Better Weight Outcomes for Kids With Family-Based Approach in Primary Care

Family-based treatment (FBT) in primary care settings prevented children with overweight and obesity from gaining more excess weight over time, the randomized PLAN trial found.

In kids ages 6 to 12 years, the percentage above the median body mass index (BMI) after 24 months was 6.21% (95% CI -10.14 to -2.29) lower in the FBT group compared with a usual care group, reported Leonard Epstein, PhD, of the University at Buffalo in New York, and colleagues.

Despite initial declines in the percentage above median BMI, a 0% change from baseline was observed at the 2-year mark in the group of kids assigned to FMT — which employed a coach to instill various behavioral change methods to spur on healthy eating and activity habits in the targeted kids and parents alike. On the other hand, a significant 6.48% increase was observed in the usual care group, the researchers detailed in JAMA.

Significantly more children assigned to FBT experienced a clinically meaningful change to their weight — defined as a BMI z-score reduction of 0.25 or more — compared with those receiving standard interventions (27% vs 9.3%, P<0.001).

And the effects of the FBT program also extended to family members, with differences in the proportion above the median BMI observed at 2 years both in parents (-1.05% vs 2.92% with usual care) and in siblings (0.03% vs 5.35%).

Furthermore, the researchers found a strong association between children’s weight outcomes and that of their siblings.

“The sibling who was not treated showed similar changes to the targeted child, and the child and parent changes were related, as were the sibling and targeted child changes,” Epstein told MedPage Today. “This suggests that parenting and the shared family environment were changed.”

“It is hard for children to change unless they are in a supportive environment, and they see other members of the family also making healthy changes,” Epstein added. “We have seen in other studies that focusing on the positive behaviors that children are doing in terms of being active and eating healthier, low-energy dense foods is associated with better results than focusing on what the child should not be doing — eating snack foods, being sedentary, etc.”

“One of the best predictors of child change is modeling parent behaviors,” he said.

The main takeaway for clinicians, said Epstein, is the importance of including expertise in behavioral change in their practices, people “who can help not only with weight issues, but with many other issues that children experience, including non-adherence, excessive media use, eating disorders, depression, substance abuse, etc.”

Families had a goal of attending at least 26 individualized sessions over the 2-year period with newly trained coaches. There was a significant link between attending treatment sessions and better outcomes for children (r = -0.32), but only 45% of children met the goal number of sessions.

The lifestyle-based intervention included tips on dietary and exercise, paired with behavioral and social support led by people trained in psychology, social work, counseling, or as dietitians. Pediatricians of both the FBT and usual care group followed the most recent recommendations from the American Academy of Pediatrics (AAP) for treating childhood obesity, calling for kids to be referred to intensive health behavior and lifestyle treatment.

However, the researchers pointed out the effects of this primary care-driven treatment were generally lower than what’s previously been seen when this treatment is delivered in speciality clinics. According to projections using previous research, children in a specialty clinic setting would see a 10.6% between group change compared with the 6.21% drop seen in this trial. Previous studies also found that FBT led 45% of children to have a meaningful BMI z-score change in speciality settings rather than the 27% seen here.

This disparity was also pointed out in an accompanying editorial by William Heerman, MD, MPH, of the Vanderbilt University Medical Center in Nashville, Tennessee, and co-authors, who wrote that while “this study represents a step in the right direction, the intervention may not yet be ready for widespread implementation without further consideration of how to pragmatically implement in pediatric primary care without losing effectiveness or sustainability.”

“[I]t is unclear whether the statistically significant changes reported in child and parent outcomes are associated with any reduction in later cardiometabolic risk, particularly because the percentage above median BMI at 24 months returned to the baseline level for children in the intervention group,” they added.

Addressing the return to baseline BMI levels seen in the trial, Epstein explained that both COVID-19 pandemic weight gain seen in both parents and children, and using non-expert coaches in only individuals rather than group settings could also be factors.

Although intensive behavior and lifestyle interventions are the recommended treatments for children younger than 12 with overweight and obesity, referral for pharmacotherapy and weight-loss surgery are also now recommended by the AAP for some.

Despite the higher efficacy of these new weight management strategies, Heerman’s group emphasized the importance of behavioral interventions in treatment, adding that they are still the “cornerstone for obesity management.”

“First, medications and surgical weight loss may not be affordable and/or accessible and they may not meet a family’s preference in young children,” the editorialists explained. “Second, the use of weight loss medications and the choice to proceed with surgery require the adjunctive and concurrent treatment with behavioral interventions.”

For the controlled PLAN trial, 452 families were enrolled across four U.S. cities and evenly assigned to FBT or usual care. All participating families included a child ages 6 to 12 years (mean 10) with overweight or obesity (mean 127 lb, BMI of 27) and a parent with overweight or obesity. When available, siblings ages 2 to 18 with overweight or obesity were also enrolled.

Overall, 84-90% of the children had obesity and 9-16% were overweight (child BMI percentile of 97.3-97.6). A little more than half were girls (53-54%), a majority were white (56-58%), more than a fourth were Black (26-29%), and 8-10% identified as multiracial.