Lisa M. Clifford

Systematic Review and Meta-Analysis of Comprehensive Behavioral Family Lifestyle Interventions Addressing Pediatric Obesity

PURPOSE To conduct a meta-analysis of randomized controlled trials examining the efficacy of comprehensive behavioral family lifestyle interventions (CBFLI) for pediatric obesity.  METHOD Common research databases were searched for articles through April 1, 2013. 20 different studies (42 effect sizes and 1,671 participants) met inclusion criteria. Risk of bias assessment and rating of quality of the evidence were conducted.  RESULTS The overall effect size for CBFLIs as compared with passive control groups over all time points was statistically significant (Hedges g = 0.473, 95% confidence interval [.362, .584]) and suggestive of a small effect size. Duration of treatment, number of treatment sessions, the amount of time in treatment, child age, format of therapy (individual vs. group), form of contact, and study use of intent to treat analysis were all statistically significant moderators of effect size. CONCLUSION CBFLIs demonstrated efficacy for improving weight outcomes in youths who are overweight or obese.

A Pilot Randomized Controlled Trial of a Behavioral Family-Based Intervention With and Without Home Visits to Decrease Obesity in Preschoolers

OBJECTIVE Tested two family-based behavioral treatments for obesity in preschool children, one meeting the Expert Committee guidelines for Stage 3 obesity intervention criteria (LAUNCH-clinic) and one exceeding Stage 3 (LAUNCH with home visit [LAUNCH-HV]), compared with a Stage 1 intervention, pediatrician counseling (PC). METHODS In all, 42 children aged 2-5 years with a body mass index (BMI) percentile of ≥95th were randomized. A total of 33 met intent-to-treat criteria. Assessments were conducted at baseline, Month 6 (posttreatment), and Month 12 (6-month follow-up).  RESULTS  LAUNCH-HV demonstrated a significantly greater decrease on the primary outcome of change in BMI z-score (BMIz) pre- to posttreatment compared with PC (p = .007), whereas LAUNCH-clinic was not significantly different from PC (p = .08). Similar results were found for secondary outcomes.  CONCLUSIONS  LAUNCH-HV, but not LAUNCH-clinic, significantly reduced BMIz compared with PC by posttreatment, indicating the need for intensive behavioral intervention, including home visitation, to address weight management in obese preschool children.

Examination of the association between lifestyle behavior changes and weight outcomes in preschoolers receiving treatment for obesity.

OBJECTIVE Preschoolers (ages 2-5 years) have been significantly underrepresented in the obesity treatment outcome literature, despite estimates that 12.1% are already obese. As such, little is known about the most important intervention targets for weight management within this age group. The aims of this study were (a) to examine lifestyle behavior changes for 30 obese preschoolers participating in a weight-control intervention and (b) to explore which lifestyle behavior changes predicted changes in body mass index (BMI) z score. METHOD Preschooler height, weight, diet (three 24-hr recalls), physical activity (accelerometry), and television use (parent report) were measured at baseline and posttreatment (6 months). A linear regression was conducted to examine pre- to posttreatment changes in diet (i.e., intake of calories, sugar-sweetened beverages, fruits and vegetables, and sweet and salty snacks) and activity (i.e., moderate-to-vigorous activity and television use) behaviors on changes in BMI z score. RESULTS Despite significant reductions in sugar-sweetened beverage intake and television use, and increases in fruit and vegetable intake, only reductions in absolute caloric intake significantly predicted reductions in BMI z score. CONCLUSION Our findings suggest that attaining healthy caloric goals may be the most important component of weight-control interventions for preschoolers. Future research using innovative methodologies, such as the Multiphase Optimization Strategy, may be helpful to prospectively identifying the lifestyle behavior changes that are most effective in helping families to achieve healthy weight outcomes for preschoolers and thereby improve intervention efficiency and decrease treatment burden for families.

Injection and non-injection drug use and infectious disease in Baltimore City: Differences by race

PURPOSE The current study examines differences in the prevalence of biologically-confirmed hepatitis C virus (HCV), HIV, and coinfection between Black and White adult cocaine/heroin users across three drug use subgroups identified in previous research (Harrell et al., 2012): non-injection smoking crack/nasal heroin users, heroin injectors, and polydrug injectors. RESULTS 59% of the 482 participants in the study were male. Significant race differences emerged between drug use subgroup memberships. Non-injection smoking crack/nasal heroin users were predominantly Black (75%), while heroin injectors and polydrug injectors were predominantly White (69% and 72%, respectively). Polydrug injectors accounted for nearly three quarters of the HCV positive diagnoses in Whites. Though HIV disease status, stratified by race, did not differ significantly between drug use subgroups, the non-injection smoking crack/nasal heroin subgroup contained over half of the HIV positive diagnoses in the sample and was predominantly Black. Despite much lower rates of injection, Blacks (8%) had a higher prevalence of coinfection than Whites (3%; X(2) (2)=6.18, p=.015). CONCLUSIONS The current findings are consistent with trends in the recent HIV transmission statistics where sexual activity has overtaken injection drug use as a HIV risk factor. The current findings also provide further support to the notion of injection drug use as an exceedingly high-risk behavior for HCV and coinfection, specifically those who are polysubstance injectors.

Disordered Eating and Health-Related Quality of Life in Overweight and Obese Children

OBJECTIVES To examine disordered eating and associations with health-related quality of life (HRQOL) in rural overweight/obese (OW/OB) children. METHODS Cross-sectional analyses were conducted with 272 rural OW/OB children aged 8-12 years (M = 10.36; SD = 1.39). Child anthropometrics, demographics, disordered eating attitudes, unhealthy weight control behaviors (UWCBs), and HRQOL were measured. Relationships between these variables were analyzed using bootstrapped multiple linear regressions. RESULTS Clinically significant disordered eating attitudes were endorsed by 17% of the sample, and the majority endorsed UWCBs. Disordered eating attitudes and weight status were the most common predictors of HRQOL. Disordered eating attitudes and UWCBs were negatively related to emotional HRQOL but were unrelated to social, school, or physical HRQOL. CONCLUSIONS Disordered eating is a serious and relevant problem in OW/OB children living in rural areas and may be indicative of impairments in emotional functioning. Early intervention may reduce the risk for eating disorders and associated negative sequelae.

The association between sleep duration and weight in treatment-seeking preschoolers with obesity.

OBJECTIVE To examine the association between nocturnal sleep duration and weight and caloric intake outcomes among preschool-aged children who are obese and enrolled in a family-based weight management program. METHODS Forty-one preschool-aged children who were obese (BMI ≥ 95th percentile) and enrolled in a weight management program completed pre- and posttreatment assessments of body mass, caloric intake, and sleep. Separate linear regression analyses examined the relationship between nocturnal sleep duration and posttreatment body mass index relative to age- and sex-linked norms (BMIz) and caloric intake. RESULTS After controlling for pretreatment BMIz, longer posttreatment nocturnal sleep was significantly associated with lower posttreatment BMIz (β=-0.21, p=0.02) and explained a significant proportion of unique variance in posttreatment BMIz (ΔR(2)=0.04). Similarly, after controlling for pretreatment caloric intake, longer nocturnal sleep duration at posttreatment was significantly associated with lower caloric intake at posttreatment (β=-0.45, p=0.003) and explained a significant proportion of unique variance in posttreatment caloric intake (ΔR(2)=0.19). CONCLUSIONS These findings extend the literature on the sleep and weight relationship and suggest that adequate sleep may be an important element in interventions for preschoolers with obesity.

Evaluating "Parent Project:" A Multi-Site Inquiry

This study evaluates Parent Project®, a parent education program for parents of at-risk adolescents. A logic model was created to highlight the relationship between program theory and measured constructs. Results comparing pre-workshop data with Week 10 data suggested significant increases in parent-reported parental support, parental behavioral control, and youth achievement, and significant decreases in youth antisocial behavior. Youth reported significant increases in maternal and paternal support and maternal behavioral control and significant decreases in antisocial behaviors.

Changes in Parent Motivation Predicts Changes in Body Mass Index z-Score (zBMI) and Dietary Intake Among Preschoolers Enrolled in a Family-Based Obesity Intervention

OBJECTIVES To examine whether changes in parent motivation over the course of a pediatric obesity intervention are significantly associated with long-term changes in treatment outcomes.  METHODS  Study hypotheses were tested with a secondary data analysis of a randomized controlled trial (N = 42). Study analyses tested whether baseline to posttreatment change in total score for a self-report parent motivation measure (Parent Motivation Inventory [PMI]) was significantly associated with baseline to 6-month follow-up changes in body mass index z-score (zBMI), dietary variables, and physical activity.  RESULTS  Increases in PMI were significantly associated with decreased zBMI, decreased consumption of sugar-sweetened beverages and sweets, and increased consumption of artificially sweetened beverages.  CONCLUSIONS  Given that increases in parent motivation were associated with some treatment benefits, future research should evaluate the impact of directly assessing and targeting parent motivation on weight outcomes for preschoolers participating in a weight management program.

Learning about Activity and Understanding Nutrition for Child Health (LAUNCH): Rationale, design, and implementation of a randomized clinical trial of a family-based pediatric weight management program for preschoolers

Obesity affects nearly 2 million preschool age children in the United States and is not abating. However, research on interventions for already obese preschoolers is limited. To address this significant gap in the literature, we developed an intervention targeting obesity reduction in 2 to 5year olds, Learning about Activity and Understanding Nutrition for Child Health (LAUNCH). This paper describes the rationale, design, participant enrollment, and implementation of a 3-arm randomized, parallel-group clinical trial comparing LAUNCH to a motivational-interviewing intervention (MI) and standard care (STC), respectively. Whereas LAUNCH was designed as a skills based intervention, MI focused on addressing the guardians motivation to make changes in diet and activity and providing tools to do so at the guardians level of readiness to implement changes. Child body mass index z-score was the primary outcome, assessed at pretreatment, posttreatment (Month 6), and 6 and 12month follow-ups (Months 12 and 18). Mechanisms of weight change (e.g., dietary intake, physical activity) and environmental factors associated with weight (e.g., foods available in the home, caregiver diet) were also assessed. This study is unique because it is one of the few randomized controlled trials to examine a developmentally informed, clinic and home skills based behavioral family intervention for preschoolers who are already obese. Being obese during the preschool years increases the likelihood of remaining obese as an adult and is associated with serious health conditions; if this intervention is successful, it has the potential to change the health trajectories for young children with obesity.

Treating Obesity in Preschoolers: A Review and Recommendations for Addressing Critical Gaps

Developing interventions targeting obesity reduction in preschoolers is an emergent area. Although intensive, multicomponent interventions seem a promising approach to preschool obesity reduction, this review identifies and discusses approaches to 3 critical gaps (poor reach to families from low-income and minority backgrounds, lack of sufficient evidence to determine the most effective and efficient treatment components and approaches to treating obesity in early childhood, and lack of consensus on how best to discern intervention effectiveness) that need to be addressed to advance the preschool obesity literature.