James A Vohs Award:
A Focus on Obesity, Part 1:
••Spring 2003/Vol. 7, No. 2

Health Systems

Lawrence Hammer, MD, discusses the Stanford Pediatric Weight Control Program
Weight Control in Children and Adolescents Proves Successful in a Family-Based Program| pdf >>

By Lawrence Hammer, MD

Introduction

The Stanford Pediatric Weight Control Program is a family-based behavioral program designed to promote healthier eating and exercise habits for overweight children aged 8 to 12 years and their families. With the exception of a hiatus in the early 1990s, the program has existed continuously since the mid 1980s and is based on the model of family-based behavioral treatment developed by Leonard Epstein, MD, at the University of Pittsburgh.¹

Before this approach to family-based treatment existed, most treatment efforts addressed weight control by using a more traditional medical model--that of individual therapy. By having children and their parents meet in separate groups, Epstein showed, in a series of controlled studies, that weight loss could be achieved and maintained over an extended period of time.² In this model, groups of parents meet at the same time as groups of children meet. Material is covered by group leaders in separate group settings for children and parents.

Structure of the Program

The Stanford program, directed by Thomas Robinson, MD, Assistant Professor of Pediatrics, consists of 24 weekly sessions spanning six months. Groups are conducted in either English or Spanish and include 9 to 12 families who pay a deposit to encourage attendance. Participants learn to classify foods into "red-light foods" (high-calorie, low-nutrient value), "yellow-light foods" (the major portion of their diet), and "green-light foods" (foods containing <20 calories per serving). Another module of the program adds exercise habits, and the maintenance-phase module alternates discussion sessions of specialized topics (eg, fast food, holidays) with a family exercise class.

Another important program component is the time spent in each session during which the family meets together to talk or to solve problems. Children and parents create reciprocal contracts in which children
set goals to reduce red-light foods and parents set goals to create a red-light-food-free environment.

Program evaluation consists of weekly weight measurement, monthly height measurement, counting the number of red-light foods whose quantity was reduced in the diet, and observing the extent to which healthier habits were acquired. The goal for each child is to maintain weight or to gradually lose no more than one pound per week; the change in percentage overweight is calculated for a six-month period.

Results for Program Participants

During one evaluation period, English-language groups included 65 children from 62 participating families. Parents and children were a mean 71% overweight. At the outset of the program, 17 parents were of normal weight, 39 were overweight (body mass index [BMI] 25-30), 26 were obese (BMI 30-40), and 7 were severely obese (BMI >40). Seventy-two parents were measured and weighed both before and after the program. Of the mothers, 63% lost a mean 4 lb each; 67% of the fathers lost a mean 6 lb each.

Thirty-two children from 30 Spanish-speaking families participated; these children were a mean 71% overweight. Twenty-three of these Spanish-speaking parents were measured before and after the program. Six were of normal weight, 11 were overweight, 18 were obese, and 1 was very obese. Of the mothers, 77% lost a mean 9 lb each. Of the fathers, 83% lost a mean 3 lb each.

Benefits of Family-Based Programs

Studies published by Epstein^1-3 and (to a limited extent) by others,^4,5 show that family-based, group weight control programs may be more feasible, efficient, and effective than individual counseling received from primary care providers. Such an approach is consistent with recommendations published by an expert committee under the auspices of the Maternal and Child Health Bureau in the US Department of Health and Human Services.⁶

Recognizing the positive efforts of a family trying to improve eating and exercise habits is very important. Changing these habits--whether for an individual person or for an entire family--is incredibly challenging. Families may have had so many difficult and failed experiences of making changes that it's hard for them to imagine that they could ever succeed. An important strategy is to notice even the smallest change and to offer congratulatory and positive comments about it. Taking the opportunity to notice each small change can be very powerful and can give families the opportunity to think about themselves in new and exciting, positive ways.

Acknowledgment

Tom Robinson, MD, MPH, provided expert advice.

References

1. Epstein LH. Family-based treatment for pre-adolescent obesity. Advances in Developmental and Behavioral Pediatrics 1985;6:1-39.
2. Epstein LH, Valoski A, Wing RR, McCurley J. Ten-year follow-up of behavioral, family-based treatment for obese children. JAMA 1990 Nov 21;264(19):2519-23.
3. Epstein LH. Family-based behavioral intervention for obese children. Int J Obes Relat Metab Disord 1996 Feb;20 Suppl 1:S14-21.
4. Levine MD, Ringham RM, Kalarchian MA, Wisnieswski L, Marcus MD. Is family-based behavioral weight control appropriate for severe pediatric obesity? Int J Eat Disord
5. Golan M, Weizman A. Familial approach to the treatment of childhood obesity: conceptual mode. J Nutr Educ 2001 Mar-Apr;33(2):102-7.
6. Barlow SE, Dietz WH. Obesity evaluation and treatment: Expert Committee recommendations. The Maternal and Child Health Bureau, Health Resources and Services Administration and the Department of Health and Human Services. Pediatrics 1998 Sep;102(3):e29. Available at: www.pediatrics.org/cgi/content/full/102/3/e29 (accessed March 20, 2003). 2001 Nov;30(3):318-28.
   

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