Systematic Review and Meta-Analysis of Comprehensive Behavioral

Family Lifestyle Interventions Addressing Pediatric Obesity

David M. Janicke,1 PHD, Ric G. Steele,2 PHD, Laurie A. Gayes,2 MS, Crystal S. Lim,1 PHD, Lisa
M. Clifford,1 PHD, Elizabeth M. Schneider,1 PHD, Julia K. Carmody,1 MS, and Sarah Westen1 MS
1
Department of Clinical and Health Psychology, University of Florida and 2Clinical Child Psychology Program,
University of Kansas

All correspondence concerning this article should be addressed to David M. Janicke, PHD, Department of
Clinical and Health Psychology, University of Florida, PO Box 100165, Gainesville, FL 32610, USA.
E-mail: djanicke@phhp.ufl.edu
Received January 16, 2014; revisions received March 29, 2014; accepted April 7, 2014

Purpose To conduct a meta-analysis of randomized controlled trials examining the efficacy of comprehen-
sive 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 sugges-
tive of a small effect size. Duration of treatment, number of treatment sessions, the amount of time in treat-
ment, 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 effi-
cacy for improving weight outcomes in youths who are overweight or obese.

Key words children; intervention outcome; meta-analysis; obesity.

Childhood obesity is a significant public health concern,
with roughly 32% of children considered overweight or
obese (Ogden, Carroll, Kit, & Flegal, 2012). The sequelae
of pediatric obesity include comorbid medical complica-
tions, such as high blood pressure, abnormal lipid pro-
teins, liver disease, sleep disordered breathing, and type
2 diabetes (Daniels, 2006). Overweight and obese children
face increased risks for poor self-esteem and body image,
peer victimization, weight stigmatization, depressive symp-
toms, and other psychological difficulties (Daniels, 2006;
Puhl, Luedicke, & Heuer, 2011). Obesity in childhood also
leads to increased risks of being obese in adulthood (Singh,
Mulder, Twisk, van Mechelen, & Chinapaw, 2008).
Pediatric interventions that lead to weight reductions
have been associated with improvements in metabolic fac-
tors (Ebbeling, Leidig, Sinclair, Hangen, & Ludwig, 2003)
and self-esteem (Janicke et al., 2008). There is a need for
evidence-based pediatric obesity interventions to treat in-
creased weight status in children and adolescents.
Research to elucidate factors contributing to the con-
tinual rise in rates of pediatric obesity provides evidence of
environment by gene interactions contributing to child and
adolescent weight status. Studies have also shown that en-
vironmental factors can alter genetic factors associated with
weight (Koletzko, Brands, Poston, Godfrey, &
Demmelmair, 2012). Potential environmental factors in-
clude consuming large portions of high-calorie nutrient-
poor foods, decreased engagement in physical activity,
and increased time spent in sedentary behaviors (Lioret,
Volatier, Lafay, Touvier, & Maire, 2009; Spear et al.,
2007). One of the strongest predictors of child weight is
parent weight status (Whitaker, Wright, Pepe, Seidel, &
Dietz, 1997). Given that parents play a significant role in
establishing patterns of eating and physical activity

Journal of Pediatric Psychology 39(8) pp. 809825, 2014

doi:10.1093/jpepsy/jsu023
Advance Access publication May 13, 2014
Journal of Pediatric Psychology vol. 39 no. 8 The Author 2014. Published by Oxford University Press on behalf of the Society of Pediatric Psychology.
All rights reserved. For permissions, please e-mail: journals.permissions@oup.com

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 810 Janicke et al.
throughout childhood (Spear et al., 2007), behavioral
family lifestyle interventions have been developed that
focus on modifying the obesogenic family environment to
address weight management in children and adolescents.
Generally, behavioral family lifestyle interventions
focus on encouraging overweight and obese children and
their parents to modify the familys dietary intake, physical
activity habits, or both. Dietary modifications generally
target reducing the consumption of high-fat/high-calorie
foods and increasing consumption of fruits and vegetables,
as well as dietary monitoring through classifications
systems such as the Stoplight diet (Epstein, 1993).
Activity targets commonly include increasing the intensity
and duration of physical activity (i.e., play, family activities,
organized sports, or structured exercise program) and
reducing time spent in sedentary activities (e.g., television
viewing). Behavioral strategies to support the adoption of
healthier lifestyle behaviors are central to these programs.
Specific strategies may include the following: parent model-
ing; monitoring of dietary intake and physical activity; goal
setting; problem solving; gradual shaping; child behavior
management strategies including differential attention and
contingency management; and stimulus control.
Parents are often considered a critical agent of change
in behavioral lifestyle interventions, as they exercise signif-
icant control over childrens eating and physical environ-
ment and, ultimately, behaviors. As such, one or both
parents are typically included in treatment. Parents are
often encouraged, if not specifically targeted, to also
follow healthy lifestyle treatment recommendations. The
format of behavioral family lifestyle interventions varies
from group based (multiple families participate at one
time) and individual family based (family meets one-
on-one with interventionist), to a combination of these
formats. The extent to which children and adolescents
are directly involved in treatment also varies across
interventions. While the vast majority of interventions
require children or adolescents to regularly attend interven-
tion sessions with their parents, some recent interventions
have adopted a parent-only model, in which only the
participating parent(s) attend intervention sessions during
which they are taught strategies to support their child or
adolescent in modifying weight-related lifestyle behaviors
(Golan, Kaufman, & Shahar, 2006; Janicke et al., 2008).
The number of content components also varies across
lifestyle interventions. Some interventions may include
only two components. For example, an intervention may
address dietary intake using behavior strategies but not
address physical activity. Others may address physical
activity and dietary intake but not use behavior strategies.
Finally, there are those interventions that are
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comprehensive, in that they address all three intervention
components. For the purposes of this review, interventions
that included content addressing all three areas (i.e., die-
tary intake, physical activity, and behavior strategies) are
referred to hereafter as comprehensive behavioral family
lifestyle interventions (CBFLIs). Owing to the increase in
outcome research examining treatments for pediatric obe-
sity, there is a need to understand the current efficacy of
these interventions, as well as to identify moderators of
treatment success to inform future clinical practice and
treatment outcome research.
Jelalian and Saelens (1999) conducted a review of pe-
diatric obesity treatments in the empirically supported
treatment series published in the Journal of Pediatric
Psychology over a decade ago. They concluded that be-
havioral lifestyle interventions could be considered well-
established treatments and that there was strong evidence
for their short- and long-term efficacy (e.g., 5 and 10 years
posttreatment) in reducing weight in school-age children.
The evidence of behavioral lifestyle interventions for ado-
lescents was only considered promising owing to the
limited number of treatment outcome studies in adoles-
cents at that time. However, there was no requirement
that the treatments reviewed by Jelalian and Saelens
(1999) be CBFLIs.
Not surprisingly, since the Jelalian and Saelens review,
a number of systemic reviews and meta-analyses of pediat-
ric obesity interventions have been published (Kitzmann
et al., 2010; McGovern et al., 2008; Oude-Luttikhuis
et al., 2009; Seo et al., 2010; Whitlock, OConnor,
Williams, Beil, & Lutz, 2010; Wilfley et al., 2007). The
general consensus from these published reports is that pe-
diatric obesity interventions result in small to moderate
short-term improvements in adiposity in children and ad-
olescents. However, a thorough examination of this litera-
ture finds mixed methodology and results across meta-
analyses, with great variety in the number of studies in-
cluded in different meta-analyses, largely owing to differing
foci and study inclusion and exclusion criteria (i.e., intent-
to-treat [ITT] analysis, different intervention components,
duration of treatment or follow-up analysis, randomization
of treatment participants, minimum sample size require-
ments, adequate control condition). Moreover, a number
of meta-analyses use broad inclusion criteria that allow for
lifestyle interventions with diverse treatment components
(two or three component programs) or interventions deliv-
ered in different settings (e.g., community, clinic, research,
and school; Kitzmann et al., 2010). While informative, one
disadvantage to this broader approach is that such clinical
heterogeneity precludes a meaningful answer as to the

intervention type to which an effect can be generalized
(Cohen, Thombs, & Hagedoorn, 2010).
Although a number of meta-analyses include interven-
tion studies with behavioral family components, many do
not provide explicit examination of interventions with a
behavioral family component or adequately define behav-
ioral components (Kitzmann et al., 2010; McGovern et al.,
2008; Seo et al., 2010; Wilfley et al., 2007). To our knowl-
edge only three meta-analyses have explicitly examined the
efficacy of pediatric lifestyle interventions that require the
inclusion of a behavioral family component (Oude-
Luttikhuis et al., 2009; Whitlock et al., 2010; Young,
Northern, Lister, Drummond, & OBrien, 2007).
However, even these three reviews do not require the use
of all three common lifestyle intervention components (i.e.,
dietary intake, physical activity, and behavioral strategies)
for study inclusion in the meta-analytic reviews.
Whitlock and colleagues identified 11 fair- or good-
quality behavioral family lifestyle intervention trials pub-
lished between 2005 and 2008 addressing weight loss in
overweight and obese children and adolescents 19 years
of age (Whitlock et al., 2010). Results revealed that behav-
ioral family lifestyle interventions of medium to high inten-
sity (i.e., 26 hr of treatment contact) had moderate to
large effects on weight outcomes compared with very low
intensity interventions (e.g., <10 hr) in the short term,
with intervention effectiveness tending to increase with
more intensive interventions. The authors also concluded
that there was insufficient evidence to draw conclusions on
outcomes >12 months after treatment.
The Cochrane Collaborative published a review that
included 54 randomized controlled trials (RCTs) published
through May 2008 and focused on lifestyle interventions
(i.e., dietary, physical activity, and/or behavioral oriented
treatment) for children and adolescents (mean age <18
years at posttreatment) (Oude-Luttikhus et al., 2009).
However, they only identified eight behavioral family life-
style interventions that qualified for a separate meta-anal-
ysis examining both short- and long-term outcomes in
elementary-age and adolescent youth. While noting many
limitations in the literature and the lack of quality data to
adequately ascertain treatment efficacy, the authors con-
cluded that behavioral family lifestyle interventions result
in significant and clinically meaningful changes in weight
status for children and adolescents compared with stan-
dard care and self-help, both in the short and long term.
Finally, Young and colleagues (2007) identified 44
pediatric obesity interventions across 16 studies for chil-
dren aged 512 years. Of these 44 interventions, 31 were
behavioral lifestyle interventions. Results indicated that rel-
ative to alternative treatment interventions, behavioral
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Meta-Analysis of Family Interventions for Obesity 811
lifestyle interventions produce larger effects at posttreat-
ment. Relative to Oude-Luttikhus et al. (2009) who re-
quired intent-to-treatment analysis for study inclusion,
Young and colleagues did not include intent-to-treatment
analysis as an inclusion criteria. This may in part account
for the larger number of interventions included and the
large effect size reported by Young et al.
While these three meta-analyses provide essential
information on the relative efficacy of behavioral family
lifestyle interventions, the most recent review was of inter-
ventions published only through May 2008. Additionally,
the target of past meta-analyses of behavioral family life-
style interventions has been on change in weight status,
and therefore, more information is needed on the impact of
these interventions on key secondary outcomes such as
dietary intake and physical activity, as well as potential
moderators of treatment effects. Finally, none of these
past reviews explicitly required that interventions were
CBFLIs, meaning they did not require interventions to
include all three treatment components to be included
(i.e., dietary intake physical activity and behavioral
strategies). Thus, the primary objective of this review is
to evaluate the efficacy of CBFLIs in reducing or stabilizing
child adiposity in overweight and obese youth. A secondary
objective of this review is to evaluate the impact of CBFLIs
on key secondary outcomes including child caloric intake,
physical activity, sedentary behavior, and parent use of
behavior management strategies. A final secondary objec-
tive of this meta-analysis is to evaluate potential modera-
tors of treatment outcome including (1) child age; (2) child
sex; (3) duration and intensity of treatment; (4) length of
time from baseline to outcome assessment; (5) whether the
parent(s) is targeted for health behavior or weight change;
(6) type of comparison control condition; (7) methodolog-
ical rigor of studies; and (8) other study characteristics
(i.e., ITT analysis used, manualized intervention, exclusion
of children over the 99th percentile for body mass index
(BMI), form of therapy [individual vs. group vs. both], and
form of contact [in-person, in-person plus internet,
phone]). These moderating variables were selected based
on findings from previous published studies, as well as
reviews and recommendations for treating pediatric obesity
(Faith et al., 2012; Jelalian & Saelens, 1999; Spear et al.,
2007; Wilfley et al., 2007), and represent potential
important directions for future intervention research.
The proposed methods will draw heavily from the
Cochrane Collaboration and represent current best practice
in systematic review methodology. This review will add to
the literature by examining only those studies that include
behavioral lifestyle interventions that are comprehensive in
nature (intervention explicitly addresses dietary intake and
 812 Janicke et al.
physical activity, and uses behavioral change strategies),
examining a greater variety of possible moderators of treat-
ment outcomes, including studies published up to April
2013, and by including standardized methods to evaluate
trial quality of included studies and rate the level of evi-
dence for our findings.
Methods
Criteria for Considering Studies for This Review
Types of Studies
RCTs comparing an active CBFLI for overweight or obesity
in children or adolescents with an attention/educational
control, other active treatment, or wait list control were
considered for this review. Studies meeting the following
criteria were included:
 RCTs published in full in peer-reviewed journals,
unpublished dissertations, and brief reports that in-
clude sufficient methodological details to allow (1) crit-
ical appraisal of study quality and (2) calculation of
effect sizes.
 Primary aim of the trial was to evaluate the efficacy or
effectiveness of an active CBFLI for overweight or obe-
sity in children or adolescents with change in weight as
the primary outcome.
 Both the treatment and the control arms of the study
must have a minimum sample size of 10 at the
posttreatment assessment.
Types of Participants
Children and adolescents, 19 years of age at baseline,
who are classified as overweight or obese based on age
and gender norms (Kuczmarski et al., 2000), were in-
cluded in this review. Studies were excluded if (1) partic-
ipants were from special populations, such as children or
adolescents with developmental disabilities, developmental
delays, or cognitive impairment, (2) child or adolescent
participants were diagnosed with a chronic illness that in-
hibits typical growth and development (e.g., cystic fibrosis)
or bulimia nervosa, (3) any of the child participants were
classified as normal weight in any of the treatment arms at
baseline assessment, or (4) children or adolescents with an
underlying diagnosis that predisposes children to obesity
or greater than normal weight gain (e.g., Prader-Willi
Syndrome, Thyroid disease).
Types of Interventions
Interventions were included if (1) the active treatment
included dietary, physical activity, and behavioral compo-
nents that focused on change in weight and weight-related
health behaviors (for explicit criteria see below), (2) the
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primary objectives of the intervention were to produce
weight loss or prevent further weight gain in children or
adolescents who were already obese or overweight at base-
line, and (3) interventions were conducted in outpatient or
community settings. Studies were excluded if the active
intervention being evaluated (1) involved a curriculum-
based school weight management program and (2) child
weight was based on subjective methods of measurement
(e.g., self-reported, parent-reported, interviewer estimated).
Active interventions in which only parents attended treat-
ment sessions, but child weight or adiposity was the pri-
mary outcome, were eligible for inclusion in this analysis.
Studies reporting only previously reported data and studies
in which medication was part of treatment were also
excluded.
Interventions that were considered to include a dietary
component must have included education, presentation,
or discussion of healthy eating, dietary guidelines, or
food preparation strategies. Interventions that were consid-
ered to address physical activity must have included one of
the following: (1) education on the importance of adequate
physical activity, (2) encouragement to increase physical
activity, (3) guidelines for recommended levels of physical
activity for children, or (4) structured physical activity time
for children during intervention sessions. Finally, for an
intervention to have been considered behavioral, the de-
scription of the active treatment must have included one of
the following terms: self-monitoring, stimulus control, goal
setting, positive reinforcement, differential or contingency
management, behavioral parent training, or problem solv-
ing. Moreover, these terms must have described efforts to
help families makes changes to child dietary intake or phys-
ical activity. Only studies that included sufficient informa-
tion to determine whether they met these inclusion criteria
were eligible for review.
Type of Outcome Measures
Change in child weight at posttreatment was the primary
outcome targeted in this meta-analysis. For inclusion, mea-
sures of child weight must have been objective, adjusted
for child age and sex, and reported as one of the following:
BMI, BMI z-score, BMI percentile, percent overweight, or
adiposity. Data were analyzed at pretreatment and
posttreatment. When available, data were also analyzed at
the first follow-up visit that occurred at least 6 months
postbaseline. Change in child weight must have been re-
ported or was able to be calculated from the inclusion of
pretreatment and posttreatment weight values. In addition,
child weight must have been assessed at the same time
points across all randomized conditions.

Search Methods for Identification of Studies
A two-phase search strategy was used to identify studies for
this review. First, five electronic databases (the Cochrane
Central Register of Controlled Trials [CENTRAL]; ProQuest
Dissertations and Theses Full Text; PsycINFO via EBSCO;
PubMed; and Web of Science) were systematically searched
by one member of the research team using the following
truncated key terms to identify studies for review: (child
OR adolescent OR family OR parent) AND (intervention
OR treatment) AND (overweight OR obesity). While the
integrity of the search terms was not significantly altered,
some changes in search strategies were necessary based on
the requirements of the particular database used (i.e., use
of MeSH terms for PubMed). Systematic searches of these
databases occurred in February 2013 and again in April
2013 to allow for identification of studies published up
through April 1, 2013. The search was limited to articles
that were available in English.
A total of 7,734 articles were identified through the
initial searches across databases, while an additional 12
articles were identified from examination of published
meta-analyses and systematic reviews reporting on inter-
ventions addressing pediatric obesity (see Figure 1 for the
PRISMA Flow diagram). Of these 7,746 studies, 192 were
removed as they represented duplicates across one or more
databases, 9 studies were removed as no full-text article of
the study was available, and 7,149 were excluded based on
an initial screening of the title and abstract. Study exclu-
sion criteria for the abstract review were as follows:
1. Participants
a. Youth >19 years of age.
b. Less than 10 participants in any condition at
posttreatment.
2. Intervention
a. At least one arm of the intervention is not a
primarily behavioral intervention.
b. Nonrandomized controlled trial.
c. Child weight was not a primary outcome of the
intervention.
3. Comparison groups
a. Study did not include at least one of the fol-
lowing control conditions: (i) no treatment con-
trol, (ii) waitlist control, (iii) education control,
or (iv) treatment as usual control.
During the second phase of the search, the remaining
298 articles were assigned to one of three teams composed
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Meta-Analysis of Family Interventions for Obesity 813
of two reviewers who each independently assessed the full
text of the remaining articles to determine eligibility for
inclusion in the analysis. When an inclusion or exclusion
decision could not be reached by the two reviewers, the full
team of reviewers discussed the concerns to yield a con-
sensus. The reviewers were not blind to the names of study
authors, institutions, or journals. Of the 298 full-text arti-
cles reviewed, 278 were excluded (see Figure 1 for reasons
for exclusions). The two-phase process resulted in 20 stud-
ies eligible for inclusion in the current meta-analysis.
Data Extraction
A coding document was developed for data extraction pro-
cedures. This included critical study information such as
references, details of participants and their demographics,
aspects of the intervention or therapy, characteristics of the
treatment team, the setting of the intervention, outcome
measures, and statistical outcomes. Both members from
each review team carried out data extraction from studies
that were identified for inclusion. All intervention and out-
come data were compared for consistency and resolved to
100% agreement with the assistance of the first author as
needed.
Assessment of Study Rigor
Study rigor was assessed on an 18-point scale developed by
Lundahl et al. (2010) and based on criteria from existing
assessment instruments and approaches, such as the
Cochrane system. Each study was rated by the first
author based on criteria such as number of participants,
attrition, quality control, inclusion of the assessment of
treatment fidelity, objectivity of measurements, and report-
ing of follow-up data. Higher scores indicate higher study
quality.
Assessment of Risk of Bias
Available information about the included trials was used to
assess risk of bias in five domains: random sequence gener-
ation (failure to use a specified randomization process),
allocation concealment (failure to blind investigators for
future randomization assignments), blinding of outcome as-
sessment (failure to conceal outcome assessors from partic-
ipant intervention group assignment), incomplete outcome
data (failure to report complete outcome data from all ran-
domized participants), and selective reporting (failure to
report results for all planned outcome data). Guidelines
from the Cochrane Handbook were followed for this as-
sessment (Higgins & Green, 2011).
 814 Janicke et al.

Identification
Studies identified through initial Studies identified through
database searches other sources
(n = 8025) (n = 12)

Study Abstracts Screened for Eligibility

(n = 8037)
Screening

Duplicate Studies/Records
Removed (n = 1672)

Studies Excluded based on

Abstract Review
(n = 6067)
Eligibility

Full Text Manuscript

Assessed for Eligibility Studies excluded after full text review
(n = 298) (n = 278)

a) All participants 19 years and above = 2

b) Not all children overweight/obese = 52
c) Curriculum-based school program = 23
d) Lack of appropriate control = 54
e) Medication intervention = 1
Included

f) Lack of data to calculate effect size = 11

g) Follow-up data from another paper = 2
h) Duplicate data from another paper = 10
i) Methods paper only = 5
j) Not a randomized controlled trial = 45
k) Intervention does not include dietary,
physical & behavioral components = 36
Studies eligible and l) Primary outcome is not objectively
included in qualitative adiposity-based variable = 10
synthesis (n = 20) m) Sample size < 10 in one condition = 15
n) Child-only intervention = 12

Figure 1. PRISMA participant flow diagram.

Rating the Quality of Evidence and Strength of
Recommendations
The Grading of Recommendations Assessment,
Development and Evaluation (GRADE) system was used
to evaluate the quality of evidence in this review. With
the GRADE system, evidence for specific outcomes is
rated across studies, rather than within individual studies.
In this approach, RCTs are initially considered to provide
high-quality evidence and observational studies are
considered to provide low-quality evidence for estimates
of intervention effects. Five factors may lead to rating
down the quality of evidence (risk of bias, inconsistency,
indirectness, imprecision, and publication bias) and three
factors may lead to rating up (large effect size, dose
response relationship exists, and consideration of all plau-
sible confounding variables). The quality of evidence for
each outcome across studies falls into one of four catego-
ries ranging from high to very low.
Data Analysis
The primary objective of this meta-analysis was to evaluate
the efficacy of CBFLIs on adiposity in children and adoles-
cents. To control for change in weight status due to the
intervention, the effect size calculated was constructed as a
comparison of the change in weight status in the control
condition as compared with the intervention condition.
Independent effect sizes were calculated for the primary
outcome variable (adiposity) in each identified study. To
minimize the distortion of standard error estimates
resulting from nonindependent effect size estimates
(Card, 2012), multiple outcomes derived from the same
sample were aggregated such that each study (or group

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of studies using the same sample) contributed only one
overall effect size at each assessment point for the primary
outcome variable. For studies reporting multiple outcome
measures assessing the same general construct (e.g., BMI,
zBMI, percent overweight), an overall effect size was
created by averaging the individual effect sizes. If studies
reported multiple analyses using subsets of the same
sample, the analysis most directly assessing change in
childrens weight or adiposity was used.
Effect sizes were calculated following the aforemen-
tioned rules (e.g., one effect size per variable per study,
etc.).
Hedges g (Hedges & Olkin, 1985) was used as the
index of standard mean difference between treatment con-
ditions in the current meta-analysis. Hedges g is preferred
as an index of mean difference when the preponderance of
studies in the sample use relatively small sample sizes, with
correspondingly greater standard errors (Card, 2012). In
studies where efficacy of treatment is represented via
other statistics (e.g., F, t, X), these values were converted
into Hedges g using standard conversion procedures.
Cohen (1969) provided guidelines for interpreting the d
effect size: small, 0.200.49; medium, 0.500.79; and
large, 0.80. Mean effect sizes based on Hedges g follow
these same conventions. All effect sizes were expressed in
terms of 95% confidence intervals (CIs). Confidence bands
that did not include zero were considered statistically sig-
nificant, while those with confidence bands including zero
were considered nonsignificant.
Before calculating mean effect sizes, individual effect
sizes were weighted to reflect the degree to which the stan-
dard error approximates population parameters (Card,
2012). Specifically, a weighted mean effect size was calcu-
lated by computing the product of each studys effect size
by its weight, calculating the sum of each individual
weighted effect size, and dividing this sum by the sum of
weights.
To examine the homogeneity of effect sizes for the
primary outcome variable, the Q statistic was used. A sig-
nificant Q statistic indicates that within-group variability
among effect sizes is greater than sampling error alone
would predict. This is presumed to signal systematic dif-
ferences between studies in the sample, perhaps suggesting
the presence of moderator variables (Card, 2012). To pre-
serve statistical power for the planned moderation analyses
described below, a fixed effect model was used when esti-
mating heterogeneity among the sample of studies (Card,
2012).
Continuous and categorical moderators were assessed
using differing methodologies. Continuous variables (e.g.,
age, duration), modeled separately, were analyzed using
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Meta-Analysis of Family Interventions for Obesity 815
weighted regression analyses, with studies with lower stan-
dard error contributing more weight in the regression equa-
tion. Categorical variables (e.g., gender, setting) were
analyzed using analysis of variance techniques to assess
differences between groups of interest. It is recommended
that 20 studies per group be included to achieve optimal
power to detect group differences (Card, 2012). Therefore,
lack of significant differences between groups found in
these analyses may be due to insufficient power, as this
study only contained 20 studies in total. For this reason,
secondary analyses of interactions between moderating var-
iables were not assessed.
To evaluate the degree to which publication bias (i.e.,
file-drawer problem; Rosenthal, 1979) inflated the result-
ing effect sizes of this meta-analysis an effect size fail-safe N
was calculated (Card, 2012). An effect size fail-safe N in-
dicates the number of unidentified studies with an average
effect size that would be necessary to reduce the obtained
mean effect size to the smallest meaningful effect size
(ESmin). Following Rosenthal (1979), the smallest meaning-
ful effect size was set to 0.1.
Results
Description of Studies
The literature search returned 20 studies that were eligible
for inclusion based on the inclusion and exclusion criteria
(see PRISMA diagram). Across these studies, 42 effect sizes
were calculated to account for multiple time points and
multiple outcomes. To prevent violations of independence,
effect sizes from a single study were averaged to create an
overall average effect size for each study, which was then
used to calculate the overall effect size across all studies.
Descriptions of study characteristics are presented in
Table I.
The majority of the studies were published in the past
10 years, although one study was published in 1985. Of
the 20 studies presented here, eight did not provide zBMI
data. In these cases, BMI, % body fat, or % overweight data
were used and averaged to yield a single estimate of weight
change for the study. For length of study period, studies
ranged from no data after measurements to follow-up 2
years after baseline. Study rigor was measured using an
18-point scale assessing methodological quality derived
from Lundahl et al. (2010). This scale was used because
it yielded the most comprehensive assessment of study
rigor identified. The average total score on this scale was
12.3, and scores ranged from 9 to 16. The average num-
ber of participants per study was 86.28, with a range of
22108. The total number of child participants across
studies was 1,671.
 816 Janicke et al.

Table I. Study Characteristics

Parent
Child Duration targeted for Outcome
Type of Sample age Percent Country where Race/ of Tx lifestyle assessment Outcome
Study authors study size range female study conducted ethnicity (month) change time point(s) assessment

Boudreau, Kurowski, 2-arm RCT 26 912 51.2% United States L 100% 6 No 6 BMI z-score
Gonzalez, Dimond, &
Oreskovic (2013)
Bocca, Corpeleijn, Stolk, 2-arm RCT 75 35 72.0% The Netherlands N.R. 4 Yes 4, 12 BMI z-score
& Sauer (2012)
Debar et al. (2012) 2-arm RCT 208 1217 100% United States W 72% 5 No 6, 12 BMI z-score
Diaz, Esparza-Romero, 2-arm RCT 43 917 51.2% Mexico N.R. 6 No 6, 12 BMI z-score
Moya-Camarena,
Robles-Sardin, &
Valencia (2010)
Golley et al. (2007) 2-arm RCT 74 69 63.52% Australia W 98% 5 Yes 12 BMI z-score
Janicke et al. (2008) 3-arm RCT 71 814 60.6% United States W 73% 4 Yes 4, 10 BMI z-score
AA 10%
H 9%
O 8%
Jiang et al. (2005) 2-arm RCT 68 1215 39.7% China N.R. 24 Yes 24 BMI
Kalarchian et al. (2009) 2-arm RCT 192 812 57.0% United States W 74% 12 No 6, 12, 18 %overweight
AA 26%
Kalavainen, Korppi, & 2-arm RCT 70 79 65.7% Finland F 98.5% 6 Yes 6, 12 BMI z-score
Nuutinen (2007)
Nemet et al. (2005) 2-arm RCT 46 616 43.5% Isreal N.R. 3 No 3, 12 BMI, BMI %
body fat
Nemet, Barzilay-Teeni, & 2-arm RCT 22 811 63.6% Isreal N.R. 3 No 3 BMI %, body
Eliakim (2008) fat %
Reinehr et al. (2010) 2-arm RCT 66 816 60.6% Germany N.R. 6 N.R. 6 BMI z-score
Sacher et al. (2008) 2-arm RCT 116 812 54.3% United Kingdom W 50% 12 No 6 BMI z-score
Savoye et al. (2007) 2-arm RCT 174 816 60.3% United States W 37%. 12 No 6, 12, 24 Body fat
AA 39%
H 24%
Senediak & Spence 3-arm RCT 33 613 N.R. United States N.R. 1 No 1 %overweight
(1985)
Shelton et al. (2007) 2-arm RCT 43 310 53.5% Australia N.R. 1 Yes 3 BMI and WC
Vos, Huisman, Houdijk, 2-arm RCT 79 817 53.2% The Netherlands N.R. 3 No 3, 12 BMI z-score
Pijl, & Wit (2012)
Wafa et al. (2011) 2-arm RCT 107 711 53.5% Malaysia N.R. 6 No 6 BMI z-score
West, Sanders, Cleghorn, 2-arm RCT 101 411 67.3% Australia W 87% 3 No 6 BMI z-score
& Davies (2010) M 6%
A 4%
I 3%
Williamson et al. (2005) 2-arm RCT 57 1115 100% United States AA 100% 6 Yes 6, 24 BMI, body fat
Note. AA African American; A Asian; F Finnish; H Hispanic; I Indigenous; L Latina; M Mediterranean; O other; W White WC waist circumference;
N.R. not reported; RCT randomized controlled trial.

Overall Weight Outcome Effect Size
The overall effect size for change in zBMI in CBFLIs as
compared with that in passive control groups over all
time points was statistically significant (g 0.473, 95%
CI [.362, .584]). This finding is consistent with Cohens
classification of a small effect size (Cohen, 1969).
Only one study yielded a negative effect size (Kalarchian
et al., 2009), indicating that the rest of the studies yielded
improved outcomes as compared with the control group.
The effect size of each individual study, as well as each
studys contribution to the overall effect size, is depicted
in Figure 2.

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 Meta-Analysis of Family Interventions for Obesity 817

Figure 2. Forest plot depicting overall effect size of each study included in the meta-analysis. The overall effect size is delineated as a dotted
vertical line. The size of the dot represents the weight of the study in contributing to the overall effect size. The error bars represent the 95%
confidence interval.

Overall Effect Sizes for Secondary Outcomes
Eight studies provided useable information on child caloric
intake. The overall effect size for change in caloric intake in
CBFLIs as compared with that in passive control groups
over all time points was not statistically significant
(g 0.086, 95% CI [.090, .263]).
There was an insufficient number of studies (e.g., less
than two) meeting inclusion and exclusion criteria for this
review that reported on physical activity, sedentary behav-
ior, and parent use of behavioral management strategies to
allow for the calculation of an effect size based on the
Cochrane review guidelines.
Posttreatment and Follow-up Assessment Weight
Outcome Effect Size
Secondary analysis separately examined weight outcomes
directly following completion of the intervention
(posttreatment) and outcomes at later follow-up assess-
ments. Based on 20 studies, the effect size for CBFLIs at
posttreatment as compared with control groups was statis-
tically significant (g 0.416, 95% CI [.307, .526]).
Furthermore, based on 11 studies, the effect size for
CBFLIs at follow-up assessment as compared with control
groups was also statistically significant (g 0.386, 95% CI
[.248, .524]. Both of these meet criteria for a small effect
size (Cohen, 1969). The difference between the effect size
for posttreatment assessments and follow-up assessments
was not statistically significant.
Moderator Analyses
A test of heterogeneity was then conducted to determine
the appropriateness of testing for moderating variables. The
Q test of heterogeneity was statistically significant (84.446,
p < .001), indicating that these studies are heterogeneous

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 818 Janicke et al.

and that study variables are significantly moderating the
study effect sizes. Therefore, analyses, with each moderator
variable modeled separately, were conducted to assess
study characteristics that may be influencing effect size
outcomes. Moderating variables were included based on
reviews and recommendations for treating pediatric obe-
sity, previous research, and their potential of representing
important directions for future intervention research (Faith
et al., 2012; Jelalian & Saelens, 1999; Spear et al., 2007;
Wilfley et al., 2007). Continuous moderator variables ex-
amined in this meta-analysis included time between base-
line and posttreatment assessment, duration of treatment,
number of sessions, child age, child sex (i.e., % female),
methodological rigor of study, and amount of time in treat-
ment for both child and parent. Duration of treatment,
number of sessions, child age, and the amount of time
that the child spent in treatment were all statistically sig-
nificant moderators. Specifically, larger effect sizes were
associated with longer treatment (duration in weeks),
more treatment sessions, a greater total amount of time
(over the course of treatment) that the child spent in treat-
ment, and greater child age. The results of continuous
moderating analyses are presented in Table II.
Categorical moderators analyzed in this meta-analysis
included whether the study sample used ITT analysis, type
of control group, use of a manualized treatment, BMI
greater than the 99th percentile as an exclusionary criteria,
if the parents were targeted for their own health behavior
change, format for therapy, and form of contact with par-
ticipants. Results from these analyses are presented in
Table III. Use of ITT analysis, format of therapy, and
form of contact were significant moderating variables,
such that individual and in-person CBFLIs were associated
with larger effect sizes.
Table II. Continuous Moderator Analyses
Moderator variables R2 value p value
Time between baseline and .043 .198
assessment
Duration of intervention .374 .004
Number of intervention sessions .264 .020
Percentage of females participants in .068 .281
intervention
Age of child participants .305 .014
Methodological rigor of study .003 .831
Amount of minutes child in .795 .000
treatment
Amount of minutes parent in .017 .603
treatment
Effect Size Fail-Safe N Calculation
A fail-safe N was calculated to help evaluate the likelihood
of our overall effect size being an overly positive represen-
tation of the true effect size. This calculation assesses the
number of studies with an effect size of zero that would
have to be included before the overall effect size would
shrink to the smallest meaningful effect size. Our calcula-
tions indicated that 75 studies with an effect size of zero
would have to be added to this meta-analysis to bring
down the overall effect size to 0.1.
Risk of Bias
Each study was assessed on five dimensions for risk of bias.
The summary risk of bias findings across all studies are
presented in Figure 3. Overall the 20 studies included in
this review exhibit relatively low risk of bias for random
sequence generation and selective reporting. Over half of
the studies examined were judged to exhibit unclear or
high risk of bias for blinding of outcome assessment. In ad-
dition, over half to the studies reviewed reported insuffi-
cient methodological details and outcome data to
determine if there was low or high risk of bias for incom-
plete outcome data and thus were classified as unclear risk
of bias. Finally, over half of the studies examined exhibited
high risk of bias for allocation concealment.
GRADE Rating
A rating of moderate (3 on a scale of 14) was assigned
to the quality of evidence for improvements in BMI Z-score
based on the GRADE system. As all trials were RCTs, our
review assumed a starting point of high-quality evidence (a
rating of 4). However, the quality of evidence was incon-
sistent and there are some potential concerns with risk for
bias (see previous section), which lowered the overall rating
from high quality to moderate quality. A rating of low
quality (2 on a scale of 14) was assigned to the quality
of evidence for changes in caloric intake based on the
GRADE system. As all trials were RCTs, our review as-
Beta
sumed a starting point of high-quality evidence (a rating
0.208 of 4). However, owing to the potential concerns for risk of
bias and the fact that the measurement of dietary intake
0.612
was viewed as imprecise, the GRADE rating was reduced
0.514
from high quality to low quality. See Table IV for a display
0.234
of the Summary of Findings Table.
0.169
0.193
0.892
Discussion
Previous reviews examining studies published before 2008
0.131 have reported that lifestyle interventions addressing pedi-
atric obesity are associated with improvements in weight

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 Meta-Analysis of Family Interventions for Obesity 819

outcomes (Jelalian & Saelens, 1999; Kitzmann et al., 2010; overweight or obese. Specifically, our inclusion criteria re-
Oude-Luttikhuis et al., 2009; Whitlock et al., 2010; quired that intervention programs address three compo-
Wilfley et al., 2007). While very informative, these reviews nents, improvements in dietary intake, increases in
included heterogeneous groups of studies with varied types physical activity, and the use of behavioral strategies to
of lifestyle intervention programs. The current meta-analy- achieve improvements in these two areas. The overall
sis extends the literature by examining studies published in effect size of 0.47 for change in BMi z-score, although
2013 and being the first to examine only multi-component small, was approaching Cohens requirement of 0.5 for a
CBFLIs to treat obesity in children and adolescents who are medium effect size. This finding is consistent with similar
past reviews (Whitlock et al., 2010; Wilfley et al., 2007)
Table III. Categorical Moderator Analyses
and suggests that multi-component CBFLIs are efficacious
in improving weight outcomes in children who are over-
Moderator
variables Categories N Effect size
weight or obese. Follow-up analysis found that effect sizes
a
did not significantly differ between results at posttreatment
Intent to treat Yes (1) 7 0.658 (0.491, 0.824)
and follow-up assessments, providing evidence that im-
No (2) 13 0.290 (0.141, 0.440)
provements in weight outcomes are maintained at follow-
Type of control Standard care 10 0.430 (0.280, 0.572)
up. The length of follow-up assessments ranged from 10 to
group Waitlist 9 0.470 (0.290, 0.650)
24 months after baseline, with a majority (8 of 10 studies)
Use of Yes 5 0.546 (0.314, 0.747)
including 12-month follow-up assessment. The analyses of
manualized No 7 0.360 (0.115, 0.605)
effect sizes examining maintenance of outcomes at follow-
treatment Not reported 8 0.437 (0.279, 0.596)
up assessments were based on a relatively small number of
BMI > 99th as Yes (1) 4 0.352 (0.279, 0.596)
studies. Thus, results should be interpreted with caution.
exclusion No (2) 11 0.392 (0.239, 0.546)
Exploratory analyses were also conducted to examine
Not reported 5 0.812 (0.546, 1.075)
potential moderators of treatment outcome. Most notably
Parent targeted Yes (1) 6 0.268 (0.049, 0.486)
dose of treatment, as measured by the number of interven-
for change No (2) 12 0.502 (0.366, 0.638)
tion sessions and the number of minutes children spent in
Not reported 2 0.689 (0.265, 1.113)
treatment sessions, was positively related to effect size.
Form of therapya Individual 2 1.291 (0.889, 1.693)
This is consistent with previous reviews (Whitlock et al.,
Group 13 0.372 (0.240, 0.504)
2010; Wilfley et al., 2007). Our results, in combination
Both 5 0.426 (0.240, 0.665)
with these previous reviews, provide support for the notion
Form of contacta In person 14 0.642 (0.498, 0.786)
that greater intervention duration and intensity are associ-
Phone only 1 0.219 (0.363, 0.801)
ated with better weight outcomes, which is similar to find-
In personOther 5 0.176 (0.007, 0.359)
ings reported in the adult obesity literature (Middleton,
Timing of Post-Treatment 20b 0.416 (0.307, 0.526)
Patidar, & Perri, 2012). However, more research
measurement Follow-up 11b 0.386 (0.248, 0.524)
specifically examining doseresponse relationships of
Note. aIndicates statistically significant moderating variable.
b
Due to multiple measurements taken within the same study, this number does CBFLIs to weight and behavioral outcomes is needed
not represent studies, instead representing measurements taken within a study. before definitive conclusions can be drawn.

Figure 3. Risk of bias.

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 820 Janicke et al.

Table IV. Summary of Findings for Multi-Component Behavioral Family Interventions to Treat Obesity in Children and Adolescents

Patient or population: Overweight and obese children and adolescents

Outcomes Illustrative comparative risks (95% CI) Relative effect No of partici- Quality of the Comments
Assumed risk Corresponding risk (95% confi- pants evidence
Control Behavior Family Therapy dence interval) (studies) (GRADE)

BMI z-score (overall) The overall mean decrease in - 1671 (20  Results were statisti-
Investigators used BMI z-score in the inter- studies) moderate cally significant. As
objective measurement vention groups was 0.47 a rule of thumb,
of anthropometric standard deviations more 0.2 SD represents a
variables. than the control groups small, 0.5 a moder-
(0.360.58 lower) ate, and 0.8 a large
difference.
Caloric Intake The overall mean decrease in - 542 (8  low Results were not sta-
Investigators used objec- caloric intake in the inter- studies) quality tistically significant.
tive measurement of ca- vention groups was 0.09
loric intake (i.e., 24-hr standard deviations more
recalls, food frequency than the control groups
questionnaires). (0.090.26 lower)
Note. GRADE Working Group grades of evidence.
High quality (): Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality (): Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality (): Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality (): We are very uncertain about the estimate.

The level of parent involvement relative to weight out-
comes in pediatric lifestyle interventions has received grow-
ing attention in the literature in recent years. Neither the
amount of time parents spent in treatment nor whether the
parents were targeted for their own lifestyle behavior
change was related to child weight outcomes in this anal-
ysis. This is consistent with a review by Faith and col-
leagues (2012) who found limited support for the notion
that greater parental involvement in treatment leads to
better child weight outcomes. However, Faith and col-
leagues did find that greater parent adherence to core be-
havioral strategies was related to greater child weight status
outcomes. It may be that the actual application of behav-
ioral strategies to address lifestyle issues within the home
leads to better child weight outcomes, which was not as-
sessed in our analysis. As noted by Faith et al. (2012), only
a few studies have reported on this important relationship
(Epstein, 1993; Wrotniak, Epstein, Paluch, & Roemmich,
2005). Future intervention trials should include data col-
lection to examine if parent use of behavioral strategies
mediates the relationship between treatment participation
and key outcomes such as changes in dietary intake, phys-
ical activity, and weight status.
A number of other potential moderators of effect size
outcomes were examined in this review. Age was a mod-
erator, such that larger effect sizes for weight outcomes
were positively associated with the mean age of child
participants. This is consistent with a review by
Oude-Luttikhuis (2009) who found larger effects for stud-
ies with children 12 years of age compared with studies
with children <12 years of age. Weight outcomes were
moderated by form of therapy (individual vs. group) and
form of contact (in person vs. phone only vs. in-person
plus other), such that therapy with individual families
and therapy delivered via in-person contacts related to
larger effect sizes. However, the number of studies in-
cluded in this moderator analyses were heavily skewed
toward group and in-person contacts that these findings
must be viewed as preliminary. The current review also
found that studies that used ITT analysis (k 7) were as-
sociated with better weight outcomes than studies that did
not use ITT analysis. While one could speculate that stud-
ies including ITT analysis are methodologically stronger
than those studies that do not include ITT analysis, our
moderator analysis examining methodological rigor of in-
cluded studies was not significant and thus did not sup-
port this conclusion.
Data from eight studies found that CBFLIs do not have
significant effects on change in caloric intake. This is sur-
prising given the effects that CBFLIs were found to have on
weight change. It is likely that the imprecise nature of as-
sessing caloric intake at least partially impacted these re-
sults (Schoeller, 1995), as it seems unlikely that the weight
changes observed were entirely due to increases in energy
expenditure. These findings highlight the need for innova-
tive future research designs to examine the specific

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mechanisms by which the interventions exert their influ-
ence. One such example may be the use of sequential,
multiple assignment, randomized trials (SMART Designs)
that provide data to enable assessment of optimal compo-
nent sequencing that can facilitate the development of
high-quality adaptive interventions (Almirall, Compton,
Gunlicks-Stoessel, Duan, & Murphy, 2012).
Consistent with the other systematic reviews in this
special issue, the GRADE system (Guyatt et al., 2011)
was used to assess the strength and quality of the evidence
of our findings. Evidence for changes in BMI z-score from
the reviewed studies was assigned a moderate GRADE
rating, indicating that further research is likely to have an
important impact on our confidence in the estimate of
effect and may change the estimate. However, evidence
for our finding on caloric intake was assigned a low qual-
ity rating, indicating that further research is likely to have
an important impact on our confidence in the estimate of
effect and is likely to change the estimate. Characteristics of
the studies included in this meta-analysis that strength-
ened the GRADE rating for weight outcomes included
the use of RCTs, evidence of a doseresponse relationship
between weight and treatment (e.g., better weight out-
comes were associated with greater treatment duration
and intensity), and an overall small effect size approaching
a medium effect. There were, however, also some
weaknesses in this literature, which precluded a stronger
GRADE rating for each outcome. For example, 75% of
studies were rated as having unclear or high risk of bias
of incomplete reporting of outcome data due to large
amounts of missing data, insufficient details regarding rea-
sons for missing data, or the use of inadequate methods for
managing missing data, which diminishes confidences in
estimation of treatment effects. Moreover, half the studies
included in this analysis were rated high on risk of bias for
allocation concealment (i.e., investigators were not blind to
randomized assignment of participants). In addition, effect
sizes across studies for weight outcomes were somewhat
inconsistent. Finally, as noted previously, the imprecise
nature of assessing caloric intake negatively impacted our
Grade rating for changes in caloric intake.
There are a variety of steps that can be taken by future
research to address these methodological limitations and
improve the scientific rigor in this area. First, many studies
were excluded from the meta-analysis owing to failure to
provide sufficient information to allow for calculation of
effect size, or properly classify the study intervention or
methodology. Similar concerns have been noted by
Klesges and colleagues, who called for researchers to
improve the reporting of contextual and generalizability
elements central to translational research
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Meta-Analysis of Family Interventions for Obesity 821
(Klesges, Dzewaltowski, & Glasgow, 2008). We echo this
call and also encourage researchers to more clearly opera-
tionally define and describe both the active intervention
and control condition on which the intervention is tested
against. Second, the overall GRADE rating for this analysis
was negatively impacted by the high risk of bias in a
number of areas. To reduce this risk of potential bias and
increase our confidence in the efficacy of CBFLIs, it is also
important for future studies to ensure proper concealment
of randomization and treatment condition assignment to
investigators and assessment staff. With regards to data
analysis, future studies should conduct ITT analyses
when examining primary and secondary outcomes, and
should clearly document why data are missing and what
strategies and assumptions used for handling missing data.
There are some important additional limitations of the
current analysis that have implications for future research.
The clinical significance of weight outcomes associated
with CBFLIs is an on-going question. Few studies in this
review reported on metabolic parameters associated with
weight changes. While these data are admittedly difficult to
gather with children, it will be critical to document
improvements not only in weight outcomes but also
metabolic parameters. Similarly, only eight studies in the
literature contained sufficient information to examine
change in dietary intake. Moreover, there were not
enough articles identified to calculate effect sizes for both
physical activity and sedentary behavior. Future studies of
lifestyle interventions for obesity should include sufficient
objective information to allow effect sizes to be calculated
for dietary intake, physical activity, and sedentary behavior,
as these effect sizes likely moderate overall effect sizes for
lifestyle interventions. Admittedly, reliable and valid assess-
ment of dietary intake is an ongoing challenge. Repeated
24-hr recalls offer the best combination of feasibility and
strong psychometric properties, but are expensive,
time-consuming, and still subject to self-reporting bias.
Strategies to reduce reporting bias and further improve
the reliability and validity of assessing dietary intake are
sorely needed. In addition, compared with other meta-
analyses, only a relatively small number of studies and
participants were included in this meta-analysis. As such,
findings from our analysis of moderators should be viewed
with caution. Finally, there is the risk of publication bias in
any meta-analysis; the discovery of additional studies of
CBFLIs might have affected the results obtained here.
However, the fail-safe calculation indicated that 75 stud-
ies with an effect size of 0 would need to be added to this
meta-analysis to result in an effect size of 0.1.
The potential for adverse events is important to con-
sider when evaluating interventions to address childhood
 822 Janicke et al.
obesity, not only in terms of the potential for delayed linear
growth but also for negative outcomes such as the devel-
opment of disordered eating behaviors and reductions in
self-esteem (Satter, 2005). Eight of the 20 studies included
in this analysis reported on adverse events. Only four of
these reported on potential changes in problematic eating
attitudes and behaviors or self-esteem (DeBar et al., 2012;
Janicke et al., 2008; Jiang, Xia, Greiner, Lian, &
Rosenqvist, 2005; Williamson et al., 2005). One study
specifically assessed for slowed linear growth (Golley,
Magarey, Baur, Steinbeck, & Daniels, 2007), while three
other studies reported on generic adverse events (Nemet
et al., 2005; Reihner et al., 2010; Sacher et al., 2010).
Across these eight studies there was no data suggestive of
an increase in negative outcomes or adverse events subse-
quent to participating in CBFLIs. This is consistent with
the findings from previous reviews (Carter & Bulik, 2008;
Oude-Luttikhuis et al., 2009; Whitlock et al., 2010). While
testing the efficacy or effectiveness of CBFLIs on reducing
or slowing weight gain in youth has important public
health implications, it is equally important that families
participating in these interventions are not exposed to ad-
ditional causes of harm. Therefore, researchers should
place a high priority on reporting information on the
number and types of adverse events associated with
tested interventions.
Given the lack of interventions addressing obesity in
young children, as well as recent findings showing that
children who are overweight at 5 years of age are four
times more likely to be obese between 5 and 14 years of
age compared with children who are normal weight
(Cunningham, Kramer, & Narayan, 2014), there is great
need for more prevention and intervention research focus-
ing on the impact of behavioral family interventions in
families of young children. Another important question is
the issue of generalizability, as well as translation and dis-
semination to real world settings. There is growing support
for the notion that longer and more intense treatment re-
sults in better weight outcomes. However, the question
arise as to how can higher intensity interventions that
seem to be related to better outcomes be delivered in
real-world settings by individuals with less expertise than
many of the obesity experts that served as interventionists
in these outcome studies? Moreover, how can we help fam-
ilies sustain participation for the longer durations neces-
sary for better weight outcomes, given the documented
barriers that many families face in real world settings
(Kottyan, Kottyan, Edwards, & Unaka, 2014; Lim &
Janicke, 2013)? Future research is needed to develop and
examine innovative strategies for implementing CBFLIs
that can be delivered with fidelity, reach large numbers
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of families in community settings, and that are feasible
for both families and providers. Telehealth, technology-
aided, and internet-based social media interventions are
areas that hold promise and are deservedly garnering
more attention (Davis, Sampilo, Gallagher, Landrum, &
Malone, 2013). Finally, developing broader multi-layered
intervention efforts that include CBFLIs within larger com-
munity change efforts, such as by Rogers and colleagues
(Rogers et al., 2013), can build awareness, as well as envi-
ronmental and social supports that have the potential to
facilitate long-term behavior change that can reach larger
numbers of children and families.
Conclusion
The current study provides evidence that CBFLIs address-
ing pediatric obesity lead to improvements in child weight
outcomes. While the overall effect size was small, it ap-
proached the medium range. There was no difference in
effect sizes for weight outcomes at posttreatment relative to
long-term follow-up. Greater duration and intensity of
treatment, as well as greater child age, were all related to
better weight outcomes. Future research is needed to better
document changes in caloric intake, physical activity, and
metabolic parameters associated with participation in
CBFLIs. Future research is also needed to develop innova-
tive strategies for feasibly implementing CBFLIs in real-
world settings while preserving the core components of
treatment with established efficacy.
Conflicts of interest: None declared.
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