April 2014 Issue

Family-Based Weight Loss
By Juliann Schaeffer
Today’s Dietitian
Vol. 16 No. 4 P. 26

Evidence shows long-term, healthful behavior changes are most successful when the entire family gets involved.

Weight is a common topic at dinner tables across America, whether revealing itself in open discussion or unspoken actions. It’s an intricate subject every family deals with differently, some through restriction or portion control practices and others not at all. But with nearly 36% of American adults and around 18% of kids aged 6 to 11 currently classified as obese, it’s an issue that isn’t going away anytime soon, according to the Centers for Disease Control and Prevention (CDC).

And although CDC statistics show signs that the rate of overweight and obesity may be leveling off, this is no time for RDs to rest on this accomplishment, according to Deanna M. Hoelscher, PhD, RD, LD, director of the Michael & Susan Dell Center for Healthy Living and John P. McGovern Professor in Health Promotion and Behavioral Sciences at the University of Texas School of Public Health. “The overall levels of obesity and overweight are beginning to level off among both adults and children. However, the rates of extreme obesity are increasing, so although we’re seeing progress, there’s still a lot to do.”

To simultaneously address adult and child weight issues, more and more weight-loss programs are taking a family-based approach, engaging all family members in education, eating, and physical activity efforts to elicit positive change, and many programs are seeing great success. Research also shows there are benefits to using a family-based approach to weight-loss efforts as well as preventing unhealthful habits.

According to peer-reviewed research and the RDs interviewed here, there seems to be a powerful force that exists within a family unit and, if harnessed appropriately, it can propel both adults and children toward more healthful habits and a happier future.

Importance of the Family Environment
Anne Marie Kuchera, MS, MA, RD, LPC, program manager for the Children’s Hospital of Pittsburgh of UPMC Weight Management & Wellness Center and an adjunct professor in the University of Pittsburgh department of sports medicine and nutrition, says parents’ own food and lifestyle habits as well as the environment they create within their household can go a long way toward promoting either healthful habits or unhealthful ones that can lead to overweight among their children. “Parents are their children’s No. 1 role models, and their personal lifestyle practices have a significant influence on their children, especially for young children, whose parents heavily guide choices and behaviors,” she says. “Additionally, the environment parents create at home will either support—or not support—efforts to make healthful choices.”

“Children see their parents as role models, so they imitate parents’ own food and lifestyle habits,” Hoelscher says, noting that parents act as gatekeepers for their home, controlling access to the foods in the house, foods served as meals and snacks, introduction of new foods, rules about foods, etc.

Katherine W. Bauer, PhD, MS, an assistant professor in the department of public health and the Center for Obesity Research and Education at Temple University in Philadelphia, has focused much of her research over the past decade on how the family environment and parent behavior can affect their children’s eating and lifestyle habits. Thus far, she says researchers have identified several components that seem to make a big difference. “We know if parents have healthier options easily accessible in the home and if they serve healthier food at meals, those background behaviors make a big difference to what kids are eating,” she says. “Moving beyond that, for a long time I think we thought that it mattered more what a parent said to a child about eating and not so much what a parent was doing themselves, but I’m finding in my research more and more that parent modeling of behavior is very highly correlated with what kids do.”

An unhealthful family-eating environment includes characteristics such as easy access to various processed and otherwise low-nutrient or high-fat foods, unhealthful habits such as watching TV during mealtimes, and otherwise unstructured mealtimes, Hoelscher says.

Conversely, Bauer says research is showing that having lots of healthful options, such as fruits, vegetables, whole grains, and low-fat dairy foods available front and center in a home, not hidden somewhere like the back of a cupboard, is critical for instilling healthful habits in children.1,2

Bauer also stresses the importance of family mealtimes. “We’re seeing more and more consistently how important family meals are,” she says, noting that this doesn’t necessarily mean dinner, though much early research has focused on that meal. “There was a recent study about the importance of family breakfast. Really, whenever families can find the time to sit down together, it seems to be a good thing,” she adds, noting that mealtimes are a great opportunity for parents to showcase healthful modeling behaviors. “Parents showing that they’re enjoying food, having a variety of food on their plate, and showing that [healthful foods] taste good, that’s all important. So I think the take-away message is that kids are watching what their parents are eating and how active their parents are, and that’s part of the whole family environment. My hypothesis is, and it’s been proven in some treatment studies, that it’s going to be really hard to change a child’s behavior if a parent isn’t willing to change themselves.”

Characteristics of a Family-Based Program
Research clearly shows that getting an entire family involved in a weight-loss program potentially could make greater inroads than addressing either a child or parent alone.2-4 But family involvement won’t guarantee success on its own, says Lori Rosenthal, MS, RD, CDN, a bariatric surgery dietitian in the department of surgery at Montefiore Medical Center in New York City. “The programs have to contain the right components to facilitate the development of lifelong healthful dietary/lifestyle changes for all, and the family members have to be ready to change,” she says.

So what components make a successful family-based weight loss program? According to Hoelscher, a successful family-based weight-loss program should include evidence-based recommendations, including the following key characteristics:

• activities that are appropriate for the child’s developmental level;

• involvement by both the parent and the child;

• the use of behaviorally based strategies or techniques that emphasize building skills and self-confidence as well as knowledge;

• educational messages on diet, physical activity, sedentary behaviors, stress, and sleep;

• positive reinforcement through group social support or home environmental changes; and

• a significant time commitment.

“Programs that are successful also should focus on parenting practices as well as checking in with the children about self-image and potential bullying issues from other children,” Hoelscher says, emphasizing that the focus of any such program should be on health, not weight.

Hoelscher says a good family-based program should address both diet and physical activity, teaching nutrition skills and encouraging activity that can be practiced over the long term. “A good program will spend more time teaching and practicing nutrition and food-related skills but should spend significant time actually getting the children to move through planned physical activity,” she explains.

In addition, Hoelscher notes that any weight-loss or weight-control program involving children should include a process to obtain physician approval before the program begins. “Children and their families should check in with their medical home and physician, just to be sure that there are no contraindications to physical activity or any steps that need to be taken to make the activities safe,” she says.

According to Kuchera, one key message of the Children’s Hospital of Pittsburgh of UPMC’s family-based pediatric weight management program, Healthy Habits 4 Life, relates to creating a supportive home environment and includes the following recommendations (many drawn from the research findings described above):

• Make plenty of healthful foods available to eat and within easy reach.

• Remove most foods from the home that are high in fat or sugar and are low in nutritional value or are especially tempting to eat in excessive amounts. Instead, go out for treats on occasion or keep just a small number in the home for special occasions.

• Make physical activity a regular part of your family’s routine.

• Enjoy meals at home on most days of the week (at least one meal per day).

• Praise your child for making healthful choices.

“We also suggest establishing healthy boundaries by limiting screen time to no more than two hours per day, establishing a structure of three meals and one to two snacks per day, limiting eating to the kitchen or dining area, and turning the television off during meals,” she says.

The Brenner FIT Program
Katie Boles, RD, LDN, is a dietitian at one such family-based weight-loss program. Brenner FIT (Families in Training) with Brenner Children’s Hospital at Wake Forest Baptist Medical Center in North Carolina is a multidisciplinary team of health care professionals that has been providing research-based care to children and families with weight problems for the past six years. Comprised of pediatricians, behavioral counselors, dietitians, physical therapists, social workers, and exercise specialists, the program is based on family systems theory, which Boles says helps to look at the family unit and how the family influences each other in a new way.

“The family is a unit, and everyone defines the family very differently,” she says. “So we automatically think of parents and kids, but there are many other people that influence a child.” Boles says every “family” that joins the Brenner program is different, and while many include parents with their children, others also include grandparents, friends, or even peers—whoever children see as their family.
“In the Brenner FIT program, we focus on the entire family because the lifestyle habits of everyone in the home as well as other influential people in a child’s life can have an effect on the habits and weight of children,” Boles says.

The program includes three tiers: nutrition; physical activity, which is focused more around play than exercise; and a scheduling and routine tier that’s led primarily by a family counselor. “All of these have to work together for weight loss to happen,” she says.

And while weight loss may be a family goal, the program is customized to each family and uses motivational interviewing practices so each family defines its own goals and guides its own treatment process. “Our staff doesn’t choose what the family should focus on,” Boles says. “We can support the family in what they’re interested in choosing, but the family drives their health behavior goals. Having a mixture of both diet and physical activity would be great, but that isn’t always the case.”

Essentially, the Brenner FIT program doesn’t like to focus on weight at all because weight loss can be a short-term solution. “The focus of Brenner FIT is more on changing health behavior habits than promoting weight loss,” Boles explains. “Weight maintenance or loss may or may not come with improving health behavior habits. However, if everyone is working on changing health behavior habits together, both children and parents are more successful because they have family members holding them accountable and doing it together.”

Boles says she has found that encouraging healthful eating behaviors rather than focusing on specific portion sizes can be much more successful over the long term. “Every time we restrict, that often works short-term but isn’t a good long-term strategy,” she says. “Sometimes we can get so focused on certain recommendations, like a palm size of meat, when in reality, a person may be way more hungry at that meal and if we could instead focus on mindful eating practices to teach them to pay attention to their hunger cues, their body would tell them how much to eat.”

Brenner FIT bases its guidelines on Ellyn Satter’s model called the division of responsibility in feeding, which defines the parents’ role in feeding children and the children’s role in eating. “What she says is that parents are responsible for what time everyone eats, where it’s going to happen, and then the actual food that’s provided,” Boles says. “And once parents do the what, when, and where, then children can naturally figure out how much to eat or whether they want to eat a particular food at all. But the moment parents start restricting or pushing food on children, kids begin pushing back.”

The Brenner FIT program offers all participants a variety of different educational opportunities, such as cooking, self-esteem, and various activity classes, and families come in for a follow-up clinic visit every two weeks, where they meet with all members of the health care team (besides the pediatrician, who only sees kids every four months). And while it’s usually a child who’s referred to the program for overweight or obesity, the program is designed to include all family members in everything it offers, whether it’s weight and height measurements, clinic visits, goal-setting, or classes.

Though every family is different, Boles says she likes to see most families in the program for 12 to 15 months. “That’s three months of taking classes and 12 months of clinic visits with a dietitian, a family counselor, an exercise specialist, and our pediatrician. So we’re all working together with each family to offer the support and guidance that each family needs,” she explains.

Instead of measuring a family’s success on weight loss alone, Boles says the program also looks at behavior goals accomplished, such as a family eating together routinely as well as improvement in lab values such as blood pressure. “Overall, we define success [by focusing] more on behavior change rather than simply changing weight,” she says.

It’s those healthful behavior changes that Boles hopes will follow families into their foreseeable future.

— Juliann Schaeffer is a freelance writer and editor based in Alburtis, Pennsylvania, and a frequent contributor to Today’s Dietitian.


6 Tips for Success
If you’re interested in either getting involved in a family-based weight-loss program or offering family-based services, the following six strategies from RDs who have experience with the process can help you get started.

1. Take baby steps to produce big changes. “As RDs, we have a lot of valuable information to share,” says Anne Marie Kuchera, MS, MA, RD, LPC, program manager for the Children’s Hospital of Pittsburgh of UPMC Weight Management & Wellness Center. “At the same time, too much information can be overwhelming to families. Offering information and advice in small ‘chunks’ is more helpful.”

Katie Boles, RD, LDN, a dietitian at the Brenner FIT program with Brenner Children’s Hospital at Wake Forest Baptist Medical Center, agrees: “Let’s say a family wants to work on schedule and routine. We might try to focus on getting one meal on the table at whatever time works for them vs. trying to address an entire day at one time. So have a family make a list of all the things they’re interested in doing and then start with one of those goals. Once that goal becomes a habit, then move to another. An all-or-nothing mentality doesn’t work because it so often can go from all to nothing.”

2. Have sensitivity while communicating. “It’s important to consider that the way parents feed their children is intensely personal,” Kuchera says. “How we communicate with parents is extremely important. This includes using our best listening skills, expressing empathy for the many challenges parents experience, affirming strengths, and asking permission to give advice.”

3. Emphasize fun over education. Making healthful eating and physical activity fun is the key to getting children, adolescents, and adults engaged in a weight-loss program, says Lori Rosenthal, MS, RD, CDN, a bariatric surgery dietitian in the department of surgery at Montefiore Medical Center. Suggest parents turn a walk or a hike into a quest for who can find the most pinecones or have parents play video games that involve physical activity with their children.

“Turn a trip to the grocery store into a game,” she suggests as one way to make healthful eating more fun for kids. “Try playing I Spy. Have your kids spot and help choose the fruits and vegetables on your shopping list. It’s fun, familiarizes children with healthful foods, and makes them more likely to try some.”

4. Focus on health, not weight. “The focus of any program needs to be on health and wellness, not weight,” Rosenthal says. “Focusing on weight can lead to the development of poor body images and disordered eating behaviors, especially in children and adolescents.”

Katherine W. Bauer, PhD, MS, an assistant professor in the department of public health and the Center for Obesity Research and Education at Temple University, agrees, and says parents should show kids how to prioritize health with their actions, not their words. “Behaviors speak much louder than your words when it comes to eating and exercise,” she says.

5. Get help when you need it. Boles encourages dietitians to determine their strengths and seek support when and where they need it, which she herself experienced firsthand when trying to offer family-based services on her own before joining the Brenner FIT program. “I realized that as a dietitian I couldn’t do it on my own,” she says. “Having that family counselor there is so incredibly necessary because there are so many other things happening that affect what a family eats and why I can’t do without a counseling degree.”

Whether it’s a pediatrician, a family marriage therapist, a family counselor, or even a social worker, Boles encourages dietitians to seek support for services that might be outside of their nutrition scope.

6. Count every detail. Remind clients that it doesn’t always take big actions that require lots of effort to elicit positive change toward more healthful behaviors. “Remember,” Rosenthal says, “even a simple act, such as a parent smiling while eating fruits and vegetables, can enroll a child in healthful eating.”

— JS


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2. Golan M, Crow S. Parents are key players in the prevention and treatment of weight-related problems. Nutr Rev. 2004;62(1):39-50.

3. Golan M. Parents as agents of change in childhood obesity—from research to practice. Int J Pediatr Obes. 2006;1(2):66-76.

4. Holland JC, Kolko RP, Stein RI, et al. Modifications in parent feeding practices and child diet during family-based behavioral treatment improve child zBMI. Obesity (Silver Spring). 2014;Epub ahead of print.