are important to sustain the change. A limitation of this study is its small size and that the control group were not followed-up to 1-year.

2.8.2.4 Triple P Positive Parenting Programme (Golley)

Key research published since the NICE guidance includes a new programme with a specific focus on parenting. Golley et al (2007a,b) have examined the effects of ‘Triple P’ Positive Parenting Program in the treatment of childhood obesity. This is an Australian parenting skills training program originally designed to reduce the prevalence of behavioural and emotional problems in

children and adolescents (Sanders et al 2003). A new group-based programme has been developed which combines parenting skills training using Triple P with healthy lifestyle information, and its use has been described in a ‘case study’ with one family (Golley at al 2007a). An RCT of this new programme has also been carried out with 111 pre-pubertal overweight/obese children aged 6 to 9 years, in a clinical setting (teaching hospital in Adelaide, Australia) (Golley at al 2007b). Families were randomized to three arms:- Parenting skills training plus intensive lifestyle education (4 two hour group sessions on parenting followed by 7 sessions on lifestyle); parenting skills training alone (parenting component only); a control group who were put on a waiting-list for 12-months. The intervention was only delivered to groups of parents – children did not attend any sessions, and parents were encouraged to deliver change at the level of the family rather than the individual child. Follow-up after 12-months showed a reduced BMI z-score of 10% with the parenting-skills training plus lifestyle intervention, and 5% reduction for both the parenting skills training group and waiting-list control. This indicates that parenting programmes delivered alongside lifestyle components may be a more effective approach for weight management than programmes that focus on parenting alone. A limitation is that the study did not have a traditional family-based ‘lifestyle’ programme arm without the parenting aspects, in order to assess the benefit of adding parenting skills to the treatment of obesity with lifestyle change.