Abstract:
Many family-based treatments for pediatric obesity teach specific parenting practices related to weight management. Although youth in these programs show increases in positive health behaviors and reductions in the extent to which they are overweight, most remain overweight after treatment. A recent trend is to create tailored programs for subgroups of families. We examine the possibility of tailoring based on family context, highlighting 3 aspects of family context that have been studied in relation to pediatric obesity: parenting style, family stress, and family emotional climate. We argue that family context may moderate treatment outcomes by altering the effectiveness of health-related parenting practices and discuss the implications of this argument for designing and evaluating tailored programs.
Key Words: families and health/illness, family context, parenting practices, pediatric obesity, treatment.
Recent data collected as part of the National Health and Nutrition Examination Survey revealed that approximately one third of youth aged 2 - 19 years are overweight or at risk for becoming overweight (Ogden et al., 2006). In the past 30 years, these rates have more than doubled among children and tripled among adolescents, with the highest rates among African American, Hispanic, and Native American youth (Ogden et al., 2006). Although in colloquial terms the label 'overweight' may reflect a wide range of above-average sizes, in medical settings this term is used to identify youth who are significantly, and dangerously, larger than their ideal weight.
Like adults, youth are commonly classified as overweight on the basis of their body mass index (BMI), calculated as the ratio kg/m^sup 2^, for which percentile scores are reported based on gender and age. Youth aged 2 - 19 years whose scores are above the 95th percentile are classified as overweight by the Centers for Disease Control and Prevention (CDC); the American Medical Association (AMA) labels these same youth as obese. Youth who score between the 85th and the 95th percentile are described as at risk for becoming overweight (by the CDC criteria) or at risk for becoming obese (by the AMA criteria). For example, a 10-year-old girl of average height (4 ft 7 in.) who weighed 74 pounds would have a BMI at the 50th percentile for her age and gender; at 88 pounds, her BMI would be at the 85th percentile and thus in the 'at-risk' range, and at 101 pounds, the BMI would be at the 95th percentile and in the overweight range according to the CDC criteria.
The widespread prevalence of pediatric obesity is of great social concern given that overweight youth are at risk for a wide range of health problems, both as children and as adults, as well as difficulties in psychosocial functioning (Jelalian & Mehlenbeck, 2003). Children who are relatively heavy at age 5 or 6 are at significantly greater risk for obesity in early adulthood than are children whose size is average or lean (Whitaker, Wright, Pepe, Seidel, & Dietz, 1998). Youth who are overweight are also at increased risk for developing significant health complications such as hyperlipidemia, hypertension, sleep apnea, orthopedic complications, and elevated insulin levels (Dietz, 1998). On average, youth who are overweight have a lower health-related quality of life (Schwimmer, Burwinkle, & Varni, 2003), a higher risk for social difficulties (Epstein, Myers, & Anderson, 1996), and lower self-esteem (Zeller, Saelens, Roehrig, Kirk, & Daniels, 2004) compared to youth of normal weight.
Pediatric Obesity and Family-Based Treatment
The risks facing youth who are overweight highlight the need for effective treatment. Our concern in this paper focuses on the efficacy of family-based programs for pediatric obesity. Family-based programs are common in the treatment of pediatric obesity (St. Jeor, Perumean-Chaney, Sigman-Grant, Williams, & Foreyt, 2002) and have been shown to be effective relative to no-treatment controls (Haddock, Shadish, Klesges, & Stein, 1994). These programs vary somewhat in format and in specific goals (McLean, Griffin, Toney, & Hardeman, 2003) but share the assumption that the best outcomes will be seen when treatment targets the behavior of multiple family members, most notably the parents (Jelalian & Saelens, 1999).
For the most part, family-based interventions for pediatric obesity have a behavioral or cognitive-behavioral focus, and a majority of these programs target elementary school-age children from the ages of about 6 to 13 years (Kitzmann & Beech, 2006). Parents are encouraged to use specific parenting practices such as those recommended by the Expert Committee on the Assessment, Prevention and Treatment of Child and Adolescent Overweight and Obesity, a panel convened by the AMA (Barlow & The Expert Committee, in press). These parenting practices include establishing regular times for meals and snacks, avoiding the use of food as a reward, and serving as a role model for healthy eating and exercise (St. Jeor et al., 2002). Many programs teach the 'Traffic Light' diet (Epstein, Myers, Raynor, & Saelens, 1998), encouraging family members to eat as much as they want of low-calorie 'green' foods such as fruits and vegetables, to eat 'yellow' foods such as grains, dairy, and proteins in moderation, and to eat limited amounts of high-fat, high-sugar, or low-nutrient density 'red' foods. These programs also commonly emphasize family lifestyle changes such as being active as a way to be healthy and fit, not just to lose weight (e.g., Epstein, Paluch, Gordy, & Dorn, 2000).
Although there is promising evidence in support of family-based treatments for pediatric obesity, there is also room for improvement. Youth who make progress in family treatment are often still overweight compared to their healthy peers (Epstein et al., 1998), and most studies document only shortterm outcomes (Jelalian & Saelens, 1999). In the search for more effective treatments, some are calling for interventions to be tailored to fit the needs of diverse patients rather than using a 'one-size-fits-all' approach (Brownell & Wadden, 1991; Epstein et al., 1998; Faith, Saelens, Wilfley, & Allison, 2001). Examples include Girls' Health Enrichment Multi-Site Study, a family-based weight gain prevention program for African American girls (Beech et al., 2003); Hip-Hop to Health Jr., an intervention targeting minority preschool children (Fitzgibbon et al., 2006); and a family-based treatment for children who are severely overweight (Levine, Ringham, Kalarchian, Wisniewski, & Marcus, 2001).
In the current review, we consider the potential utility of tailoring treatments for pediatric obesity on the basis of characteristics of the family context. Our focus on family context is consistent with the recent emphasis on systemic and ecological models of children's health (Kazak, Simms, & Rourke, 2002; Wood & Miller, 2005) and of pediatric obesity in particular (Davison & Birch, 2001). It is our contention that when family context is taken into account, treatments can be tailored to address the needs of families who might otherwise fail to benefit from a generic family-based program (Kitzmann & Beech, 2006).
Family Context, Pediatric Obesity, and Treatment Outcomes
What is meant by the term family context? This term, like the related term family functioning, has been used to refer to a wide range of family characteristics and patterns of interaction that provide the context for child socialization. The assumption that family context is a multidimensional construct is apparent in the most commonly used measures of family functioning. Examples include the Family Assessment Device, which assesses family problem solving, communication, roles, affective responsiveness, affective involvement, and behavioral control (Epstein, Baldwin, & Bishop, 1983); and the Family Adaptability and Cohesion Evaluation Scales, which assess family cohesion, family adaptability, and family communication (Olson, Portner, & Lavee, 1985). Parents' characteristic styles of interacting with their children also contribute to family context, with child socialization being shaped by the dialectic between family patterns and parent-child relationship patterns (Hinde, 1989). Thus, family context has been operationalized by a range of variables, with some conceptual overlap among them.
Multiple dimensions of family context are assumed to interact to influence the health of children and adolescents (Wood & Miller, 2005), including their weight (Zeller et al., 2007). However, only a few of these dimensions have been empirically studied in relation to pediatric obesity. We have organized these dimensions in three categories: those related to (a) parenting style, (b) family stress, and (c) family emotional climate. We recognize that these categories do not represent all aspects of family context, but they do reflect three aspects that have been studied to date in research on pediatric weight.
Our emphasis here is on how these examples of family context may promote or hinder the progress made by youth being treated for weight problems. Essentially, we are interested in family context as a moderator of treatment effects. The process of moderation is illustrated in Figure 1. This figure encompasses two ideas. The first idea is that parenting practices that are taught in family-based programs for pediatric obesity (such as serving meals only at the table and engaging children in food preparation) should be associated with positive treatment outcomes (assessed in terms of the degree to which the child or adolescent is overweight but also in terms of weight-related health behaviors such as healthy eating and exercise). The second idea represented in Figure 1 is that family context (e.g., parenting style, family stress, and family emotional climate) should moderate the association between parenting practices and child outcomes. Moderation implies that the strength of the association between parenting practices and treatment outcomes will depend on the family context in which the parenting practices are enacted. For example, parents may invite children to participate in food preparation, but the effects of this specific parenting practice on children's weight management would be expected to vary depending on family context. The activity might be quite successful in families who are already used to interacting together and enjoy spending time with one anodier; in this case, the activity may be an effective way for the child to learn to select and prepare healthy foods. By contrast, this same parenting practice may have few beneficial effects in a family that is more disengaged or conflictual.
The interrelations among parenting practices, child outcomes, and family context are likely to be much more complex than portrayed by Figure 1 and may include both bidirectional influences and processes of mediation. We believe that our focus on moderation has heuristic value as a first step in examining variables and processes that are relevant for tailoring family-based programs to meet the needs of certain subsets of families. If family context moderates treatment outcomes by increasing or decreasing the effectiveness of health-related parenting practices taught in many family-based programs for pediatric obesity, then interventions that teach weight-related parenting practices can be tailored to take into account the family context in which these practices are enacted at home.
In the following sections, we highlight three examples of family context that have been studied in relation to pediatric obesity: parenting style, family stress, and family emotional climate. Ultimately, we are interested in the extent to which each of these examples of family context may moderate treatment outcomes. The most straightforward evidence of moderation would be in the form of statistical tests of the interaction between parenting practices (the independent variable) and family context (the moderator) in the prediction of treatment outcomes (the dependent variable). However, no study to date has direcdy tested family context as a moderator of treatment outcomes. Therefore, the evidence reported here is based primarily on simple correlations among variables. First, we report evidence that characteristics of the family context are associated with weight problems in youth. We also discuss hypothesized mechanisms of these associations, including processes of causation, reverse causation, and bidirectional influence. These mechanisms or mediational processes are not our main focus, but they are mentioned as a way to interpret the correlations reported in the literature. Second, we report the results of research testing correlations between family context and treatment outcomes.
Parenting Style
Parenting style, characterized by the degree of parental firmness and responsiveness (Baumrind, 1989), has been defined as a 'constellation of attitudes toward the child that are communicated to the child, and that taken together, create an emotional climate in which the parent's behaviors are expressed' (Darling & Steinberg, 1993, p. 348). Parenting style and parenting practices are considered distinct constructs, with parenting style serving as a context that moderates the influence of specific parenting practices (Darling & Steinberg). Most researchers conceptualize parenting style in terms of four prototypes (Baumrind; Maccoby & Martin, 1983): Authoritative parents demonstrate high levels of demandingness balanced by high responsiveness; authoritarian parents are demanding but provide low levels of responsiveness; permissive parents are less demanding but highly responsive; and disengaged parents show low levels of both dimensions. Authoritative parenting is generally considered the most helpful for child socialization (Baumrind).
Parenting style and pediatric obesity. There are strong conceptual reasons to expect that parenting style should be related to the management of children's health behaviors, and empirical evidence suggests that an authoritative parenting style promotes more positive health behaviors in children (Tinsley, Markey, Ericksen, Ortiz, & Kwasman, 2002). One possible mechanism of this association is through the effects of parenting style on the development of children's self-regulation. Authoritative parenting seems to provide the structure and support needed for children to internalize and maintain positive behaviors, whereas nonauthoritative parenting may interfere with children's ability to learn self-regulation (Grolnick & Farkas, 2002), including the selfregulation of eating (Davison & Birch, 2001).
Indeed, research suggests a correlation between adolescents' reports of authoritative parenting and their eating and activity patterns. Dutch adolescents (ages 16-17 years) who described their parents as authoritative reported eating significandy more fruit than those who described dieir parents as nonauthoritative (Kremers, Brug, de Vries, & Engels, 2003). Similarly, Schmitz et al. (2002) found that female (but not male) adolescents aged 11-15 years who described their mothers as authoritative also reported higher physical activity and fewer sedentary habits. However, Gable and Lutz (2000), using parent responses on the Child-Rearing Practices Report, found no association between authoritative or authoritarian parenting and the physical activity or sedentary behavior of children aged 3-10 years. In these cases, parenting style is assumed to shape children's weight-related healdi behaviors, although conceptually a reverse pattern of causation may also be possible. That is, youths' problematic patterns of overeating and sedentary behavior may elicit parenting that is less authoritative over time.
There is mixed evidence on the question of whether parenting style is associated with a lower risk for obesity. The National Institute of Child Health and Human Development Study of Early Child Care and Youdi Development used a combination of observational and self-report data to assess parenting style when children (N = 872) were 54 months old in order to predict their weight status as first graders. Compared to children whose mothers showed authoritative parenting, children of authoritarian mothers had an almost five times higher risk of being overweight and children of permissive and neglectful mothers had almost a three times higher risk (Rhee, Lumeng, Appugliese, Kaciroti, & Bradley, 2006). However, smaller studies, using selfreported parenting style, have failed to find these associations. Agras, Hammer, McNicholas, and Kraemer (2004) found that parenting style as assessed by the Parental Authority Questionnaire was uncorrelated with children's risk for obesity at age 9.5; by contrast, low parent concern about the child's weight was a significant predictor of the child's weight status. Gable and Lutz (2000) found that parents' self-reported authoritative and authoritarian styles did not distinguish obese from nonobese children.
Parenting style and the treatment of pediatric obesity. We would expect that the effectiveness of parenting practices taught in family-based treatment programs to be moderated by parenting style, with the authoritative parent being more effective than the nonaudioritative parent in enacting these practices and fostering family members' lifestyle changes. However, limited research has examined parenting style as it relates to the treatment of pediatric obesity. Golan (2006) reported that a permissive parenting style was correlated with fewer reductions in the availability of fattening foods at home and lower weight loss in 6- to 11-year-old children whose parents were involved in a family-based public health intervention. Other research suggests that positive dimensions of parenting style may predict progress in treatment. Stein, Epstein, Raynor, Kilanowski, and Paluch (2005) used the Children's Report of Parental Behavior Inventory to assess three dimensions of parenting style: acceptance versus rejection, psychological control versus autonomy, and firm versus lax control. Only the first of these dimensions emerged as significantly associated with other treatment-related variables in their evaluation of a family-based intervention with 6- to 12-year-olds. Increases in fathers' acceptance over the course of treatment were significandy correlated with decreases in the child's percent overweight. It should be noted, however, that the researchers considered each dimension of parenting style in isolation, meaning that this measure of parental acceptance may be best described as a measure of parent support rather than parenting style per se.
Two other lines of evidence provide indirect support for the idea that parenting style may moderate the effectiveness of treatments for pediatric obesity. First, programs targeting the parent as the 'exclusive agent of change' have emphasized the importance of an authoritative parenting style, with an emphasis on the parent being an effective authority figure who supports and directs the child's weight management (Golan, 2006). Research on these programs has shown significantly lower dropout and better weight loss both in comparison to programs without parent involvement and in comparison to treatment targeting parents and children together (Golan). Second, Epstein, McKenzie, Valoski, Klein, and Wing (1994) found significantly greater weight loss in children whose parents received additional training in general parenting skills, relative to parents who received training only in basic behavior management of weight-related behaviors. However, other familybased treatments for pediatric obesity have found die benefits of general parenting training to be apparent only briefly (Aragona, Cassidy, & Drabman, 1975) or not at all (Israel, Stolmaker, & Andrian, 1985).
Family Stress
Stress is generally associated with poorer health behaviors, poorer health outcomes, and poorer adherence to medical treatment in part because of its disruptive impact on health-related routines (Wood & Miller, 2005). Here, we focus on stress as a correlate of pediatric obesity and as a possible influence on the treatment of this condition. How might family stress increase a child's risk for obesity? One hypothesized mechanism is the psychophysiological pathway by which stress-related emotional arousal is accompanied by increases in corticosteroids and catecholamines, in turn affecting fat storage and blood sugar levels (Campbell, 2003; Lissau & Sorensen, 1994). Family stress may also affect children through its disruptive impact on health behaviors. One example is that parents who are under stress because of long work hours or other commitments may have less time to prepare healthy meals (Davison & Birch, 2001) and presumably also to monitor physical activity and sedentary behavior.
Although most research conceptualizes stress as a contributor to illness, the reverse may also be true: pediatric illness in itself can be a stressor for families. Pediatric obesity is a chronic condition that can potentially be disruptive in family life. Both the illness and its treatment can create stress for the family. The child who is overweight may show restricted ability to participate in physical activities with the family, place demands on the family's food resources, and develop associated health problems requiring treatment. Initiating treatment for pediatric obesity may also be stressful for the family as treatment requires adjustment to new routines such as eating family meals at the table, eliminating calorie-dense foods, making sure that healthy foods are available to prepare at home, making time for physical activity, and reducing sedentary behaviors such as TV watching and video games. These changes create new and potentially stressful dynamics in family relationships, especially if parents have low confidence in their ability to facilitate treatment or feel uncomfortable giving their child suggestions or directives about weight management.
Family stress and pediatric obesity. No research to date has directly examined the correlation between family stress and child obesity. Indirect evidence about the effects of stress can be found in research on socioeconomic status (SES), as low SES is associated with more stressful living conditions (Baum, Garofalo, & Yali, 1999). Low-SES families also experience stress related to lower access to health insurance and medical care, particularly in minority populations (Kirby, Taliaferro, & Zuvekas, 2006). Importantly, children from low-SES families are at higher risk to become overweight (Vieweg, Johnston, Lanier, Fernandez, & Pandurangi, 2007). Low-SES families may have limited access to resources such as transportation and finances needed to buy, prepare, and store healthy meals at home. In addition, the design of urban neighborhoods can limit opportunities for physical activity and time outdoors (Saelens, Sallis, & Frank, 2003). In sum, there is emerging evidence suggesting that because of higher family stress levels, it may be more difficult for low-SES families to engage in positive weight-related health behaviors than for families of higher SES (Germann, Kirschenbaum, & Rich, 2007).
Family stress and the treatment of pediatric obesity. Families who have high levels of stress may find it difficult to access and participate in treatment because of the many demands on the family's time, energy, and other resources. By contrast, we would assume that treatment for pediatric obesity should be maximally effective under conditions of low family stress. Germann et al. (2007) evaluated a family-based program in which low-income minority parents and youth (average age 13 years) used self-monitoring to keep track of their eating and physical activity. Those families with lower levels of stress were more likely to adhere to the self-monitoring program and less likely to drop out of the treatment than the higher stress families. These results, although not extensive, suggest possible benefits of tailoring family-based treatments on the basis of level of family stress.
Emotional Climate
Finally, we examine emotional climate as a contextual influence on parenting practices related to children's overweight. Our focus on emotional climate is consistent with Repetti, Taylor, and seeman's (2002) argument that family social environments are important predictors of children's mental and physical health. Repetti et al. described 'risky families' as those characterized by relationships that are conflictual, cold, unsupportive, and neglectful, and they posit that these family characteristics create vulnerabilities for children or interact with children's physical vulnerabilities to disrupt healthy functioning. As in the case of family stress, discussed in the previous section, the hypothesized mechanisms of these effects are through the physiological stress response and through disruptions in health behaviors. Others have noted bidirectional influences by which the development, diagnosis, or expression of the illness engenders negative changes in the family's emotional climate (Fisher, 2005). We focus here on three aspects of emotional climate that have been studied in terms of their relation to pediatric obesity: conflict, support, and cohesion.
Emotional climate and pediatric obesity. Research on family conflict has produced mixed results with respect to links between conflict and pediatric obesity. Zeller et al. (2007) assessed family functioning using parents' responses to the Family Environment Scale (FES) and to a questionnaire about family interactions at mealtimes. Mothers of obese youth aged 8-16 years reported significantly higher family conflict in general and more parent-child conflict about eating compared to mothers of youth who were not overweight (Zeller et al., 2007). Beck and Terry (1985) also found higher FES conflict scores in families of obese 8- to 12-year-olds compared to children of the same age-group who were of normal weight. In a comparison of underweight, normal weight, overweight, and obese adolescents, however, Mendelson, White, and Schliecker (1995) found no difference in family conflict as measured by modiers' and adolescents' responses to the Self-Report Measure of Family Functioning. These mixed results may reflect age differences across the three samples; by adolescence, youths' weight problems may be less influenced by family conflict than would be true for younger children. Methodological issues are also important in interpreting these results. Mendelson et al.'s use of four rather than two weight groups may have limited their chances of detecting weightrelated differences across groups.
Another aspect of family emotional climate is family support, a construct that reflects family members' acceptance, involvement, and concern (Moens, Braet, & Soetens, 2007). In much research, family support is actually defined in terms of parental support for the child, measured in terms of the extent to which the child views the parent as someone to confide in and to look for help in solving problems (Wills & Cleary, 1996). The example of parental support shows some conceptual overlap with parenting style, but there are two reasons that we consider parental support and parenting style separately. First, parenting style is a multidimensional construct that encompasses much more than the presence or absence of parental support. Second, researchers themselves vary in terms of whether or not they conceptualize parental support in terms of styles of parenting. In this section, we review studies in which the researchers' conceptualization of parent support did not refer to parenting style.
Longitudinal research on more than 800 children aged 9-10 years showed that teachers' perceptions of low parental support were uncorrelated with the child's concurrent weight status but did predict the child's risk for obesity 10 years later (Lissau & Sorensen, 1994). This suggests the possibility that in a community sample, low parent support has a cumulative effect on children's health behaviors over time, evidenced in weight problems by young adulthood. Other cross-sectional research suggests that findings may vary based on the source of information about the family. Zeller et al. (2007) found no difference in the level of family support reported by parents of obese children compared to parents of normal-weight children of the same age (8-16 years). Similarly, Moens et al. (2007) found that parents of overweight children aged 7-13 years did not differ from other parents in terms of their selfreported levels of support for their child. However, observations during mealtimes showed that these parents demonstrated lower support than other parents. Lower parent support was also reported by overweight females in late adolescence, who described their fathers as less caring relative to the views of a normal-weight comparison group (Turner, Rose, & Cooper, 2005). Together, these results suggest that whereas parents of overweight youth do not see diemselves as any less supportive than parents of normalweight youth, observers and the youth themselves may view these parents as relatively less supportive.
Finally, family emotional climate reflects in part the family's level of cohesion-the degree of engagement versus autonomy among family members (Maynard & Olson, 1987). Two studies suggest that families of overweight youth may be less cohesive than other families according to parent report. Beck and Terry (1985) compared families with overweight parents and overweight children to families in which both parents and children (aged 8-12 years) were of normal weight. Reports on the FES indicated that the overweight parents of overweight children viewed their families as less cohesive relative to parents in the comparison group. Banis et al. (1988) also used the FES to measure cohesion and found that families of obese children aged 7-12 years were less cohesive compared to ratings provided by parents in the normative sample. However, Stradmeijer, Bosch, Koops, and Seidell (2000) found that cohesion scores on the Family Dimension Scale did not distinguish ratings provided by mothers of moderately overweight versus severely overweight youth (aged 10 16 years). In only one study were obese youth asked to report on family cohesion. Mendelson et al. (1995) found that overweight female (but not male) adolescents reported lower family cohesion relative to a normal-weight comparison group. The researchers speculated that family members have more negative attitudes about weight problems in women than in men, and these attitudes are more damaging for family cohesion in the families of overweight female adolescents relative to their male counterparts. This interpretation suggests the possibility of bidirectional influence, in which the adolescent's obesity may create tensions in the family that are expressed through lower cohesion.
Family emotional climate and the treatment of pediatric obesity. Our assumption is that families with a negative emotional climate would likely find it difficult to institute many common elements of family-based treatments for pediatric obesity, such as engaging in family meals at the table and participating in physical activities together. Indeed, research suggests that family emotional climate is associated with children's progress in treatment for obesity, although the direction of cause and effect is unclear. For example, success in treatment for pediatric obesity is predicted by several aspects of family support. Uzark, Becker, Dielman, and Rocchini (1987) found that 10- to 16-year-olds' progress in treatment was significantly correlated with their perception that other family members were also willing to diet. Using a combined data set from four intervention studies with 10-year outcome data, Epstein, Valoski, Wing, and McCurley (1994) found that family support for modifications in eating and activity was significantly correlated with change in percent overweight in samples of children aged 6-12 years. By contrast, Dalton (2006) found that family cohesion scores on the Family Adaptability and Cohesion Evaluation Scales were uncorrelated with change in the weight or waist circumference of a primarily African American sample of children aged 6-12 years during the first 3 months of treatment.
Other research has examined multiple aspects of emotional climate simultaneously to predict outcomes in treatment for pediatric obesity. Kirschenbaum, Harris, and Tomarken (1984) used responses on the FES to create several factor scores to represent aspects of family functioning. Families who had high 'chaos' scores-those who reported being in open conflict and providing little encouragement for individual assertiveness-were more likely to drop out of treatment than families with low scores on this factor. Research also suggests that therapy that targets family relationships (and thus, potentially, family emotional climate) can be helpful in the treatment of pediatric obesity. In a randomized study, family therapy plus conventional treatment involving dietary counseling and pediatrician visits proved more effective than conventional treatment alone (Flodmark, Ohlsson, Ryden, & Sveger, 1993). More recently, Nowicka, Pietrobelli, and Flodmark (in press) found solution-focused family therapy to produce significant increases in family expressiveness, decreases in family chaos, and decreases in children's BMI scores.
Conclusions
A wide range of professionals work with children with weight problems, including pediatricians, nutritionists, dieticians, exercise scientists, social workers, psychologists, and family dierapists. Although parent involvement has been most formalized in familybased treatments, parents are involved to some extent in all approaches to treatment for pediatric obesity. Parents are commonly asked to change specific parenting practices related to children's eating and activity, such as limiting children's TV watching and engaging children in the preparation of healthy foods. We have argued that the success of these parenting practices will depend in part on the family context in which they occur. In this review, we have examined nonaudioritative parenting style, high family stress, and a negative family emotional climate as three examples of family context that may interfere with parents' ability to implement parenting practices commonly promoted in treatments for pediatric obesity. It should be noted that although we addressed each of these examples individually, these three dimensions of family context are likely to be interrelated. Further research is needed to determine the best ways to conceptualize and measure family context as a multidimensional construct.
No research to date has directly examined the moderating effects of family context in the treatment of pediatric obesity. Therefore in the current review, we examined indirect evidence for this assertion in the form of correlational research showing associations between family context and the severity of children's weight problems or between family context and children's progress in treatment. Research findings were not always consistent across studies, but on balance, the evidence suggests that compared to normal-weight children, overweight children are likely to experience more nonauthoritative parenting and more family conflict, as well as lower family support and family cohesion. We note the direction of cause and effect is unclear; the family context may contribute to negative health behaviors associated with obesity, but the child's overweight condition may also engender negative changes in the family context. Either way, these correlations suggest the possibility that families with an overweight child may need additional help in order to be effective in managing children's health behaviors related to weight.
In the treatment of pediatric obesity, success (defined broadly to include variables such as weight change, adherence, and attrition) also appears to be correlated with characteristics of the family context. The evidence reviewed here suggests that treatment is less successful in the context of permissive parenting and more successful in the contexts of low family stress and high family support. However, this conclusion is based on correlational data from a very limited number of studies, none of which directly addressed whether family context moderated treatment outcomes.
How can the results of these studies inform our discussion about the need to tailor programs to meet the needs of diverse families? In the following sections, we outline the logical next steps in applying these ideas to research and practice.
Recommendations for Future Research
Clearly, there is a need for a direct test of the assumption that family context moderates treatment effectiveness. There are two stages to accomplishing this goal. The first stage would be to implement treatment as usual but to obtain information on the family context as part of any pre- and posttreatment data collection. In our earlier discussion of die multidimensionality of the family context construct, we mentioned several questionnaire measures that are commonly used to assess family functioning; observational methods have also been used reliably for this purpose. Statistical analyses could then test whether scores on the family context measure interact with exposure to treatment (the independent variable) in predicting children's outcomes (the dependent variable). This could be accomplished using either regression models (Baron & Kenny, 1986) or analyses of variance (Frazier, Tix, & Barron, 2004).
The next research step would be to tailor an intervention on the basis of family functioning and to evaluate the intervention's efficacy. One way to tailor programs is to develop a treatment specifically for a high-risk group, such as families who show high levels of family stress. Another is to provide different (or more) treatment components depending on level of need, for example, a basic treatment for families experiencing low or average stress and additional support for families experiencing high stress. Although we would expect a tailored intervention to fare better than a nontailored approach, there is always the risk that adding treatment components may take attention away from basic methods that have proven effective.
Recommendations for Applied Work
Practitioners who work with youth and their families can be emboldened by the knowledge that the health behaviors associated with overweight are amenable to change. The basic advice is constant-that is, to maintain a healthy diet, increase physical activity, and reduce sedentary behavior. However, a negative family context may make it more difficult to implement these treatment recommendations. On the basis of our review, we offer the following suggestions for ways that practitioners can increase their attention to family context as a potential influence on the treatment of pediatric obesity.
The most fundamental recommendation is to incorporate questions about family context in the intake interview or other assessments. Initiating discussion about family matters would provide both the interventionist and the family a chance to consider possible stumbling blocks that will interfere with treatment success. Ideally, such discussion would provide a mechanism by which the interventionist could provide support and help the family to problem solve. For example, interventionists may want to screen for potential stressors that contribute to, or may be caused by, the child's overweight status. They can then promote stress reduction by helping families to problem solve issues related to the management of time, transportation, and resources needed to buy and prepare healthy foods, reduce sedentary behaviors, and schedule exercise. In some cases, resources such as transportation, translators, and child care may need to be directly provided in order to facilitate participation in treatment and to minimize program attrition.
Second, practitioners can attend to family context when they make recommendations to clients. For example, the Expert Committee recommendations state that physicians and other healthcare providers can address weight problems in children and adolescents in part by 'encouraging an authoritative parenting style in support of increased physical activity and reduced sedentary behavior, providing tangible and motivational support for children' and by 'discouraging a restrictive parenting style regarding child eating' (Barlow & The Expert Committee, in press). To increase the chance that these recommendations would in fact be implemented, it may be best first to assess parenting style and the family's characteristic ways of providing support. This would provide information to both the practitioner and the family about how much and what types of changes would be needed to meet these guidelines.
The practitioner can also consider either including a family-oriented professional on the interdisciplinary treatment team or using a family professional as a consultant or as a service provider for families who are struggling. This treatment team member can be introduced in a nonstigmatizing way such as 'someone who can help your family work together to improve your child's health.' Of course, these interventions to target family functioning must be adapted to the demands of the primary care setting (Haley et al., 1998), where the child's medical treatment (not general family functioning) is the foremost concern.
Summary
In this review, we have focused on parenting style, family stress, and family emotional climate as three examples of family context as it may influence the treatment of pediatric obesity. Certainly, this list of family context variables is not exhaustive; the family's readiness to change (Barlow & The Expert Committee, in press), family ethnicity (Davison & Birch, 2001), and child and parent psychiatric problems (Jelalian, Wember, Bungeroth, & Birmaher, 2007) also have been discussed as potentially important contextual influences. There are strong conceptual reasons to predict that these and other examples of family context should influence the success of treatment for pediatric obesity. Further research is needed to determine how the multiple, interrelated dimensions of family context should best be conceptualized and measured. Applied research is also needed to determine if treatment would be more successful when tailored based on characteristics of the family context.
[Reference]
References
Agras, W., Hammer, L., McNicholas, F., & Kraemer, H. (2004). Risk factors for childhood overweight: A prospective study from birth to 9.5 years. Journal of Pediatrics, 145, 20-25.
Aragona, J., Cassidy, J., & Drabman, R. S. (1975). Treating overweight children through parental training and contingency contracting. Journal of Applied Behavioral Analysis, 8, 269-278.
Banis, H. T, Varni, J. W., Wallender, J. L., Korsch, B. M., Jay, S. M., Adler, R., Garcia-Temple, E., & Negrete, V. (1988). Psychological and social adjustment of obese children and their families. Child Care, Health and Development, 14, 157-173.
Barlow, S. E., & The Expert Committee, (in press). Expert committee recommendations on the assessment, prevention, and treatment of child and adolescent overweight and obesity. Pediatrics.
Baron, R. M., & Kenny, D. A. (1986). The moderator-mediatory variable distinction in social psychological research: Conceptual, strategic, and statistical considerations. Journal of Personality and Social Psychology, 51, 1173-1182.
Baum, A. B., Garofalo, J. P., & Yali, A. M. (1999). Socioeconomic status and chronic stress: Does stress account for SES effects on health? Annals of the New York Academy of Sciences, 896, 131-144.
Baumrind, D. (1989). Rearing competent children. In W. Damon (Ed.), Child development today and tomorrow (pp. 349-378). San Francisco: Jossey-Bass.
Beck, S., & Terry, K. (1985). A comparison of obese and normal-weight families' psychological characteristics. American Journal of Family Therapy, 13, 55-59.
Beech, B. M., Klesges, R. C, Kumanyika, S. K., Murray, D. M., Klesges, L., McClanahan, B., Slawson, D., Nunnally, C, Rochon, J., McLainAllen, B., & Pree-Cary, J. (2003). Child- and parent-targeted interventions: The Memphis GEMS pilot study. Ethnicity and Disease, 73(Suppl. 1), 40-53.
Brownell, K. D., & Wadden, T. A. (1991). The heterogeneity of obesity: Fitting treatments to individuals. Behavior Therapy, 22, 153-177.
Campbell, T. (2003). The effectiveness of family interventions for physical Alness. Journal of Marital and Family Therapy, 29, 263-281.
Dalton, W. T. (2006). Family functioning and children's progress in outpatient treatment for overweight. Unpublished dissertation. University of Memphis, Memphis, Tennessee.
Darling, N., & Steinberg, L. (1993). Parenting style as context: An integrative model. Psychological Bulletin, 773, 487-496.
Davison, K. K., & Birch, L. L. (2001). Childhood overweight: A contextual model and recommendations for future research. Obesity Reviews, 2, 159-171.
Dietz, W. H. (1998). Consequences of obesity in youth: Childhood predictors of adult disease. Pediatrics, 101, 518-525.
Epstein, L. H., McKenzie, S. J., Valoski, A., Klein, K. R., & Wing, R. (1994). Effects of mastery criteria and contingent reinforcement for family-based child weight control. Addictive Behaviors, 19, 135145.
Epstein, L. H., Myers, M. D., & Anderson, K. (1996). The association of maternal psychopathology and family socioeconomic status with psychological problems in obese children. Obesity Research, 4, 65-74.
Epstein, L. H., Myers, M. D., Raynor, H. A., & Saelens, B. E. (1998). Treatment of pediatric obesity. Pediatrics, 101, 554-570.
Epstein, L. H., Paluch, R. A., Gordy, C. C, & Dorn, J. (2000). Decreasing sedentary behaviors in treating pediatric obesity. Archives of Pediatric and Adolescent Medicine, 154, 220-226.
Epstein, L. H., Valoski, A., Wing, R.R., & McCurley, J. (1994). Ten-year outcomes of behavioral family-based treatment for childhood obesity. Health Psychology, 13, 373-383.
Epstein, N. B., Baldwin, L. M., & Bishop, D. W. (1983). The McMaster family assessment device. Journal of Marital and Family Therapy, 9, 171-180.
Faith, M. S., Saelens, B. E., Wilfley, D. E., & Allison, D. B. (2001). Behavioral treatment of childhood and adolescent obesity: Current status, challenges, and future directions. In J. K. Thompson & L. Smolak (Eds.), Body image, eating disorders, and obesity in youth: Assessment, prevention, and treatment (pp. 313-340). Washington, DC: American Psychological Association.
Fisher, L. (2005). Using family models in health research: A framework for family intervention in chronic disease. In W. M. Pinsof & J. L. Lebow (Eds.), Family psychology: The art of the science (pp. 549-571). New York: Oxford University Press.
Fitzgibbon, M. L., Stolley, M. R., Schiffer, L., Van Horn, L., KauferChristoffel, K., & Dyer, A. (2006). Hip-Hop to Health Jr. for Latino preschool children. Obesity, 14, 1616-1625.
Flodmark, C, Ohlsson, T., Ryden, O., & Sveger, T. (1993). Prevention of progression to severe obesity in a group of obese schoolchildren treated with family therapy. Pediatrics, 91, 880-884.
Frazier, P. A., Tix, A. P., & Barron, K. E. (2004). Testing moderator and mediator effects in counseling psychology research. Journal of Counseling Psychology, 51, 115-134.
Gable, S., & Lutz, S. (2000). Household, parent, and child contributions to childhood obesity. Family Relations, 49, 293-300.
Germann, J. N., Kirschenbaum, D. S., & Rich, B. H. (2007). Child and parental self-monitoring as determinants of success in the treatment of morbid obesity in low-income minority children. Journal of Pediatric Psychology, 32, 111-121.
Golan, M. (2006). Parents as agents of change in childhood obesityFrom research to practice. International Journal of Pediatric Obesity, 1, 66-76.
Grolnick, W. S., & Farkas, M. (2002). Parenting and the development of children's self-regulation. In M. H. Bornstein (Ed.), Handbook of parenting: Vol. 5. Practical issues in parenting (2nd ed., pp. 89-110). Mahwah, NJ: Lawrence Erlbaum Associates.
Haddock, C. K., Shadish, W. R., Klesges, R. C, & Stein, R. J. (1994). Treatments for childhood and adolescent obesity. Annals of Behavioral Medicine, 16, 235-244.
Haley, W. E., McDaniel, S. H., Bray, J. H, Frank, R G., Heldring, M., Johnson, S. B., Lu, E. G., Reed, G. M., & Wiggins, T. G. (1998). Psychological practice in primary care settings: Practical tips for clinicians. Professional Psychology: Research and Practice, 29, 237-244.
Hinde, R. A. (1989). Reconciling the family systems and the relationship approaches to child development. In K. Kreppner & R. M. Lerner (Eds.), Family systems and life-span development (pp. 149-163). Hillsdale, NJ: Lawrence Erlbaum Associates.
Israel, A. C, Stolmaker, L., & Andrian, C. A. G. (1985). The effects of training parents in general child management skills on a behavioral weight loss program for children. Behavior Therapy, 16, 169-180.
Jelalian, E., & Mehlenbeck, R (2003). Pediatric obesity. In M. C. Roberts (Ed.), Handbook of pediatric psychology (pp. 529-543). New York: The Guilford Press.
Jelalian, E., & Saelens, B. E. (1999). Empirically supported treatments in pediatric psychology: Pediatric obesity. Journal of Pediatric Psychology, 24,223-248.
Jelalian, E., Wember, Y. M., Bungeroth, H, & Birmaher, V. (2007). Practitioner review: Bridging the gap between research and clinical practice in pediatric obesity. Journal of Child Psychology and Psychiatry, 48, 115-127.
Kazak, A. E' Simms, S., & Rourke, M. T. (2002). Family systems practice in pediatric psychology. Journal of Pediatric Psychology, 27, 133-143.
Kirby, J. B., Taliaferro, G' & Zuvekas, S. H. (2006). Explaining racial and ethnic disparities in health care. Medical Care, 44, 1-64-1-72.
Kirschenbaum, D. S., Harris, E. S., & Tomarken, A. J. (1984). Effects of parental involvement in behavioral weight loss therapy for preadolescents. Behavior Therapy, 15, 485-500.
Kitzmann, K. M., & Beech, B. M. (2006). Family-based interventions for pediatric obesity: Methodological and conceptual challenges from family psychology. Journal of Family Psychology, 20, 175-189.
Kremers, S., Brug, J., de Vries, H., & Engels, R (2003). Parenting style and adolescent fruit consumption. Appetite, 41, 43-50.
Levine, M. D., Ringham, R. M., Kalarchian, M. A., Wisniewski, L., & Marcus, M. D. (2001). Is family-based behavioral weight control appropriate for severe pediatric obesity? International Journal of Eating Disorders, 30, 318-328.
Lissau, I., & Sorensen, T. (1994). Parental neglect during childhood and increased risk of obesity in young adulthood. Lancet, 343, 324-327.
Maccoby, E. E., & Martin, J. A (1983). Socialization in the context of the family. Parent-child interaction. In P. H. Mussen (Series Ed.) & E. M. Hetherington (Vol. Ed.), Handbook of child psychology: Vol 4. Socialization, personality, and social development (4th ed., pp. 1-101). New York: Wiley.
Maynard, P. E., & Olson, D. H. (1987). Circumplex model of family systems: A treatment tool in family counseling. Journal of Counseling and Development, 65, 502-504.
McLean, N., Griffin, S., Toney, K., & Hardeman, W. (2003). Family involvement in weight control, weight maintenance and weight-loss interventions: A systematic review of randomised trials. International Journal of Obesity, 27, 987-1005.
Mendelson, B. K, White, D. R., & Schliecker, E. (1995). Adolescents' weight, sex, and family functioning. International Journal of Eating Disorders, 17, 73-79.
Moens, E., Braet, C, & Soetens, B. (2007). Observation of family functioning at mealtime: A comparison between families of children with and without overweight. Journal of Pediatric Psychology, 32, 52-63.
Nowicka, P., Pietrobelli, A., & Flodmark, C. (in press). Low-intensity family therapy intervention is useful in a clinical setting to treat obese and extremely obese children. International Journal of Pediatric Obesity.
Ogden, C. L., Carroll, M. D., Curtin, L. R., McDowell, M. A., Tabak, C. J., & Flegal, K. M. (2006). Prevalence of overweight and obesity in the United States, 1999-2004. Journal of the American Medical Association, 395, 1549-1555.
Olson, D. H., Portner, J., & Lavee, Y. (1985). FACES III. St. Paul: University of Minnesota.
Repetti, R. L., Taylor, S. E., & Seeman, T. E. (2002). Risky families: Family social environments and the mental health and physical health of offspring. Psychological Bulletin, 128, 330-336.
Rhee, K. E., Lumeng, J. C, Appugliese, D. P., Kaciroti, N., & Bradley, R. H. (2006). Parenting styles and overweight status in first grade. Pediatrics, 117, 2047-2054.
Saelens, B. E., Sallis, J. F., & Frank, L. D. (2003). Environmental correlates of walking and cycling: Findings from the transportation, urban design, and planning literatures. Annals of Behavioral Medicine, 25, 80-91.
Schmitz, K. H., Lyde, L. A., Phillips, G. A., Murray, D. M., Birnbaum, A. S., & Kubik, M. Y. (2002). Psychosocial correlates of physical activity and sedentary leisure habits in young adolescents: The Teens Eating for Energy and Nutrition at School study. Preventive Medicine: An International Journal Devoted to Practice and Theory, 34, 266-278.
Schwimmer, J. B., Burwinkle, T. M., & Varni, J. W. (2003). Healthrelated quality of life of severely obese children and adolescents. Journal of the American MedicalAssociation, 289, 1813-1819.
St. Jeor, S. T., Perumean-Chaney, S., Sigman-Grant, M., Williams, C, & Foreyt, J. (2002). Family-based interventions for the treatment of childhood obesity. Journal of the American Dietetic Association, 102, 640-644.
Stein, R. I., Epstein, L. H., Raynor, H. A., Kilanowski, C. K., & Paluch, R. A. (2005). The influence of parenting change on pediatric weight control. Obesity Research, 13, 1749-1755.
Stradmeijer, M., Bosch, J., Koops, W., & Seidell, J. (2000). Family functioning and psychosocial adjustment in overweight youngsters. International Journal of Eating Disorders, 27, 110-114.
Tinsley, B. J., Markey, C. N., Ericksen, A. J., Ortiz, R. V., & Kwasman, A. (2002). Health promotion for parents. In M. H. Bornstein (Ed.), Handbook of parenting: Vol. 5. Practical issues in parenting (2nd ed., pp. 311-328). Mahwah, NJ: Lawrence Erlbaum Associates.
Turner, H. M., Rose, K. S., & Cooper, M. J. (2005). Schema and parental bonding in overweight and non-overweight female adolescents. International Journal of Obesity, 29,381-387.
Uzark, K. C, Becker, M. H, Dielman, T. E., & Rocchini, A. P. (1987). Psychosocial predictors of compliance with a weight control intervention for obese children and adolescents. Journal of Compliance in Health Care, 2, 167-178.
Vieweg, V. R., Johnston, C. H., Lanier, J. O, Fernandez, A, & Pandurangi, A. K. (2007). Correlation between high risk obesity groups and low socioeconomic status in school children. Southern Medical Journal, 100, 8-13.
Whitaker, R. C., Wright, J. A., Pepe, M. S., Seidel, K. D., & Dietz, W. H. (1998). Early adiposity rebound and the risk of adult obesity. Pediatrics, 101, E5.
Wills, T. A., & Cleary, S. D. (1996). How are social support effects mediated? A test with parental support and adolescent substance abuse. Journal of Personality and Social Psychology, 71, 937-952.
Wood, B. L., & Miller, B. D. (2005). Families, health and illness: The search for mechanisms within a systems paradigm. In W. M. Pinsof & J. L. Lebow (Eds.), Family psychology: The art of the science (pp. 493520). New York: Oxford University Press.
Zeller, M. H., Reiter-Purtill, J., Modi, A. C., Butziller, J., Vannatta, K., & Davies, W. H. (2007). Controlled study of critical parent and family factors in the obesigenic environment. Obesity, 15, 126-136.
Zeller, M. H, Saelens, B. E., Roehrig, H., Kirk, S., & Daniels, S. (2004). Psychological adjustment of obese youth presenting for weight management treatment. Obesity Research, 10, 1576-1586.
[Author Affiliation]
Katherine M. Kitzmann
William T. Dalton III
Joanna Buscemi**
[Author Affiliation]
* This work was supported in part by funds from the Center for Applied Psychological Research, University of Memphis. The authors would like to thank Gilbert Parra and Yeh Hsueh for their helpful comments on the manuscript and Stephanie Aring, Heather Gamble, and Ericka Midgett for their work as research assistants.
** Katherine M. Kitzmann is an Associate Professor in the Department of Psychology at the University of Memphis, 202 Psychology Building, Memphis, TN 38152-3230 (k.kitzmann@mail.psyc.memphis.edu). William T. Dalton III is an Assistant Professor in the Department of Psychology at the East Tennessee State University, P. O. Box 70649, Johnson City, TN 37614 (daltonw@mail.etsu.edu). Joanna Buscemi is a Graduate Student in the Department of Psychology at the University of Memphis, 202 Psychology Building, Memphis, TN 38152-3230 (jbuscemi@memphis.edu).
