March 2018 Issue

CPE Monthly: Family Approaches to Weight Management
By Alexandria Hardy, RDN, LDN
Today's Dietitian
Vol. 20, No. 3, P. 46

Suggested CDR Learning Codes: 4020, 5370, 6040
Suggested CDR Performance Indicators: 6.3.11, 8.1.4, 8.3.6, 9.2.1
CPE Level 2

Take this course and earn 2 CEUs on our Continuing Education Learning Library

Obesity rates in the United States have been steadily rising over the past 30 years, with more than one-third of all children, adolescents, and adults being classified as overweight or obese.1,2 Children of obese parents have an 80% to 85% higher chance of being overweight, with family environment being the predominant factor.3,4 Odds ratios for obese toddlers and teenagers aren't more encouraging, with an odds ratio of 1.3 and 17.5, respectively.4 Culture, community, policy, and media are other contributors to a family's health. The pervasive increase suggests that rising obesity rates may be due more to modifiable risk factors such as diet and physical activity than to genetics.5,6

Traditional weight loss interventions have emphasized diet or physical fitness, or a combination of the two, and have targeted a single population, such as adults or children. Family-based weight management offers a targeted inclusive approach that's believed to be more successful.7-9 When parents or other caregivers are included, they "serve as role models, authority figures, and behavioralists to mold their children's eating and activity habits," according to the Expert Committee's report published in 2010.5 By modeling healthy behaviors and encouraging family change, these programs may be a key to reversing the trend of obese children growing into obese adults.

Children in particular may benefit from a family approach to weight management, as health-promoting behaviors such as diet and exercise are influenced by their family life.1 According to Chen and Escarce in a 2010 longitudinal study, "For children, family represents the primary source of social learning, influence, and exposure to and adoption of health habits."8 The home environment has a huge impact on the health and behavior of family members, whether or not it's intentional. For example, parents who purchase primarily processed, packaged, nutrient-poor foods have little hope of creating and serving a healthful family meal from those ingredients. In much the same way, family time that centers around sedentary activities models a lifestyle of insufficient activity.

Today's culture also is responsible for our obesigenic environment. "Influences from a modern environment promote weight gain by encouraging energy overconsumption coupled with underexpenditure resulting in a discrepancy in the energy balance affected by physical activity, calorie intake, and time spent in sedentary behaviors," according to Jacy Downey of Iowa State University.10

A multifaceted approach is essential to address the physical, mental, social, and emotional comorbidities that accompany obesity. Hypertension, CVD, diabetes, apnea, arthritis, cancer, and osteoporosis are among the physical comorbidities. Negative self-esteem, behavioral and learning problems, depression, and poor body image influence psychological health.6,11 Ideally, clinicians from each practice area should address these comorbidities; positive outcomes are most consistently seen when program scope is narrow and program education provided by practitioners are appropriate.9 Clinicians who have participated or are participating in family-based weight management programs include physicians, licensed psychologists, RDs, trained health educators, practice enhancement assistants, and physical educators.

This continuing education course explores adult and pediatric weight management through the lens of family-based programs. Effectiveness, barriers, and implementation structures are discussed.

Variables to Consider
Family-based approaches to weight management comprise many variables that contribute to or detract from their success. Family structure, home environment, population, attendance, tools, and staffing are a few of these variables that merit careful thought and consideration.

Family Structure
Family structure plays a role in determining the success of a family-based weight management program. Children with no siblings are more likely to have a higher BMI in kindergarten to fifth grade.8 Consequently, children with siblings who have normal BMIs are more likely to be at a healthy BMI themselves; research is being conducted to determine the causality behind these findings.8

Environment
Creating a safe and supportive environment is important when considering a family approach to weight management. All members of the family must be targeted and included, so multiple learning styles may need to be used to address different needs. Assessing developmental levels and using appropriate materials to educate participants is key.12 Education time should be split between parents and children, with the same message taught so goals complement each other. The underlying theme of a family weight management program always should be to improve health, never to "lose weight" or "get skinny."12 The dialogue that's exchanged and the message communicated should be positive and encouraging; clinicians must assess whether they have a weight bias that could inadvertently lead to shaming participants.

Length
Current programs vary in length from seven weeks to one year.13 Length is sometimes linked to long-term success, as long-term physical activity programs were more successful in meeting goals and making lifestyle changes.9 Programs that lasted six months were less successful than seven- to 12-month-long programs.9 Hadley and colleagues analyzed a variety of intervention strategies and discovered that program efficacy wasn't defined by one standard approach or structure. Providing a narrow focus area and targeting a specific age of children/adolescents were common features of successful programs.9 For example, adolescents aged 12 to 17 were more likely to meet physical activity goals, while teenagers aged 16 to 19 were more successful at losing weight.9

Intensity
Program intensity, classified by contact hours, is another metric used to analyze efficacy. Intensity ranges from very low (<10 hours/program) to low, moderate, and high (>75 hours). Moderate- and high-intensity programs are the most commonly planned and studied types of interventions.14 Time constraints and financial limitations have driven researchers and clinicians to ask whether lower-intensity programs (10 to 25 contact hours) could be equally effective.14

Population
Much of the existing research has been conducted in white, Hispanic, and black families.11,10 Research shows a wide variety in the ages of the children and adolescent participants (2 to 19 years old), but many studies have focused on the 6- to 12-year-old demographic, perhaps because children can take some responsibility for their health but are not as autonomous as teenagers.10 BMIs of participating children and adolescents range from 85th to 94th percentile (overweight) to the 95th percentile and above (obese).15 Parent participants also have been overweight or obese (BMI >25).

Attendance
Williams and colleagues studied 4- to 7-year-old children and their primary caregivers to determine what factors had the biggest impact on participation in a family-based weight management program. They classified participants as completers, partial completers, or noncompleters based on their attendance. Participants were unlikely to begin or complete a program if they were from single parent or low-income households, were older, or were black, and also were likely to be labeled as disengaged.11 The child's mental and emotional state, gender, and BMI had little to do with their attendance.11

Of the 155 enrolled families, attendance was split fairly evenly between noncompleters, partial completers, and completers. More than one-third of the study's families dropped out of the program; out of those 50 families, 60% didn't attend a single session.11 All 50 were considered noncompleters. Fifty-six families attended fewer than two-thirds of the sessions and were considered partial completers, and the remaining 49 families were classified as completers (attending more than two-thirds of the sessions).11 Attendance was highest (49%) in the beginning of the program, when meetings were the most frequent. As the study progressed and the sessions became biweekly and then monthly, participation dropped to 27.8% and 30%, respectively.11 This supports the research hypothesis that early family engagement is key to further participation and program completion.11

Program Tools
Family-based weight management programs use a variety of tools to assess and educate families. Nutrition assessment and education tools include scales, stadiometers, calipers, food frequency or other nutrition questionnaires, food logs, BMI, and growth curve charts. Physical activity tracking tools include but are not limited to accelerometers, pedometers, or other physical activity trackers, and the Progressive Aerobic Cardiovascular Endurance Run, or PACER, fitness test. Behavioral therapy tools include behavioral questionnaires, weekly program goals, and individual family strategy goals. Tools differ based on available resources, size and length of program, and age of participants.

The Role of Responsibility
Within the framework of a family-based weight management program, there are certain responsibilities that are assigned to individual parent/child participants and other responsibilities that are family oriented. The inclusion of parents in weight management programs is supported by scientific evidence from Williams and colleagues that indicates "parental involvement in the treatment of childhood obesity may improve children's weight-related outcomes."11 In a family approach where inclusion is central to success, the same research has shown that the structure of the "home environment, reinforcement of eating behaviors and attitudes towards food, and perceptions of physical appearance" are all parental responsibilities.11

There are many ways to engage the entire family and meet program goals. Meal planning, grocery shopping, and food preparation are examples of activities that children of all ages can do with their parents. Children and even adults who are given choices and allowed to provide input are more likely to try new foods.16 RDs working in family-based programs can provide children and adolescents age-appropriate kitchen chores such as tearing salad greens, measuring herbs and spices, or preparing a fruit salad. When considering physical activity, RDs or other program staff can suggest working as a family to set goals to reduce electronic "screen time." The American Academy of Pediatrics recommends screen time for two hours or less per day for most age groups. As families work to decrease screen time, they should be encouraged to brainstorm activities that include physical movement and are engaging. Bowling, miniature golf, trampoline parks, or laser tag take the focus off of exercise and onto the fun that movement can bring. Letting family members take turns when planning active outings can empower them and encourage participation.

Program Structure
Family physician offices, pediatric clinics, private practices, fitness centers, and children's hospitals are examples of sites that can host a family-based weight management program. Curriculum ranges from that of national programs like SHAPEDOWN, developed by a multidisciplinary team from the University of San Francisco's School of Medicine, to regional and city specific outreach. All programs, regardless of location and curriculum, benefit from the inclusion of the following three targeted approaches to weight management: nutrition, physical activity, and behavioral therapy.

Multidisciplinary programs that address the building blocks of physical activity, diet, and social behaviors are most effective at prompting positive behavior change. An expert committee from 15 different professional organizations has created a tiered obesity treatment plan, with interventions ranging from broad goals and single providers to a multidisciplinary team and the potential inclusion of medication or weight loss surgery.5

Nutrition
Topics discussed throughout the programs include basic nutrition, food composition, healthful eating cues, food exposure, portions, and label reading.11,14 Ideally, nutrition lessons are taught by an RD and are typically based on an existing curriculum.

Motivational interviewing (MI) is a technique that dietitians successfully have used for nutrition counseling as a form of patient-centered communication.5 How MI is employed will be different depending on children's ages. The goal of using MI in a family-based weight management program is to positively increase the individual and family's willingness to change by using a compassionate, nonconfrontational interviewing format.

Physical Activity
Clinicians provided fitness education with the following themes: self-monitoring active time, usage and purpose of trackers, basic fitness principles, energy balance, the importance of sleep, and national activity recommendations.11,14

Less than one-half of children aged 3 to 11 engage in 60 minutes of moderate to vigorous physical activity each day; that percentage dwindles to fewer than 10% of adolescents.10 One of the major contributors to inactivity is screen time. Families need to evaluate their current screen usage, set healthful limits, and swap previous sedentary time for family-friendly physical activities.3

Behavioral Therapy
Topics discussed throughout the programs include praise and privileges, effectively using rewards, modeling healthful behaviors, developing habits, setting a good example, social reinforcement, and stimulus control.11,14

The most holistic of the building blocks, this component includes self-esteem and social competence.13 The goal is to increase self-perception in a variety of areas, including scholastic, social, and athletic competence as well as physical appearance, behavioral conduct, and self-worth.13 A helpful way to do this is to identify triggers (eg, environmental and emotional) that result in an unhealthful response and determine how to manage or remove the triggers.14

Each of these focus areas include practical tips, positive reinforcement, and encouragement for participants to continue on the road to health after the program concludes. Clinicians provide direction on continued goal-setting and realistic timelines to meet goals.

Efficacy of Family-Based Programs
A variety of metrics exist to determine program success, but most studies define efficacy as successfully meeting program goals, completing the program, and improving overall health. Some studies experienced success in one particular area (eg, physical activity) while others reported multiple markers of achievement (eg, met weight loss goals and increased daily step count by 500 each week).

Building Healthy Families
Ruebel and colleagues analyzed data from two sessions of the Building Healthy Families (BHF) program to determine what components of the program had the most impact on desired health outcomes. There were 62 total participants enrolled in these two sessions (22 obese children aged 7 to 12, 20 mothers, and 20 fathers).15 BHF was loosely based on Stoplight, another family-based weight management program, and used the same education materials.15 The Stoplight, or Traffic Light, diet strives to maximize nutrition while minimizing calories; it was created by researcher and family weight management pioneer Leonard Epstein. Foods are divided into three categories based on their nutrient density. Green foods contain <20 kcal per serving, yellow foods are dietary staples, and red foods are high-calorie (>200 kcal/serving) and high-fat (>5 g/serving) foods.7,15 Stoplight participants attended weekly sessions that were 1.5 to 2 hours in length; the program lasted 12 weeks, and data were collected only on families who attended 10 or more sessions.15

Each session consisted of a nutrition lesson by an RD, an exercise portion lead by a physical educator, and behavioral counseling by a licensed psychologist.15 Each family was asked to set an individual family strategy goal, and participants collectively set weekly program goals, which "included a body weight loss goal of 1 to 2 lbs for adults and 0.5 to 1 lb for children, an energy intake goal of reducing high-calorie and -fat foods consumed from the previous week by one until participants reached two of these foods per day, and a physical activity goal of increasing steps by 1,000 steps per day from the previous week."15 The individual family strategy goals were developed with aid from the behavioral counselors and "focused on specific strategies necessary to meet the program goals and behaviors."15

At the conclusion of the study, 72% of the children and 96% of the parents lost weight, with an average loss of 4.52% and 7.39%, respectively.15 Total body fat, body mass, and BMI all decreased significantly, while fat-free mass, energy intake, and cardiorespiratory fitness all improved significantly in the children.15 Parents saw similar success with significant improvements in body fat and cardiorespiratory fitness and decreased energy intake.15 Researchers hypothesized that overall success was due primarily to dietary change, specifically a reduction in "red foods" per the Stoplight curriculum.15 This translated to an average 430 kcal deficit/day in children. Not surprisingly, the participants who were consistently successful at meeting their weekly goals saw a positive correlation with their weight loss.15

Buffalo Healthy Tots
Quattrin and colleagues studied overweight or obese preschoolers who were treated independently or with an overweight or obese parent. The purpose of this study was to determine whether pediatric weight loss was more successful when the child was specifically targeted or when there was parental inclusion. The research was conducted as part of the Buffalo Healthy Tots program, a "family-based, weight control intervention … in urban and suburban pediatric practices."17 Study treatment included 13 nutrition and physical activity education sessions over the course of a year and three follow-up sessions the following year. Children who were treated as part of the intervention group experienced decreases in BMI from baseline, with greater losses in long term weight loss in children with higher baseline BMIs.17 Parents who were treated with their children and received similar education regarding weight and behavior lost an average of 14 lbs. Parents of the control group of preschoolers who weren't active study participants didn't experience significant weight changes.17

Quattrin credits the success of the study to behavioral interventions, such as the practice enhancement assistants who provided education and support for the intervention group in each stage of the study. The assistants were trained in exercise science, nutrition, and psychology and provided similar education to the parents, who tracked diet, weight, and activity for themselves and their children. The use of these specially trained assistants suggests that a multidisciplinary team could be more effective at evoking long-term change than a single practitioner.17

Review of Family Approaches
Kitzman-Ulrich and colleagues reviewed 46 studies that examined weight management in an overweight pediatric population or implementation of a more healthful diet and increased physical activity in normal-weight children.18 This review illustrated that equipping parents with the proper tools and skills was key to the child's success. Research showed that parents who set appropriate boundaries, created supportive home environments, and used positive reinforcement had improved study outcomes.18

When programs focus on weight management as their primary aim, only 21% of programs are able to achieve significant change in weight reduction, per a meta-analysis of 64 programs.11 Programs that included a counseling component were more effective at promoting positive change in the diet and increasing physical activity levels of the children and adolescent participants.9 Physical activity goals were more likely to be achieved when programs included a skills-building component and when tracking activity was mandatory.9 An additional benefit of behavioral therapy is improving familial relations and communication throughout the program.9

Future of Family-Based Weight Management
The National Institutes of Health has provided an $8.8 million grant to Leonard Epstein, PhD, of the University at Buffalo; the purpose is to make family-based weight management programs more accessible to needy families, with a goal of treating 500 families or 1,200 children, parents, and siblings.7 The grant will allow clinicians to "implement and evaluate highly successful, family-based obesity treatment in the primary care setting, an optimal setting given the established relationship between patients and their primary care providers."7 The grant will use a "team science" approach by incorporating multiple disciplines and partnerships with other pediatric researchers. By using this approach, Epstein is hopeful that results will be directly applied to other clinicians currently in practice.

Participating offices are located in New York, Ohio, and Missouri and will provide enrolled families with "enhanced standard treatment" (control group) or health coaching (intervention).7 Standard treatment for participants includes being seen in the office by a physician four times per year for two years with a focus on nutrition and healthful eating. The intervention group also will be seen in the office by their physicians but will additionally receive individualized education from a trained health counselor.7

The main study goal is to determine best practices for facilitating a family-based weight management program in a primary care office. Subgoals include strategizing and troubleshooting solutions related to the common barriers of time, space, staffing, funding, and perception.7

RD Takeaways
Sarah E. Barlow, MD, MPH, prepared an excellent summary paper on the prevention, assessment, and treatment of child and adolescent overweight and obesity, summarizing evidence-based recommendations and providing annual and per visit guidelines for clinicians to implement.5 According to Barlow, when assessing a family, collecting a 24-hour recall or using a food frequency questionnaire to help understand current dietary intake is essential. Furthermore, focusing on sugar-sweetened beverages, produce, familial obesity, and eating patterns outside the home give dietitians an idea of current health practices and enables them to gauge readiness to change.5

Dietitians, along with the other clinicians who service this population, should use their clinical judgment and experience in conjunction with national recommendations to provide best practices. Evidence-based prevention strategies include limiting sugar-sweetened beverages, promoting the USDA recommendations for produce intake and proper portions, limiting screen time and removing televisions from sleeping areas, consuming breakfast, and encouraging family meals at home while limiting fast food and restaurant dining.5 Additional nutrition-specific recommendations for intervention include consuming adequate calcium and fiber, using the Dietary Reference Intakes to ensure macronutrients are properly balanced, choosing nutrient-poor foods infrequently, and exclusively breast-feeding for six months, with continued breast-feeding after 12 months per the American Academy of Pediatrics.5

In addition, consider the value of incorporating hands-on experiences. Enabling a family to participate in a healthful kitchen makeover and a grocery shopping tour personalizes the experience and empowers the participants to make changes. A grocery store tour would be an ideal experience to practice label reading, discuss packaging claims, and identify more healthful alternatives to current family favorites. A mock kitchen can be set up in the office with a refrigerator and pantry. These can include a variety of nutrient-poor and nutrient-dense items (using food models, packages, and labels) with which participants can take turns "stocking" their kitchen. Meal planning is another skill set that should be developed, including how to build a shopping list, define a correct portion size, and create nutrient-dense meals.

Resources
RDs can encourage using online and printable free resources both within a program and at home. The USDA's Choose MyPlate is an excellent interactive resource, as well as the Whoa, Slow, Go model by Coordinated Approach to Children's Health. Both resources can be used for a variety of audiences and are available in multiple languages. The Stoplight or Traffic Light diet is another visual resource that can be modified easily for child and adult populations; supplementary materials include food lists and a workbook.

Different learning styles need to be accounted for, and RDs may need to be creative in their approaches. For example, young children are likely to benefit from food models and other visual aids, while a technological component may be more appropriate for tweens and teens. Adults enrolled in family-based weight management programs were provided with a mixture of lectures, media material, and instructions on how to support and encourage their children's progress.9 Using mixed media and different approaches to parental education was most effective when the program's scope was narrow (eg, nutrition based vs "weight loss").9

Barriers
Finances can be a major barrier to participation in family-based weight management programs. There may be lack of reimbursement from insurance providers or families may be unable or unwilling to pay out of pocket. Parents may deny a weight problem (in themselves or their children) and refuse participation. Populations with the greatest barriers include single parent households, racial minorities, and lower income families; with time and resources again playing a role in their limited participation.8 Regular attendance can be an issue as well, with risk factors attributed to demographics, psychosocial characteristics, and family dynamics.11 Late-stage family engagement and lack of parental involvement also can limit success, as can program location.7 Perhaps the biggest hurdle is a participant's readiness to change, whether that manifests as a child who sneaks candy bars after school or a parent who doesn't prioritize meeting their physical activity goals.

Conclusion
Family-based approaches to weight management have existed since the 1970s and are successful instigators of change.15 "The complexity of obesity prevention lies less in the identification of target health behaviors and much more in the process of influencing families to change behaviors when habits, culture, and environment promote less physical activity and more energy intake."5 Future research is needed to determine how to standardize program variables to deliver high-quality, impactful education every time.15

Family structure also is a key component to consider. Families are essential in providing the support needed for children and adolescents to be successful in their weight loss and healthful living endeavors, both socially and interpersonally.8 The Obesity Action Coalition proposes that a child's home environment and family dynamics play a bigger role in successful weight management than do genetics.3 This is encouraging for dietitians as these are modifiable risk factors if the entire family is on board to make changes in the pursuit of a more healthful lifestyle.

It's imperative that obesity is addressed early in life to prevent some of the long-term physical and psychological consequences that can arise.6 Modeling positive health behaviors is a simple, observable parenting decision that can be repeated throughout the child's lifetime. Children ultimately know and emulate the behaviors that are modeled for them. If they see parents who prioritize eating healthfully and exercising, they're more likely to do the same. Weight management programs and strategies that engage the entire family offer substantial whole-health benefits and are an effective step on a lifelong journey to health.

— Alexandria Hardy, RDN, LDN, is a consultant in corporate wellness and a freelance food and nutrition writer based in Pennsylvania.

Learning Objectives
After completing this continuing education course, nutrition professionals should be better able to:
1. Use existing research and recommendations to construct a family-based weight management program.
2. Analyze current barriers to meeting program goals and positive outcomes.
3. Contrast a family approach to weight management with a traditional individualized approach.
4. Assess the three disciplines that address the mental, physical, and emotional aspects of weight management.
5. Evaluate the populations best served by family-based weight management programs.

CPE Monthly Examination

1. What is the increased likelihood that a child of an obese parent is going to be obese compared with the child of a parent with a normal BMI?
a. 20% to 25%
b. 40% to 45%
c. 60% to 65%
d. 80% to 85%

2. What's the main reason that it's important to include all family members when making healthful lifestyle choices?
a. Parents serve as role models, authority figures, and behavioralists.
b. Children like to be included in their parents' activities.
c. Children and adolescents need supervision while their parents receive education and counseling.
d. Parents should include their children's preferences in all of their decisions.

3. What is a common barrier to participation in family-based weight management programs?
a. Healthy BMI range
b. Infrequent meetings
c. Lack of readiness to change
d. Lack of financial reimbursement

4. Why is it essential to engage the family early in the program?
a. It results in increased physical activity.
b. It leads to higher attendance rates and likelihood of completion.
c. It results in decreased sugar-sweetened beverage intake.
d. Participants are more likely to meet weight-loss goals.

5. In what age range are children/adolescents most likely to be successful in meeting weight loss goals?
a. 3 to 6
b. 7 to 10
c. 11 to 14
d. 16 to 19

6. What three components are recommended for inclusion in a family-based weight management program?
a. Endurance training, healthful cooking, psychosocial therapy
b. Nutrition, physical activity, behavioral counseling
c. Exercise, therapy, grocery shopping
d. Meal planning, fitness, behavioral interventions

7. Children without siblings are more likely to have a higher BMI in what grades?
a. Pre-K to first
b. Kindergarten to second
c. Kindergarten to fifth
d. Fifth to eighth

8. What should be the underlying theme of a family-based weight management program?
a. Weight loss
b. Increasing physical activity
c. Limiting sedentary activities
d. Improving health

9. Programs of what duration are more likely to yield long-term changes when compared with shorter duration programs?
a. One to three months
b. Three to six months
c. Seven to 12 months
d. 12 to 18 months

10. Which of the following is an example of a family responsibility?
a. Discussing and planning weekly meals
b. Daily weigh-ins
c. Identifying environmental triggers
d. Forcing children to finish their meals

References
1. Childhood obesity facts. Centers for Disease Control and Prevention website. https://www.cdc.gov/healthyschools/obesity/facts.htm. Updated January 25, 2017. Accessed January 2, 2017.

2. Adult obesity facts. Centers for Disease Control and Prevention website. https://www.cdc.gov/obesity/data/adult.html. Updated September 1, 2016. Accessed January 2, 2017.

3. Obesity — the link between your weight and your family. Obesity Action Coalition website. http://www.obesityaction.org/educational-resources/resource-articles-2/childhood-obesity-resource-articles/obesity-the-link-between-your-weight-and-your-family. Accessed January 2, 2017.

4. Weiss R, Bremer AA, Lustig RH. What is metabolic syndrome, and why are children getting it? Ann N Y Acad Sci. 2013;1281(1):123-140.

5. Barlow SE; Expert Committee. Expert committee recommendations regarding the prevention, assessment, and treatment of child and adolescent overweight and obesity: summary report. Pediatrics. 2007;120(Suppl 4):S164-S192.

6. Childhood overweight. Obesity Society. http://www.obesity.org/obesity/resources/facts-about-obesity/childhood-overweight. Updated May 2014. Accessed January 2, 2017.

7. Family weight-loss program to treat more than 1,000 parents and children. University at Buffalo website. https://www.buffalo.edu/ubnow/stories/2016/09/epstein-family-based-weight-loss.html. Updated September 15, 2016. Accessed January 2, 2017.

8. Chen AY, Escarce JJ. Family structure and childhood obesity, Early Childhood Longitudinal Study — Kindergarten Cohort. Prev Chronic Dis. 2010;7(3):A50.

9. What works for the prevention and treatment of obesity among children: lessons from experimental evaluations of programs and interventions. Child Trends website. http://www.childtrends.org/wp-content/uploads/2013/03/Child_Trends_2010_03_25_FS_WWObesity.pdf. Updated March 2010. Accessed January 2, 2017.

10. Downey J. Parenting practices related to positive eating, physical activity and sedentary behaviors in children: a qualitative exploration of strategies used by parents to navigate the obesigenic environment. Iowa State University website. http://lib.dr.iastate.edu/cgi/viewcontent.cgi?article=4971&context=etd. Published 2014.

11. Williams NA, Coday M, Somes G, Tylavsky FA, Richey PA, Hare M. Risk factors for poor attendance in a family-based pediatric obesity intervention program for young children. J Dev Behav Pediatr. 2010;31(9):705-712.

12. Schaeffer J. Family-based weight loss. Today's Dietitian. 2014;16(4):26-29.

13. Archuleta M, VanLeeuwen D, Turner C. Fit families program improves self-perception in children. J Nutr Educ Behav. 2016;48(6):392-396.

14. Benzo RM. Acceptability and efficacy of a low intensity family-based weight loss intervention. Iowa Research Online website. http://ir.uiowa.edu/cgi/viewcontent.cgi?article=5883&context=etd. Published 2015.

15. Ruebel ML, Heelan KA, Bartee T, Foster N. Outcomes of a family based pediatric obesity program — preliminary results. Int J Exerc Sci. 2011;4(4):217-228.

16. Build a healthy diet with smart shopping. Nutrition.gov website. https://www.nutrition.gov/shopping-cooking-meal-planning/food-shopping-and-meal-planning/build-healthy-diet-smart-shopping. Updated May 18, 2017.

17. Quattrin T, Roemmich JN, Paluch R, Yu J, Epstein LH, Ecker MA. Efficacy of family-based weight control program for preschool children in primary care. Pediatrics. 2012;130(4):660-666.

18. Kitzman-Ulrich H, Wilson DK, St George SM, Lawman H, Segal M, Fairchild A. The integration of a family systems approach for understanding youth obesity, physical activity, and dietary programs. Clin Child Fam Psychol Rev. 2010;13(3):231-253.