Comparison of Family-Based Behavior Modification and Nutrition Education for Childhood Obesity 1

Transcription

1 Journal of Pediatric Psychology, Vol 5. No. I, 1980 Comparison of amilybased Behavior odification and Nutrition Education for Childhood Obesity 1 Leonard H. Epstein, 1 Rena R. Wing, Linda Steranchak, Barbara Dickson, and Joyce ichelson Western Psychiatric Institute and Clinic and Children's Hospital of Pittsburgh. University of Pittsburgh School of edicine The effects of behavior modification and nutrition education procedures were compared for overweight children, aged 612, and their mothers. Information on diet and exercise were included for mothers and children in both groups. The groups were provided equivalent information on appropriate diet and exercise but differed in the use of behavioral therapy procedures to prompt and reinforce habit change for the behavior modification group. Results showed behavior modification was associated with superior relative weight change compared to nutrition education. The weight losses of children and parents in the behavior modification group were very similar (rho =. 75), while parentchild weight loss was unrelated in the nutrition education group (rho =.26). Obesity, or the accumulation of excess fat, often begins at an early age, and research (Abrahams, Collins, & Nordsieck, 1971; Charney, Goodman, c Bride, Lyon, & Pratt, 1976) suggests that overweight children are at a significantly higher risk of being overweight as adults than thin children. Stunkard and Burt (1967) estimated the odds against an overweight child becoming an average weight adult as 4:1 at age 12. The odds rise to 28:1 for those who do not reduce during adolescence. One of the most important determinants of fatness level of children is the fatness level of their parents. Using data from the TenState Nutrition 'Appreciation is expressed to Drs. Alien Drash and Dorothy Becker, Children's Hospital of Pittsburgh, for their support, and to John Heiser, for assistance during followup meetings. This research was supported in part by Grant HDH1252O01 from the National Institute of Child Health and Human Development and ental Health. All correspondence should be sent to Leonard H. Epstein, Western Psychiatric Institute and Clinic, 3811 O'Hara Street, Pittsburgh, Pennsylvania O /79/03OOO025JO3.00/ Society of Pediatric Psychology

2 26, Epstein, Wing, Steranchak, Okkson, and ichdson Survey, Garn and Clark (1976) showed that at age 12 children from two obese parents are three times as fat as children with no obese parents. These investigators found a correlation of.25 between the fatness of parents and offspring. The relative importance of genetic factors versus common environmental factors is difficult to determine. Garn, Cole, and Bailey (1976) found that the relationship between the fatness of foster parents and their adopted children was comparable to that found in biological offspring. or both "social" and biological families, the chance of a child being obese increased in stepwise fashion from two thin parents, through two medium parents, and on to two fat parents. Shared environment may also explain the correlation between the weight of spouses (r =.30) (Garn & Clark, 1976) and between the weight of petowners and their dogs (ason, 1970). Obesity may "run in families" because overweight parents provide an environment that is conducive to overeating and underexercising, selectively reinforce such behaviors, and/or serve as a model of these behaviors. Activity patterns of parents and their children seem to be related (Griffiths & Payne, 1976), and foodeating habits of parents and children may be similar. ailure to treat the family as a whole may explain the limited success of previous programs for childhood obesity (Brownell & Stunkard, 1978; Coates &Thoreson, 1978). Diet programs (Alley, Narduzzi, Robbins, Weir, Sabeh, & Darowski, 1968; Asher, 1966), drug therapy programs (Hoffman, 1957), and exercise programs (oody, Wilmore, Girandola, & Royce, 1972) have all tried to treat the overweight child without modifying the habits of those around him or her. Behavior modification programs, which stress the development of new eating and exercise habits as a way to lose weight, and provide specific strategies for changing the environment, may be particularly well suited to the problem of the overweight child. Several behavioral studies (Kingsley & Shapiro, 1977; Rivinus, Drummond, & CombrinckGraham, 1976; Wheeler & Hess, 1976) have included parents in the treatment of overweight children. In these studies, parents were taught to implement changes in the diet and exercise habits of the children, but were not instructed to modify their own behaviors. or example, Aragona, Cassady, and Drabman (1975) taught parents of overweight children to reinforce their children for specific behavior changes and arranged contracts with the parents such that money was returned to the parent if the child attended meetings, completed assignments, and reached preset weight loss criteria. Although the evidence suggests that parental health habits affect children's weight, there has been no research which compares alternative treatments using a parentchild approach. In the present study, the weight changes of children aged 612 and mothers who participated in a

3 Behavior odification for Childhood Obesity 27 familybased behavior modification treatment program were compared to changes in a familybased nutrition education group. ETHOD Subjects Twentyeight persons, 15 children and 13 adults, participated in the study. The subjects were recruited by referral from local physicians and in response to newspaper, television, and radio advertisements. A total of 18 families with overweight children between the ages of 612 came to an initial orientation; 16 families signed up for the program. Two families reported they were unable to attend all treatment sessions and dropped out of the study at the first session. One other family attended three sessions and then dropped out, leaving 13 families participating. Two of these families were referred by physicians, the others were recruited by the media announcements. Inclusion criteria for the child were: (a) The child should be 612 years of age, (b) greater than 20% above ideal weight, according to American Child Health Association heightweight tables; (c) have no medical problem that contraindicates weight loss; and (d) have at least one parent willing to participate in the program. Descriptive characteristics of participating subjects are presented in Table I. Two families, one in each of the two treatment groups, had two children enrolled. In each case, only the youngest child was included in calculations. The families that had two children enrolled were amily 4 in the behavior modification group, and amily 6 in the nutrition education group. Procedure The children were placed into the Behavior odification and Nutrition Education groups by blocking procedures to control for percentage overweight and age of child. Children were divided at the median of age and weight and then randomly assigned to the two groups. Each group met once per week during the 7 weeks of treatment and once per month during the 3 months of followup. At each treatment meeting subject's weight was taken. Children's heights were taken at the beginning and end of treatment and at the 3month followup. During treatment and followup meetings, the adults and children were seen separately. The adults were always seen by either an experienced behavior modification psychologist or an experienced dietician. Children were seen by two female psychology undergraduate students.

4 PI a 3 T o s a. Table I. Descriptive Characteriitics of Subjects in Behavior odification and Nutrition Education Groups amily Behavior modification X Nutrition education S 6 7 Y Age Sex Children Height Weight %Over Age Sex Height Adults Weight %Over

5 Behavior odification for Childhood Obesity 29 Table II. Summary of Treatment Techniques Technique Diet Exercise Behavioral techniques Behavior modification 1,200 or 1,500 calories Instruction in aerobics/spot reducing, stretching Selfmonitoring, training in social reinforcement and modeling, slowing down eating rate. phone contact. Contract for selfmonitoring, not eating Red foods, losing weight Treatment Nutrition education Same Same Contract for attendance The treatment techniques used in the two groups are presented in Table II, and are described as follows: Diet and Nutrition Education Both groups were provided two lectures in caloriecounting and basic nutrition using a colorcoded, caloriebased food exchange system developed by Epstein, asek, and arshall (1978). This system involves coding all foods into red, yellow, and green categories, corresponding to high, medium, and low calorie foods, within a food group. Also, the colors correspond to colors of a traffic light: red foods are ones you should stop when you see and not eat; yellow foods are ones you should approach with caution and eat in limited amounts, and green foods are ones which you can eat as much of as you like. oods are coded according to their calorie density. Red foods are the foods within a group (i.e., fruits, vegetables, dairy, protein, etc.) that have high caloric density. These foods are those that were at least 20 calories more than the average food within the category. Yellow foods are the basic reference foods required for balanced nutrition. Green foods, or free foods, are very low calorie foods that people can eat as much of as they want. Examples of foods within the color code and various groupings are shown in Table III. The objectives of the diet and nutrition education were to meet the nutritional requirements for health and growth, restrict calories to 1,200 or 1,500 calories per day, and eliminate high caloric density foods from the diet. In order to meet the objectives, these three diet rules were used: (a) eat the basic core diet supplying 900 balanced calories, (b) do not exceed the 1,200 or 1,500 calorie limit, (c) and do not eat more than four red foods per week.

6 30 Epstein, Wing, Steranchak, Dickson, and lchdson Table III. Examples of Red, Yellow, and Green oods ood group ree foods Vegetables High protein ilk & dairy Breads & starches ruits & juices ats Sweets Green Boullion Asparagus Lemon juice Yellow Color codes Corn Baked chicken Skim milk Bagel, bread Apple argarine rench dressing Red Potato salad ried chicken Whole milk Donut Sweetened applesauce Thousand Island dressing Candy bar. Cake Subjects in the Nutrition Education group received additional lectures on food with information about labelreading and suggestions for lowcalorie recipes. Exercise Subjects in each group were provided common information on aerobics exercise (Cooper, 1970) to increase caloric expenditure, and calisthentics/stretching for body reshaping and injury prevention. At each meeting during an exercise session, subjects were provided direct training in calisthentics or were taken for a one to twomile walk. Subjects in both groups were instructed to decrease inactivity, specifically televisionwatching. Subjects were advised to do spotreducing exercises during commercials if they were watching television. Subjects in the Nutrition Education group were also instructed on exercising in the cold or heat. Behavioral Techniques A variety of behavioral procedures shown to be important in weight control were included in the Behavior odification program. Contingency contracting. Contracting is a behavioral technique which is designed to influence adherence to a treatment regimen and reduce attrition (Epstein & Wing, in press). Prior to entering the study, all families deposited $65 to be returned during the seven treatment and six followup sessions. The requirements for monetary return for subjects in the Behavior odification group during treatment were as follows: $1 for selfmonitoring of daily calorie and weight measures for the child; $1 for consumption of fewer than four red foods per week for each child; and $3 per meeting for weekly weight loss of 1 pound for both parent and child.

7 Behavior odification for Childhood Obesity 31 During followup, criterion for monetary return was loss of 2 pounds during the month for both parent and child. or subjects in the Nutrition Education group, $5 was returned at each treatment and followup meeting if both the child and participating parents attended. The attendance contract for the Nutrition Education group was designed as a control for the effect of entering into a contract. Selfmonitoring. Selfmonitoring involves selfobservation and selfrecording of caloric intake and weight. Selfmonitoring has been shown to be an important independent factor in weight loss (Romanczyk, 1974). Also, selfmonitoring of caloric intake may be a necessary component for selfregulation of caloric intake and basic component of selfcontrol (Kazdin, 1974). Adult and child subjects in the Behavior odification group were instructed to monitor caloric intake and weight and were provided food diaries (Abbott, 1977) and data sheets for daily recording of caloric intake and weight. Social reinforcement/prompts. Parents and children in the Behavior odification group were trained to praise other family members appropriately for making changes in eating and exercise behaviors. In addition, parents and children were told of the importance of being a good model for other family members. Change eating behaviors. Subjects in the Behavior odification group were instructed how to change eating behaviors by removing environmental stimuli that prompt eating and by changing the act of eating by slowing down eating rate (Epstein, Parker, ccoy, & cgee, 1976). Therapist contact. Recent research (Jeffery & Wing, 1979) has shown that frequency of therapist contact, whether in vivo or phone, may be important in influencing behavior change. Subjects in the Behavior odification group were thus provided increased therapist contact by phone calls during treatment and followup. During treatment, therapists called participants between visits to assess progress in behavior change and to provide support. During followup, subjects were called weekly during the first month, once every other week during the second month, and not at all during the third month. easurement Weights were obtained on a balancebeam scale at the beginning of each treatment and followup meeting. Height was obtained at the beginning and end of treatment and at the last followup meeting. Percentage overweight was calculated for parents and children using ideal weight for height charts (parents: etropolitan Life Insurance norms; children: American Child Health Association norms).

8 32 Epstein, Wing, Steranchak, Okkson, and ichdson Table IV. Changes During Treatment and ollowup for Subjects in the Behavior odification and Nutrition Education Groups Height (inches) Weight (pounds) Percent over Group Behavior modification Children Adults Pre Nutrition education Children X Adults X U Pre Post U Pre Post U

9 Behavior odification for Childhood Obesity 33 RESULTS The pre and post heights, weights, and percent overweights of all subjects are presented in Table IV. Children and mothers from two families, one in each group, finished treatment but did not attend followup (Subjects 2, 8, 14, 21). Their endoftreatment values were used for followup data in all calculations. The major dependent variable used was percent overweight, rather than weight. Percent overweight, or relative weight, is preferable for use with children because children's weight is very dependent on both their age and height, and relative weight provides estimates of overweight that takes into account height and age changes which can be compared across children. The baseline percent overweights for mothers and children were evaluated using a factorial ANOVA to ensure initial equivalence of groups. There were no group differences, (\, 22) = 1.98, p>.10; or group by parentchild interaction, (l, 22) =.55, p>.10; but the children were significantly more overweight than the parents, (l, 22) = 6.66, p<.05, as the average child was 64.4% overweight while the average mother was 35.1Vo overweight. Changes in percent overweight were assessed by a threefactor repeated measures or one factor ANOVA, with groups and parent/child as between factors, and pre, post, and postfollowup changes as the within trials factor. The results showed only a significant Group effect, (l, 22) = 4.33, p<.05. All other main effects and interactions were nonsignificant. The significant Group effect was due to greater average percent overweight change during treatment and followup for participants in the Behavior odification (Jc = 12.9) than for participants in the Nutrition Education group (x = 4.7). The relationship between parent and child weight loss was investigated by relating percent overweight losses of parents and children in each group by computing the Spearman nonparametric rank order correlation coefficient. The Spearman rho for the Behavior odification group was.75, r(4) = 2.98, p<.05, and the values for the Nutrition Education group were rho =.26, /(5) = 0.60,p>.05. A better understanding of the different relationships between parent and child weight loss was attempted by correlating relative weights of parents and children during base line. Parent and child relative weights were slightly, but not significantly more related for the Behavior odification [rho =.43, /(4) =.94, p >.05] families than for the Nutrition Education [rho =.21,^(5) = \A0,p> AO] families. Thus, the relationship between parent and child change probably was not due to greater similarity in relative baseline weights of parents and children.

10 34 Epstein, Wing, Steranchak, Dickson, and khdson The similarity in parent and child relative weight change for Behavior odification participants may also be due to the relationship between initial weight and weight loss (urray, 1977). Since heavier parents had heavier children, the relationship in weight change could be due to heavier persons losing more weight than lighter persons, both heavy parents and heavy children may lose more weight than lighter parents and children, and the family relationship may be a function of this. However, rho's calculated for initial relative weight change for parents and children in each group show lack of correlation for all sets of data. The correlations of percent overweight with weight change for children and parents for the Behavior odification group were.14,.47, and for the Nutrition Education group.10,.03. Thus, the observed parentchild effect was probably not due to a relationship between initial relative weight and relative weight change. Participation in the two programs was uniformly high, with attendance during treatment for the Behavior odification group at 89.3%, while attendance for the Nutrition Education Group was 71.9%. Analysis of weekly attendance showed families in the Behavior odification group attended more reliably, (l, 14) = 4.76, p<.05, than families in the Nutrition Education group. DISCUSSION The results of this study are consistent with other reports showing that Behavior odification treatment procedures are associated with better weight loss in children than traditional obesity treatments (Brownell & Stunkard, 1978; Coates & Thoreson, 1978; Kingsley & Shapiro, 1977). The Behavior odification and Nutrition Education groups were provided the same nutrition and dietary information, but the Behavior odification groups were also given training in selfregulation skills and procedures to optimize motivation. The Nutrition Education procedures provided complete instructional information on what should be done, but no direct training in how to change. Also, the nutrition education procedure did not provide for arranging natural motivating conditions to reinforce whatever habitchange did occur. Behavior modification, on the other hand, provided specific skills related to the regulation of food intake. In addition to teaching skills for selfregulation, behavior modification also arranged the environment to increase the probability that new behaviors are performed. Several techniques were used in the present study to promote behavior change. The first was modeling, which uses parent behavior to set the occasion for child behavior. Second, weekly phone calls to the children can both prompt and reinforce habit change. Contracting for behavior and

11 Behavior odification for Childhood Obesity 35 weight change, and parental praise and reinforcement for habitchange also could reinforce appropriate eating and exercise behavior. These results show the superiority of behavior modification procedures for weight loss in children. The relationship between motherchild weight loss and child weight loss was stronger for families in the Behavior odification than Nutrition Education groups. This correspondence is in support of the idea that changes in eating and exercise habits are being made at the family level. REERENCES Abbott Diet Diary. Chicago: Abbott Laboratories, Abrahams, S., Collins, G., & Nordsieck,. Relationship of childhood weight status to morbidity in adults. HSHA Health Reports, 1971, 86, Alley, R. A., Narduzzi, J. V., Robbins, T. J., Weir, T.., Sabeh, C, & Darowski, T. S. easuring success in the reduction of obesity in children. Clinical Pediatrics, 1968, 7, Aragona, J., Cassady, J., & Drabman, R. S. Treating overweight children through parental training and contingency contracting. Journal of Applied Behavior Analysis, 1973, 8, Asher, P. at babies and fat children: The prognosis of obesity in the very young. Archives of Diseases in Children. 1966, 41, Brownell, K. D., & Stunkard, A. J. Behavioral treatment of obesity in children. American Journal of Diseases in Childhood, 1978, 132, Charney, E., Goodman, H. C, cbride,., Lyon, B., & Pratt, R. Childhood antecedents of adult obesity. Do chubby infants become obese adults? New England Journal of edicine, , 69. Coates, T. J., & Thoreson, C. E. Treating obesity in children and adults: A public health problem. American Journal of Public Health, 1978, 68, Cooper, K. H. The new aerobics. New York: Bantam, Epstein, L. H., asek, B. J., & arshall, W, R. A nutritionally based school program for control of eating in obese children. Behavior Therapy, 1978, 9, Epstein, L. H., Parker, L., ccoy, J.., & cgee, G. Descriptive analysis of eating regulation in obese and nonobese children. Journal of Applied Behavior Analysis, 1976, 9, Epstein, L. H., & Wing, R. R. Behavioral contracting in health care. Clinical Behavior Therapy Reviews, in press. Garn, S.., & Clark, D. C. Trends in fatness and the origins of obesity. Pediatrics, 1976, 57, Garn.S.., Cole, P. E.,& Bailey, J.. Effect of parental fatness of biological and adoptive children. Ecology of ood and Nutrition, 1976,5, 13. Griffiths,., & Payne, P. R. Energy expenditure in small children of obese and nonobese parents. Nature. 1976, Hoffman, R. H. Obesity in childhood and adolescence. American Journal of Clinical Nutrition, 1957, 5, 110. Jeffrey, R. W., 4 Wing, R. R. requency of therapist contact in the treatment to obesity. Behavior Therapy. 1979, 10, Kazdin, A. E. Selfmonitoring and behavior change. In. J. ahoney <t C. E. Thoresen (Eds.), Se(fcontrol: Power to the person. onterey, Calif.: Brooks/Cole, Kingsley, R. G., & Shapiro, J. A comparison of three behavioral programs for the control of obesity in children. Behavior Therapy, 1977, 8, 3036.

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