Obesity Preventionobr_745 114..130

Interventions that involve parents to improvechildren’s weight-related nutrition intake and activitypatterns – what nutrition and activity targets andbehaviour change techniques are associated withintervention effectiveness?

R. K. Golley, G. A. Hendrie, A. Slater and N. Corsini

CSIRO Food and Nutritional Sciences, The

Commonwealth Scientific and Industrial

Research Organisation (CSIRO), Adelaide,

Australia

Received 29 November 2009; revised 18

January 2010; accepted 10 February 2010

Address for correspondence: Ms G Hendrie,

CSIRO Human Nutrition, PO Box 10041,

Adelaide BC, SA 5000, Australia. E-mail:

gilly.hendrie@csiro.au

SummaryParent involvement is an important component of obesity prevention interven-tions. However, the best way to support parents remains unclear. This reviewidentifies interventions targeting parents to improve children’s weight status,dietary and/or activity patterns, examines whether intervention content andbehaviour change techniques employed are associated with effectiveness. Seven-teen studies, in English, 1998–2008, were included. Studies were evaluated by tworeviewers for study quality, nutrition/activity content and behaviour change tech-niques using a validated quality assessment tool and behaviour change techniquetaxonomy. Study findings favoured intervention effectiveness in 11 of 17 studies.Interventions that were considered effective had similar features: better studyquality, parents responsible for participation and implementation, greater paren-tal involvement and inclusion of prompt barrier identification, restructure thehome environment, prompt self-monitoring, prompt specific goal setting behav-iour change techniques. Energy intake/density and food choices were more likelyto be targeted in effective interventions. The number of lifestyle behaviourstargeted did not appear to be associated with effectiveness. Intervention effective-ness was favoured when behaviour change techniques spanned the spectrum ofbehaviour change process. The review provides guidance for researchers to makeinformed decisions on how best to utilize resources in interventions to support andengage parents, and highlights a need for improvement in intervention contentreporting practices.

Keywords: Behaviour change, child, obesity prevention, parent involvement.

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Introduction

Globally, 5–30% of children (1) and 10–70% of adults (2)are overweight or obese. Preventing excess weight gain inchildhood is critical to reducing the prevalence of over-weight and obesity and associated health consequences (1).

Previous child obesity prevention reviews have focusedon the relationship between intervention effectiveness andintervention components (e.g. the presence or absenceof nutrition, activity, behaviour modification or familyinvolvement) (3,4), intervention settings (e.g. school, home)(5), intervention duration (3) or target population (5,6).

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Campbell and Hesketh concluded in their 2007 review ofnine studies targeting young children (0 to 5 years) that‘families can be supported to make effective changes whichseem likely to influence the propensity for fatness in theirchildren’ (5). However, how best to engage and supportparents in obesity prevention interventions across eachstage of childhood remains unclear.

As role models and providers of food and opportunitiesto be active, parents shape children’s weight-related foodand activity behaviours in powerful ways (7). To date childobesity prevention efforts have tended to focus on schools,which while a promising public health intervention setting,has had limited success, particularly long-term (3). Reach-ing the range of settings in which children spend their time– including their homes through their parents – is likely toenhance the long-term impact and sustainability of obesityprevention efforts (3,5). While there is some evidencethat parent involvement and family-targeted interventionsare effective (3,5,8), the best way to engage and supportparents in such interventions remains unclear.

The 2007 Cochrane review of interventions to preventobesity in children concluded that ‘the interventionsemployed to date have, largely, not impacted on weightstatus of children to any significant degree’ (3). Innovativeand effective obesity prevention will require sophisticatedinterventions and evaluation methodology, reflecting themultiple and integrated food and activity behaviours thatinfluence energy balance, and the wider environments inwhich these behaviours occur (3). The 2007 Cochranereview highlights ‘decision makers need much more infor-mation upon which to base policy and programme deci-sions, than has been [reported] in the past’ (3).

While reviews support multi-component interventionsfor child obesity prevention – encompassing nutrition,activity, behaviour modification and family involvement –little attention has been given to the specific strategies ortechniques used to change weight-related food and activitybehaviours in children. There is little literature critiquingthe specific nutrition or activity targets or behaviour changetechniques used in obesity prevention interventions. Thequestion of whether the lifestyle target or behaviour changecontent moderates the effectiveness of child obesity preven-tion interventions remains largely untouched (9). A lack ofconsistent language and systematic categorization of life-style behaviour targets and behaviour change techniqueshas limited the ability to make firm conclusions (9).Abraham and Michie sought to address this limitation bydeveloping and validating a comprehensive taxonomy ofbehaviour change techniques (9). Such taxonomies providea consistent language and novel way of describing inter-ventions that will enable intervention content-based ratherthan study design-based comparison and critique.

Therefore, of interest to this review are the interventiontargets and behaviour change techniques that are relevant

to engaging and supporting parents and modifying thehome setting as a means of preventing excess weight gainand/or improving children’s nutrition and activity behav-iours. The objective of this review is to determine whetherthe food and activity behaviours targeted and behaviourchange techniques employed in family-targeted interven-tions are associated with intervention effectiveness.

Methods

Criteria for considering studies for review

Inclusion criteria

Types of studies. Prospective studies of any duration,evaluating the effectiveness of a researcher-introducedintervention run in parallel with a control or comparisongroup, with outcomes measured at baseline and (at aminimum) post intervention.

Types of participants. Intervention participation involvedat least one parent or caregiver, either with or without theirchild/ren. At least one intervention outcome assessed inchildren aged 1–18 years.

Type of intervention. Interventions including a nutrition oractivity component AND a behaviour change componentwhich intend to increase physical activity, decrease seden-tary activity, change nutrition intake or weight status inchildren AND involving parents or caregivers as a keyparticipant. Parental involvement was defined using thecriteria: able to identify parental exposure to intervention;identify active parental participation (i.e. beyond receipt ofa newsletter or pamphlet), and/or the intervention behav-iour occurs in the home AND parental or home outcomesare assessed. Studies where the intervention targeted fami-lies alone and where families were targeted within a com-prehensive intervention were considered. The studies wherefamilies were targeted alone are considered here.

Types of outcome measures. Studies with at least oneobjectively measured primary outcome or, a subjectiveoutcome assessed using a validated tool. Primary outcomeswere assessed at the child level, and included weight status,or lifestyle behaviours (nutrition and activity level), ormetabolic health markers. Secondary outcomes were deter-minants of children’s lifestyle behaviours, focusing onparental characteristics such as parent or child knowledge;parent and child interactions such as feeding practices;environmental measures such as food availability; and pre-dictors of behaviour change such as self efficacy.

Exclusion criteriaTo focus on recent interventions, studies were limited tothose published in English between 1998 and 2008. Studies

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not applicable to the general population (i.e. pregnancy,lactation, weaning/preterm infants, athletes, weight lossdiets, eating disorders, behavioural/learning difficulties,disabilities, cystic fibrosis, diabetes and asthma) wereexcluded.

Search methods for identification of studies

A three-step search strategy covering both published andunpublished literature was used. A list of search termsand keywords were developed from relevant reviews (4)and refined based on the review aim, lifestyle behavioursof interest (10) and behaviour change technique framework(9). An information specialist refined this list, with searchterms developed and combined under the followingheadings:

1. child (1–18 years), e.g. child, adolescent;2. caregiver or home, e.g. parent, caregiver or guardian,

family;3. nutrition-related, activity-related, weight-related, e.g.

fruit or vegetable, obesity, activity;4. behaviour change theory, e.g. behaviour change,

behaviour modification;5. study design, e.g. randomized controlled trial, clinical

controlled trial, intervention or evaluation study;6. limits applied – 1998–2008, human, English.

Following piloting and title/abstract text word analysisin PubMed, the main search was undertaken in September2008 in: PubMed (MESH and keyword); Web of Science;Cochrane databases; PsycINFO; dissertation abstracts (nofurther searching of grey literature). Search term lists werecomprehensive, inclusive and adapted for the individualdatabases searched (available from authors). Finally, refer-ence lists of identified reviews and articles were searchedfor additional studies.

Title screening and abstract keyword searching assessedsearch results against the exclusion criteria. The firstauthor assessed abstracts (and full text where necessary)against review criteria using a standard review criteriaform. Fig. 1 summarizes review article selection. Seventeenstudies evaluated interventions targeting parents or homeenvironment alone (family targeted alone) and arereviewed here. Thirteen studies evaluated interventionswhere parent involvement was part of a wider interven-tion (e.g. school or community intervention) and arereviewed separately.

Data extraction and synthesis

Two reviewers independently extracted all data fromincluded studies including measures of methodological

quality and intervention content coding (see Tables 1 and 2for details of information extracted).

Two reviewers independently scored the methodologyquality of all studies using the Effective Public HealthPractice Project quality assessment tool (11). In an assess-ment of 213 quality assessment tools, this tool wasidentified as useful for systematic reviews that evaluaterandomized and non-randomized intervention studies(12). Eight quality components were scored (weak/moderate/strong): selection bias, study design and alloca-tion bias, confounders, blinding, data collection methods,withdrawals and dropouts, intervention integrity andanalysis. An overall quality rating was assigned; ‘strong’where four of six key quality assessment criteria wererated as strong, with no weak ratings; ‘moderate’ if lessthan four criteria were rated strong and one criterion wasrated weak; and ‘weak’ where two or more criteria wererated weak. Reviewer differences were resolved by discus-sion and consensus.

Potentially relevant studies identified and screened for retrieval (n = 2651)

Studies excluded on the basis of title and abstract (n = 2613) because of study population (n = 1360) study design (n = 509) review articles (n = 150) type of intervention (n = 158) no parent involvement (n = 395) obesity management (n = 41)

Studies retrieved for more detailed evaluation (n = 38)

Studies excluded on the basis of study design, intervention type or no parent involvement (n = 4)

Potentially appropriate studies to be included in the systematic literature review (n = 34)

Additional studies identified from hand searching reference lists of studies to be included in review and relevant review articles (n = 10).

Studies eligible for review (n = 30 described in 44 papers)

Family targeted (n = 17 studies described in 24 papers)

Family combined (n = 13 studies described in 20 papers)

Studies included in this review Family targeted (n = 17

studies described in 24 papers)

Studies where parent involvement was part of a wider intervention (e.g. school or community intervention) were considered outside the scope of this review as difficult to disentangle parent component effectiveness from wider intervention effectiveness. (n = 13 studies described in 20 papers)

Figure 1 2002 Quorum statement flow diagram. Interventions involvingparents or caregivers to facilitate improvements in children’s nutrition,activity or weight status.

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Table 1 Study setting and design, intervention description and summary of results for family targeted interventions to improve children’sweight-related nutrition intake or activity patterns

Study and quality rating Participants and data points Intervention description Intervention focus and key results

Epstein 2001 (25)USAUniversity

CCT

Moderate qualityrating

Families with obese parentand non-obese children(primary school/mixed gender)

N = baseline/follow-upTreatment 1: 13/13 (100%)Treatment 2: 13/13 (100%)

Baseline and 12 months(follow-up)

Delivery: Individual and group. Weekly for 8weeks, followed by 4 bi-weekly and 2 monthlymeetings.

Intervention: Comprehensive behaviouralweight loss program for parents plusenvironmental changes and activities forchildren.

Target behaviour: Decrease intake of fat andsugar (Treatment 1), increase intake of fruit andvegetables (Treatment 2).

Behaviour change componentAgent of change:† Parent (high intensity) andchild.Social cognitive theory13 behaviour techniques reported spanning 5out of 5 behaviour change process steps.*

Weight status: Percentageoverweight: NS

NutritionFruit and vegetables (serves):Treatment 1 +0.72 � 1.11,Treatment 2 -0.55 � 1.31;F(1,24) = 7.20; P = 0.025).

Fat and sugar foods (serves):Time effect (P < 0.001)Treatment 1 -4.5 � 7.97,Treatment 2 -8.5 � 7.6;Group effect NS.

Haire-Joshu 2008 (20)USACommunity (Parents asTeacher sites, includeshome visits)

RCT

Moderate quality rating

Families attending 16 sites(preschool agedchildren/mixed gender)

N = baseline/follow-upIntervention: 759/642(605 for analysis) (80%)Control: 899/745 (701for analysis) (78%)

Baseline and end ofintervention (average7 months, range6–11 months)

Delivery: Group, home visits and newsletter.At least 5 home visits, on site group activitiesand newsletters offered on an annualbasis.

Intervention: Control group received standardParents As Teachers parenting and childdevelopment program. Intervention groupreceived an additional 4 home visits, 1 tailorednewsletter and storybooks. Interventioncomponents offered over 1 year (average 7months).

Target behaviour: Encourage positive fruit andvegetable environment and positive parent-childcommunication and environment.

Behaviour change componentAgent of change: Parent only (low intensity).Social ecological model/behavioural learningtheory9 behaviour techniques reported spanning4 out of 5 behaviour change processsteps.

NutritionFruit and vegetables (serves):NS (However, in normalweight children only. Interventiongroup +0.23 vs. control -0.11;P = 0.02)

De Boudeaudhuij 2002 (15)BelgiumSchool (home component)

Quasi experimental

Moderate quality rating

Families – parent and child(high school/mixed gender)

N = baseline/ follow-upIntervention: combinedparent and child 55/44 (80%)Control: child only 71/50 (70%),parent only 47/40 (85%)

Baseline, 6 weeks (end ofintervention), 10 weeks(follow-up)

Delivery: Individually tailored letter, letterprovided feedback on intake, attitudes,self-efficacy, food substitution advice andmanaging high-risk situations.

Intervention: Nutrition messages to the family toreduce fat intake (treatment 1), provided nutritionmessages to the individual (parent or child) toreduce fat intake (treatment 2).

Target behaviour: Reduce fat intake

Behaviour change componentAgent of change: Parent alone or child alone orfamily alone (all low intensity).Health education model6 behaviour techniques reported spanning 4 outof 5 behaviour change process steps.

NutritionFat intake: NS

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Table 1 Continued

Study and quality rating Participants and data points Intervention description Intervention focus and key results

De Boudeaudhuij 2000 (16)BelgiumCommunity (homecomponent)

CCT

Weak quality rating

Families – two parents and twochildren (high school/gendernot reported)

N = baseline/follow-upIntervention: families 20/18(90%)Control: families 20/17 (85%)

Baseline, 6 weeks (end ofintervention)

Delivery: Individually tailored letter, providednutrition message and education.

Intervention: Treatment 1 – messages to thefamily to reduce fat intake. Letter providedfeedback on intake, attitudes, self-efficacy, foodsubstitution advice and managing high risksituations. Treatment 2 – general nutritioneducation provided in a letter. Importance of ahealthy diet, information on fat reduction,health risks, general guidelines and ways toreduce fat.

Target behaviour: Reduce fat intake

Behaviour change componentAgent of change: Parent (low intensity) andchild.Health education model6 behaviour techniques reported spanning 4 outof 5 behaviour change process steps.

NutritionFat intake: time effect:Decreased intake in all familymembers F(1,17) = 5.8, P < 0.05

McGarvey 2004 (26)USACommunity Women InfantsChildren (WIC) sites

Prospective cohort

Weak quality rating

Parents of children attendingchosen sites (preschool/mixedgender)

N = baseline/follow-upIntervention: families 185/121(65%)Control: families 151/65 (43%)

Baseline and 12 months (endof intervention)

Delivery Group and individual, every 2 months,individual session every 6 months

Intervention: Usual care – existing WIC programprovided by health departments, with groupsession. Intervention – formed part of existingWIC program, 6 key nutrition and physicalactivity messages were presented toparents in written format and promoted insessions and reinforced by staff and thecommunity.

Target behaviour: 6 key and activity messages

Behaviour changeAgent of change: Parent (low intensity).Social ecological model/behavioural learningtheory10 behaviour techniques reported spanning4 out of 5 behaviour change processsteps.

NutritionFruit and vegetables: NSOffering water: increased0.64(0.19, 1.09) vs. 0.16(-0.16,0.49)F(1,145) = 8, P = 0.009

ActivityEngaging in active play:0.47(0.14,0.8) vs.-0.22(-0.7,0.26)F(1,161) = 7.03, P = 0.01

Wilfley 2007 (29)USAUniversity

RCT

Strong quality

Families – at least one parentoverweight and children20–100% overweight (primaryschool/mixed gender)

N = baseline/follow-upControl 49/37 (76%)Intervention 1 (BSM): 51/42(82%)Intervention 2 (SFM): 50/43(86%)

Baseline, 5 months (end ofweight loss – out of reviewscope), 9 months (postmaintenance intervention) and2 years

Delivery: Group and families. Following a 5month standard weight loss program, the controlgroup received no intervention.

Intervention: Following weight loss programreceived a 4 month weight maintenanceintervention (16 weekly sessions). Twomaintenance strategies were compared –behavioural skills (BSM) and social facilitation(SFM). BSM taught strategies to assist weightloss maintenance and SFM focused on creatinga supportive social environment.

Target behaviour: Weight maintenance

Behaviour change componentAgent of change: Parent (high intensity) andchild (compared with child and parent).Social cognitive theory8 behaviour techniques reported spanning 3 outof 5 behaviour change process steps.

Weight statusBMI z-score: Interventions vs.Control -0.08 (-0.16 to -0.01,P = 0.007); Effect size = -0.402 year follow-up: NS.

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Table 1 Continued

Study and quality rating Participants and data points Intervention description Intervention focus and key results

Anand 2007 (17)CanadaCommunity (home visitsonly)

RCT

Moderate quality rating

Stable household of aboriginalfamilies in Canada – at leastone parent and one child livingin the same house (all personsin the house aged 5–70years/mixed gender)

N = baseline/follow-upControl: 28/23 households(82%)Intervention: 29/28 households(96%)

Baseline and 6 months(end of intervention)

Delivery: Family households

Intervention: Aboriginal health counsellorsmade regular home visits to help families setdietary and physical activity goals. Otherprogram goals were the provision of filteredwater, a physical activity program for childrenand educational events about healthylifestyles.

Target behaviour: Nutrition (food group) andactivity behaviours

Behaviour change componentAgent of change: Parents (low intensity) andchildren.Social cognitive theory4 behaviour techniques reported spanning3 out of 5 behaviour change processsteps.

NutritionDecrease in fats/oils/sweets(serves): Intervention group -4.9vs. -3.0; P = 0.006

Increase in water consumption+0.3 vs. -0.1; P = 0.04

Decrease in soft drink/juice -0.3vs. -0.1; P = 0.02

ActivityPhysical activity: NSScreen time: NS

Paineau 2008 (21)FranceCommunity (homecomponent)

RCT

Moderate quality rating

Volunteer families – one parentand at least one child (primaryschool/mixed gender)

N = baseline/follow-upControl 418/393 familiesIntervention A: 297/280families (94%)Intervention B: 298/274families (92%)

Baseline, 10 months (end ofintervention)

Delivery: Families received information aboutnutrition.

Intervention: Internet monitoring, generalinformation but no individual advice.Intervention groups received monthlytelephone counselling to change foodhabits and meet dietary targets, internetmonitoring and newsletter for eightmonths.

Target behaviour: Reduce fat and increasecomplex carbohydrates (group A); reduceboth fat and sugar and increase complexcarbohydrate intake (group B).

Behaviour change componentAgent of change: Child and parent (highintensity).Nil behaviour model identified6 behaviour techniques reported spanning3 out of 5 behaviour change processsteps.

NutritionIntervention effects:

Decreased % energy fatA: -3.3(-4.0 to -2.6); P < 0.01B: -2.3 (-3.0 to -1.5); P < 0.01

Complex carbohydrates %energy:A: 3.3 (2.6 to 4.0); P < 0.01B: 2.4 (1.6 to 3.1); P < 0.01

Harvey-Berino 2003 (18)USACommunity (home visitsonly)

CCT

Moderate quality rating

Volunteer native Americanfamilies – overweight motherand child (toddler/mixedgender)

N = baseline/follow-upControl: 20/20 (100%)Intervention: 23/20 (87%)

Baseline and 16 weeks(end of intervention)

Delivery: Mother received weekly parentsupport sessions (PS), based on ActiveParenting curriculum based on psychologicaland behavioural goals.

Intervention: Families received an obesityprevention program plus parenting supportaimed at reducing obesity (OPPS).

Target behaviour: Development of appropriateeating and exercise behaviours.

Behaviour change componentAgent of change: Parents alone (high intensity).Social ecological model12 behaviour techniques reportedspanning 5 out of 5 behaviour change processsteps.

Weight statusWeight/height z-score: PSincrease 0.31 � 1.1, OPPS-0.27 � 1.1; P = 0.06

NutritionEnergy intake: PS 6.8 � 55.4,OPPS -39.2 � 89.4; P = 0.06

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Table 1 Continued

Study and quality rating Participants and data points Intervention description Intervention focus and key results

Wardle 2003 (19)UKCommunity (home visitsonly)

CCT

Moderate quality rating

Families who had previouslyparticipated in a study(preschool/mixed gender)

N = baseline/follow-upControl: 45/44Intervention – Exposure: 50/48(34 compliant with intervention)(68–96%)Intervention – Information:48/48 (100%)

Baseline and 2 weeks(end of intervention)

Delivery: Parent, information based educationusing leaflets about fruit and vegetablerecommendations.

Intervention: Self-administered daily for 2 weeks,Repeated exposure to children of a targetvegetable to increase acceptance and liking.Parents received information about theexposure techniques.

Target behaviour: Fruit and vegetable intakeand liking

Behaviour change componentAgent of change: Parent alone (low intensity).Social ecological model6 behaviour techniques reported spanning4 out of 5 behaviour change processsteps.

NutritionVegetable intakeIntervention group (g) 4.1(1.4) to9.0(1.7); t(33) = 4.36; P < 0.001Control group 5.7(2.1) to 7.3(1.8);t(47) = 1.02; P = 0.06

DeterminantsLiking of target vegetableincreased in exposuret(33) = 6.64; P < 0.001, andcontrol group t(43) = 4.19,P < 0.001

Horodynski 2005 (22)USACommunity (home visits)

Quasi experimental

Moderate quality rating

Low income families enrolledin Early Head Start program(toddlers/mixed gender)

N = baseline/follow-upControl: 73/53 (73%)Intervention: 62/43 (69%)

Baseline, 4 weeks(after group intervention), 6months (after individualreinforcement sessions)

Delivery: Group and families, Early Head Startprogram – 4 group sessions and 18 weeklyhome visits over 6 months.

Intervention: Nutrition Education Aimedat Toddlers focused on improving mealtime interactions by training adults to beresponsive to toddlers’ verbal/non-verbalcues.

Target behaviour: Parental role modelling,introducing new foods, parenting skills

Behaviour change componentAgent of change: Parent alone(high intensity).Social ecological model9 behaviour techniques reported spanning4 out of 5 behaviour change processsteps.

DeterminantsTrend decrease in TV viewingduring mealsIntervention vs. control -19% vs.+2%; P = 0.077

Ransdell 2003 (13,30)USACommunity (homecomponent

RCT

Weak quality rating

Mother daughter pairs withirregular or inactive physicalactivity habits (highschool/females only)

N = baseline/follow-upControl (home based): 10/10(100%)Intervention (communitybased): 7/7 (100%)

Baseline and 12 weeks(end of intervention)

Delivery: Individual and group, 3 sessions perweek for 12 weeks.

Intervention: Interventions aimed at increasingphysical activity and health-relatedfitness.

Target behaviour: Home-based fitness exerciseencouraged via education material (treatment 1);group-based exercise sessions 3 timesper week, recreational type exercise(treatment 2).

Behaviour change componentAgent of change: Parent (high intensity) andchild.Behavioural learning theory9 behaviour techniques reported spanning5 out of 5 behaviour change processsteps.

Physical activity/fitnessTreatment 2 greater increase inmuscular endurance (sit ups)than Treatment 1: Change of 32.1vs. 13.15; P = 0.03

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Table 1 Continued

Study and quality rating Participants and data points Intervention description Intervention focus and key results

Salminen 2005a,b (23,31)FinlandClinical (home visits)

Concurrent cohort

Weak quality rating

All children in families of highrisk adults on hospital register(primary and highschool/mixed gender)

N = baseline/ follow-upControl: 768 children (high risk245, low risk 523)/623 (highrisk 200, low risk 423) (81%)Intervention: 515/432 children(84%)

Baseline and 2 years (end ofintervention)

Delivery: Family and group, 2 sessions atschool and 3 sessions at home over2 years.Intervention: Family-oriented health educationprogram (nutrition, exercise, smoking),shared decision-making approach delivered bya nurse. Nutrition and exercise goals set forfamily.

Target behaviour: Healthy behaviours – nutrition,exercise and smoking.

Behaviour change componentAgent of change: Children and parents (lowintensity).Health education7 behaviour techniques reported spanning4 out of 5 behaviour change processsteps.

DeterminantsFavourable changes in the use offat and salt and exercise in theintervention group relative to thecontrol groups.

Niinikoski 2007 (27,32–34)FinlandClinical

CCT

Moderate quality rating

Children recruited into STRIP at5 months and randomised at 7months and followed up untilage 14 years. (mixed gender)

N = baseline/follow-upControl: 552/278 (50%) notethis is at 14 yearsIntervention: 540/254 (47%)

Baseline and then majority ofoutcomes measured annuallyover study period (end ofintervention)

Delivery: Families seen by study team every 1–3months until child aged 2 years, and then twiceper year there after.

Intervention: Targeted CHD risk factors,introduce a low saturated fat, low cholesteroldiet to their infants. Parents alone (highintensity) (treatment 1), and with counsellingaimed at controlling CHD risk factors(treatment 2).

Target behaviour: CHD risk factors, nutrition(fat and saturated fat)Behaviour change componentAgent of change: Parent (high intensity) andchild.Child development theory6 behaviour techniques reported spanning4 out of 5 behaviour change processsteps.

Blood lipidsLower total cholesterol (3.91–4.23vs. 4.11–4.30; P < 0.001) inintervention than control childrenduring 14 years

NutritionTotal fat intake(31 vs. 31–32%; P < 0.001)Saturated fat intake (12 vs. 13%;P < 0.001) intakes lower inintervention group compared tocontrol during 14 years

Saakslahti 2004 (28)FinlandClinical

CCT

Weak quality rating

Families from the STRIP cohortfollowed up for 3 years(preschool/ mixed gender)

N = baseline/ follow-upControl: 112/85 (76%)Intervention: 116/86 (74%)

Baseline, 1 year, 2 years, 3years (end of intervention).

Delivery: Families, one intensive session withparents and children each year, pluseducational material sent out twice peryear.

Intervention: Physical activity was introduced tofamilies during their routine STRIP visit, aimed atincreasing parent’s knowledge about physicalactivity in the attempt to change children’sbehaviour.Target behaviour: Physical activity

Behaviour change componentAgent of change: Parent (high intensity) andchild.Child development theory6 behaviour techniques reported spanning4 out of 5 behaviour change processsteps.

Physical activityChildren in the intervention spentmore time playing outdoors(F(1,527) = 4.21; P = 0.041) andless time playing indoors(F(1,527) = 3.88; P = 0.049).

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The nutrition and activity intervention content werecoded using definitions developed for this review based onWorld Health Organization recommendations and existingliterature (10). Behaviour change techniques were codedusing standardized definitions outlined in the taxonomy byAbraham and Michie (Table 3) (9). The taxonomy defines26 behaviour change techniques with standard definitionsprovided in a five-page coding manual. Two reviewers inde-pendently coded all interventions following the codingmanual guidelines (i.e. coded only text describing the

intervention itself, coded for most comprehensive interven-tion described, technique checklist utilized with frequentreference to technique definition). For quality assurance,the behaviour change techniques were also independentlycoded by two reviewers with a psychology background.Coding differences were infrequent and were resolved bydiscussion and consensus using the technique definitionsand coding guidelines.

Because of heterogeneity in outcomes and outcomeassessment methodology, meta-analysis was not under-

Table 1 Continued

Study and quality rating Participants and data points Intervention description Intervention focus and key results

Tershakovec 1998a,b(24,35)USAClinical

CCT

Strong quality rating

Hypercholesterolemic childrenbetween 85–130% overweight(primary school/ mixed gender)

N = baseline/ follow-upControl:At risk control: 87/78 (90%)Not at risk control: 81/78 (96%)Intervention:PCAT: 86/73 (85%)Counselling: 88/66 (75%)

Baseline, 3 (end ofintervention), 6, 12 months(follow-up)

Delivery: Families, self paced over 10 weeks

Intervention: Two control groups (1) at riskcontrol; (2) not at risk control, no contact oreducational material provided.Intervention groups received the Parent ChildAuto Tutorial (PCAT): Home-based educationprogram using material for parents and childrenabout ‘heart smart’ nutrition recommendations.Education focus was on how to make dietarychanges in the home, positive food experiencesand role modelling of ‘heart smart’ foodconsumption.

Target behaviour: ‘Heart smart’ nutrition – fatintake

Behaviour change componentAgent of change: Child and parent (lowintensity).Behavioural learning theory7 behaviour techniques reported spanning 3 outof 5 behaviour change process steps.

NutritionIntervention effect: Bothintervention groups decreasedtheir fat intake significantly morethan the high-risk control group(P < 0.05).

Beech USA 2003 (14,36)CommunityUniversity

RCT

Moderate quality rating

African-American girls at risk ofobesity (primaryschool/females only)

N = baseline/follow-upControl: 18/18 (100%)Intervention:Child target: 21/21 (100%)Parent target: 21/21 (100%)

Baseline and 12 weeks (end ofintervention)

Delivery: Group, control group monthly for 12weeks (3 meetings) plus information mail outsbi-monthly, intervention group weekly sessionsfor 12 weeks.

Intervention: Focused on enhancing children’sself-esteem in general. Increasing knowledgeand behaviour change skills to promote healthyeating and increase physical activity (treatment1); sessions teaching parents eating and activityskills to encourage healthy eating and physicalactivity in their children (treatment 2).

Target behaviour: Healthy eating and increasedactivity.

Behaviour change componentAgent of change: Parent alone (high intensity)versus child alone.Behavioural learning theory5 behaviour techniques reported spanning 4 outof 5 behaviour change process steps.

NutritionIntervention effect: Decreasedserves of sweetened drinksconsumed, combined adjustedmean difference intervention vs.control 1.57(0.40) servesP = 0.03.

*refer to Table 3 for details of behaviour change techniques and five step behaviour change process framework.†Agent of change defined as the primary target/s for exposure to and participation in the study intervention. Parental participation categorised as lowor high based on level of parental engagement using the frequency of contact and/or between session activities parents were asked to undertake.CCT, clinical controlled trial; RCT, randomized controlled trial.

122 Content analysis of child obesity interventions R. K. Golley et al. obesity reviews

© 2010 The Authorsobesity reviews © 2010 International Association for the Study of Obesity 12, 114–130

Tab

le2

Res

ults

sum

mar

yof

eval

uatio

nsof

fam

ilyta

rget

edin

terv

entio

nsto

imp

rove

child

ren’

sw

eig

ht-r

elat

ednu

triti

onin

take

orac

tivity

pat

tern

s

Stu

dy

Wei

ght

stat

us/li

pid

sN

utrit

ion

inta

ke/a

ctiv

ityp

atte

rns

Det

erm

inan

tsof

nutr

ition

/act

ivity

beh

avio

urIn

terv

entio

nef

fect

ive*

End

-IFU

Ep

stei

n20

01(2

5)P

erce

ntov

erw

eig

ht✕

Frui

tan

dve

get

able

s(s

erve

s)✓

Par

enta

lfoo

dha

bits

✓–

Yes

Hig

hfa

t/hig

hsu

gar

food

s(s

erve

s)✓

Chi

ldfe

edin

gp

ract

ices

✓

Hai

re-J

oshu

2008

(20)

–Fr

uit

and

veg

etab

les

(ser

ves)

✕P

aren

talk

now

led

ge

✓N

o–

Par

enta

lmod

ellin

g✕

Chi

ldfe

edin

gp

ract

ices

✓

Frui

tan

dve

get

able

avai

lab

ility

✓

De

Bou

dea

udhu

ij20

02(1

5)–

Tota

lfat

inta

ke(%

ofen

erg

y)✕

Soc

ials

upp

ort

and

inte

ntio

n✓

No

No

Atti

tud

es,

self-

effic

acy,

awar

enes

s,fa

mily

per

cep

tion

and

frie

nds

per

cep

tions

✕

De

Bou

dea

udhu

ij20

00(1

6)–

Fat

inta

ke(%

ofen

erg

yto

tal,

satu

rate

d,

mon

o-un

satu

rate

d,

pol

y-un

satu

rate

d)

✓C

hild

attit

udes

,se

lf-ef

ficac

y,in

tent

ion

✓Ye

s–

Fam

ilyp

erce

ptio

nan

dfr

iend

sp

erce

ptio

ns✓

Soc

ials

upp

ort

and

awar

enes

s✕

McG

arve

y20

04(2

6)–

–O

fferin

gw

ater

,en

gag

ing

inac

tive

pla

y✓

No

–O

fferin

gfr

uit

and

veg

etab

les,

mea

ltim

eb

ehav

iour

,ro

lem

odel

ling

with

fam

ilyac

tivity

,te

levi

sion

view

ing

whi

leea

ting

,ef

ficac

y,ou

tcom

eex

pec

tanc

y,ris

kp

erce

ptio

nan

dre

adin

ess

toch

ang

e

✕

Wilfl

ey20

07(2

9)B

MI

z-sc

ores

✓–

–S

elf

effic

acy,

frie

ndsu

pp

ort

and

par

ticip

atio

n✓

Yes

No

%ov

erw

eig

ht✓

Per

ceiv

edb

arrie

rs,

pos

itive

alte

rnat

ives

,w

eig

htco

ncer

nsan

dp

rob

lem

cop

ing

✕

Ana

nd20

07(1

7)B

ody

fat,

wei

ght

,w

aist

circ

umfe

renc

e✕

Food

gro

upin

take

(ser

ves)

:fa

tsan

doi

ls,

wat

er,

soft

drin

k✓

Kno

wle

dg

e✓

Yes

–

Blo

odp

ress

ure

✕Fo

odg

roup

inta

ke(s

erve

s):

bre

ad/c

erea

ls,

frui

tan

dve

get

able

s,m

eat/p

oultr

y,d

airy

✕A

ttitu

des

✕

Ene

rgy

and

mac

ronu

trie

ntin

take

✕

Act

ivity

leve

land

scre

entim

e✕

obesity reviews Content analysis of child obesity interventions R. K. Golley et al. 123

© 2010 The Authorsobesity reviews © 2010 International Association for the Study of Obesity 12, 114–130

Tab

le2

Con

tinue

d

Stu

dy

Wei

ght

stat

us/li

pid

sN

utrit

ion

inta

ke/a

ctiv

ityp

atte

rns

Det

erm

inan

tsof

nutr

ition

/act

ivity

beh

avio

urIn

terv

entio

nef

fect

ive*

End

-IFU

Pai

neau

2008

(21)

BM

Iz-

scor

e,fa

tm

ass

✕E

nerg

yin

take

✓Fo

od-r

elat

edq

ualit

yof

life

(no

harm

)✓

Yes

–an

dci

rcum

fere

nces

Mac

ronu

trie

ntin

take

s✓

Sed

enta

ry/p

hysi

cala

ctiv

ity✕

Har

vey-

Ber

ino

2003

(18)

Wei

ght

/hei

ght

zsc

ore

✓E

nerg

yin

take

✓Fo

odp

ract

ices

✓Ye

s–

Fat

inta

ke✕

War

dle

2003

(19)

–In

take

ofta

rget

veg

etab

le✓

Liki

ngan

dra

nkin

gof

veg

etab

les

✓Ye

s–

Hor

odyn

ski2

005

(22)

––

Chi

ld-p

aren

tm

ealt

ime

beh

avio

ur(d

irect

obse

rvat

ion)

,fe

edin

gch

ildre

nkn

owle

dg

ean

dfe

edin

gse

lf-ef

ficac

y✕

No

No

Tele

visi

onon

dur

ing

mea

ltim

e✓

Ran

sdel

l200

3(1

3,30

)B

ody

com

pos

ition

✕S

treng

than

den

dur

ance

✓P

artic

ipat

ion

inae

rob

ic,

mus

cula

ran

dfle

xib

ility

activ

ities

✓Ye

s–

Hei

ght

/wei

ght

✕A

erob

icca

pac

ity,

flexi

bili

ty✕

Blo

odp

ress

ure

✕

Sal

min

en20

05a,

b(2

3,30

)–

Fat

inta

ke,

salt

inta

kean

dhi

gh

fibre

choi

ces

✕Fa

tty

pe,

hig

hfib

rech

oice

s✓

No

–

Exe

rcis

efre

que

ncy

and

inte

nsity

✕

Niin

ikos

ki20

07(2

7,32

–34)

BM

Ina

Fat

and

satu

rate

din

take

✓–

Yes

–Li

pid

pro

file

✓

Saa

ksla

hti2

004

(28)

–Ti

me

spen

tou

tdoo

rsan

din

doo

rs✓

–N

o–

Ters

hako

vec

1998

a,b

(24,

35)

Wei

ght

zsc

ore

✓Fa

tin

take

(%of

ener

gy)

and

ener

gy

inta

ke✓

Kno

wle

dg

e✓

Yes

No

Bee

chU

SA

2003

(14,

36)

BM

I✕

Sw

eete

ned

drin

ks(s

erve

s)✓

Low

and

hig

hfa

tfo

odp

ract

ices

✓Ye

s–

%b

ody

fat

✕Fr

uit

and

veg

etab

les

and

wat

er(s

erve

s)✕

Bod

yw

eig

htco

ncer

ns✓

Wai

stci

rcum

fere

nce

Ene

rgy

and

fat

inta

ke✕

Act

ivity

–tim

ean

din

tens

ity✕

*End

-I,

end

inte

rven

tion;

✕N

ost

atis

tical

lysi

gni

fican

tch

ang

e;✓

Sig

nific

ant

chan

ge

(see

Tab

le1

for

det

ails

);FU

,fo

llow

-up

.

124 Content analysis of child obesity interventions R. K. Golley et al. obesity reviews

© 2010 The Authorsobesity reviews © 2010 International Association for the Study of Obesity 12, 114–130

taken. Results are presented in narrative form. A study wasclassified as supporting ‘intervention effectiveness’ wherethere was (i) a significant change in an objective measure ofadiposity (e.g. body mass index z score or percent over-weight) or health risk factor (e.g. cholesterol); OR (ii) atleast one significant change in a measure of dietary intakeor activity level AND a significant change in at least onedeterminants of nutrition/activity behaviour. The frequencyof ‘intervention effectiveness’ by study characteristics andintervention content was assessed.

Results

Study description and quality assessment

Table 1 summarizes the 17 family-targeted only studiesreviewed. Most studies involved preschool or primary-school aged children (14 studies) (Table 1). Two interven-

tions targeted girls only (13,14). The intervention settingincluded the home directly in 11 studies, either alone (15–19) or in conjunction with a community or educationsetting (13,20–22) or a clinical or research setting (23,24).Fourteen studies targeted parents only or identified parentsas the primary agent of change (Table 1). Twelve studiesevaluated interventions up to 6 months duration (7–12weeks duration), with only five evaluating interventions 12months or longer (23,25–28). Individual counselling,group sessions, and written materials only were the topthree modes of intervention delivery. Outcome evaluationfocused on short-term effects (end of intervention) withonly eight studies conducting follow-up post intervention(Table 1). Two studies were rated as strong (24,29), fiveweak (13,16,23,26,28) and 10 studies were rated moderatequality (Table 1). The quality criteria on which studiesperformed most poorly were those relating to selectionbias, confounders and dropouts.

Table 3 Behaviour change technique taxonomy and frequency of techniques use

Processes underpinning behaviourchange process

Behaviour change techniques as defined by Abraham andMichie taxonomy

All studies(n = 17)

Effective studies(n = 11)

Ineffective studies(n = 6)

Identify and motivate readiness tochange

Provide general information on behaviour-health link 10 5 5Provide information consequences 1 0 1Provide information about others approval 0 0 0Provide general encouragement 6 4 2Motivational interviewing 0 0 0

Facilitate motivation to change Prompt intention formation 8 5 3Prompt specific goal setting 4 4 0Prompt self-monitoring of behaviour 6 5 1Agree behavioural contract 0 0 0

Provide relevant information andadvice/behaviour changestrategies

Provide instruction 15 10 5Anticipatory guidance* 4 2 2Tailored or personalised delivery* 3 1 2Environmental restructuring* 6 5 1Feeding practices* 5 2 3Parenting Skills: generic* 2 1 1Parenting Skills: specific to lifestyle behaviours* 2 2 0Time management (including planning) 1 1 0Provide contingent rewards 2 2 0Teach to use prompts/cues 1 1 0

Build self-efficacy (andindependence)

Set graded tasks 2 2 0Model/demonstrate the behaviour 3 2 1Provide performance feedback 6 4 2Prompt practice 3 2 1Provide opportunities for social comparison 6 3 3Plan social support/social change 3 2 1Prompt identification as role model/position advocate 7 4 3Prompt self-talk 2 2 0

Prevent and manage relapse Prompt barrier identification 8 6 2Prompt review of behavioural goals 3 2 1Use of follow-up prompts 1 1 0Relapse prevention 1 1 0Stress management 0 0 0

*Validity/reliability for these behaviour change techniques is limited. Techniques in bold are additional techniques developed for this review.Techniques in italics are more common in effective interventions.

obesity reviews Content analysis of child obesity interventions R. K. Golley et al. 125

© 2010 The Authorsobesity reviews © 2010 International Association for the Study of Obesity 12, 114–130

Study intervention content summary

Intervention focusTable 1 summarizes the lifestyle behaviours targeted ineach intervention. Nutrition behaviours were targeted by12 studies. General healthy eating and food choices werethe most frequently targeted nutrition behaviours (e.g. fruitand vegetables or soft drink intake), followed by energyor nutrient intake (e.g. fat or kilojoule intake), menuplanning/food procurement (e.g. low-fat meal practices)and child-feeding behaviours (e.g. offering of water). Sixstudies targeted activity, changing physical/sedentary activ-ity levels or behaviours equally common. Weight status wasa reported intervention target in three studies; and onereported blood lipids as a primary outcome.

Behavioural change techniquesAll but one study (21) reported the behaviour changemodel underpinning the intervention (Table 1). Behav-ioural learning theory and ecological models (familyenvironment) most frequently underpinned the study inter-vention (10 and 5 studies, respectively). Seven studies wereunderpinned by multiple theories. Table 3 lists the behav-ioural change techniques used to code intervention descrip-tions. The average number of behaviour change techniquesreported was eight (range 3–13). The majority of studiesreported using the following techniques: provide instruc-tion (15 studies), provide general information (10), promptintention formation (8) and prompt barrier identifica-tion (8). Identify role model, general encouragement,prompt self-monitoring, provide performance feedbackand provide opportunities for social comparison or envi-ronmental restructuring were also commonly used tech-niques (described in at least a third of study interventions).

Behaviour change techniques are most effective whenused in combination and facilitate movement through abehaviour change process (37). The behaviour change tech-niques defined by the Abraham and Michie taxonomy werecategorized into five processes of behaviour change: iden-tify and motivate readiness to change, facilitate motivationto change, provide relevant information and advice/ facili-tate behaviour change, build self efficacy and independenceand help prevent and manage relapse. Only three of the 17studies employed behaviour change techniques across allbehaviour change processes (13,18,25). An additional eightstudies employed behaviour change techniques in four offive behaviour change processes, missing motivation tochange (15,16,22,23) or prevent and manage relapse(19,20,26). The remaining six studies had significant limi-tations in their use of behaviour change techniques acrossthe behaviour change process. Supporting maintenance ofbehaviour change was the least utilized behaviour changeprocess.

Intervention effectiveness

Study outcomes favoured ‘intervention effectiveness’, asdefined earlier, in 11 of the 17 studies reviewed (Table 2.Detailed results for all outcomes are available fromauthors).

Weight status and health risk factors

Eight interventions included a measure of weight status(14,17,18,21,24,25,27,29). For the six interventions withan obesity prevention focus (14,17,18,21,25,29), threereported significant results (Table 2). One study targetedcoronary risk factors and reported significant decreases inthe cholesterol levels of children in the intervention (26).

Nutrition and activity

Ten studies reported dietary changes in terms of fatintake (14–18,21,23–25,27), two with significant results(Table 2). Four studies intended to reduce energy intake toprevent excess weight gain (14,17,18,21), all with signifi-cant results. Among the interventions that reported foodoutcomes, consumption of fruit and vegetables was mostcommon (14,17,19,20,25), followed by sweetened bever-ages (14,17), high-fat foods (17,25) and water consump-tion (14,17). Two studies reported significant increases infruit and vegetable consumption, one using behaviouralstrategies (25), and the other using an exposure techniqueto increase children’s liking and intake of one chosen veg-etable (19). Two studies reported change in intake in termsof high-fat foods; one found a trend towards significance(17) and the other non-significant (25). Six studies includeda measure of physical activity (13,14,17,21,23,28) but onlyone reported a significant change in the activity levels inchildren (28). Television viewing time was included as anoutcome in four studies (14,17,18,26) with no significantresults reported.

Determinants of lifestyle behaviours

Fourteen of the 17 family interventions included one ormore determinants of lifestyle behaviours as study out-comes. These included parent characteristics such as knowl-edge; parent and child interactions such as feeding practices;environmental measures such as food availability; andpredictors of behaviour such as self efficacy. Study results forthese outcomes are summarized in Table 2.

Study characteristics, intervention content andintervention effectiveness

For the 11 studies where results favoured interventioneffectiveness, all but two were rated as either strong or

126 Content analysis of child obesity interventions R. K. Golley et al. obesity reviews

© 2010 The Authorsobesity reviews © 2010 International Association for the Study of Obesity 12, 114–130

moderate study quality. A median of eight behaviourchange techniques were reported in the interventiondescription (range 4–13). Six studies included behaviourchange techniques that covered the spectrum of behaviourchange processes (or all steps apart from maintenance/relapse prevention). Seven engaged parents as the primaryagent of change and had a higher degree of intensity orengagement with parents as part of the intervention. Of thesix studies where results did not support intervention effec-tiveness, there were no studies rated as strong study qualityand there were three rated as moderate quality. A medianof seven behaviour change techniques were reported perintervention (range 3–10). One did not include behaviourchange techniques in several behaviour change process cat-egories. Three engaged parents as the primary agent ofchange but only one had a high degree of engagement withparents during the intervention. The following behaviourchange techniques appeared more frequently in ‘effectiveinterventions’: prompt barrier identification, restructurethe home environment, prompt self-monitoring, promptspecific goal setting, set graded tasks, provide contingentrewards and prompt self-talk (Table 3). The number oflifestyle behaviours targeted in the interventions did notappear to be associated with intervention effectiveness.Targeting either a single or a group of lifestyle behavioursappeared effective in certain circumstances. However,in ‘effective interventions’, energy intake/density andfood choices (positive or negative) were more likely to betargeted.

Discussion

Although child obesity prevention research highlights theimportance of the home setting (5), parents are a difficultgroup to engage and support (38). This review evaluatedthe recent literature where interventions target parents as ameans of preventing excess weight gain and improvingchildren’s nutrition and activity behaviours. The focus wasthe intervention content and whether the food and activitybehaviours targeted and behaviour change techniquesemployed were associated with effectiveness. The 17studies reviewed were heterogeneous in study population,nature of the comparison group, intervention content and,in particular, the outcomes and assessment methodologyused. While the heterogeneity limited the ability to performmeta-analysis, it was possible and useful to make compari-sons using a consistent vocabulary describing the quality ofthe study methodology (11), and the specific nature of theintervention content, using a validated behaviour changetaxonomy (9).

Studies where there was support for intervention effec-tiveness tended to be of better quality. Interventions con-sidered effective also tended to have a cluster of features,including: parents responsible for intervention participa-

tion and implementation (rather than the child), a higherdegree of meaningful parental involvement (i.e. rangingfrom a 2 week parent-led vegetable taste protocol to 8–13group sessions or home visits over about 6 months),targeting energy intake/density or food choices, use of(slightly) more behaviour change techniques and use ofparticular techniques (environmental restructuring, specificgoal setting, monitoring and barrier identification).Intervention effectiveness was also favoured where use ofbehaviour change techniques spanned a behaviour changeprocess (37).

All but one of the studies reviewed reported that theintervention was underpinned by behaviour change theory,most commonly behavioural or ecological (environmental)models of behaviour change. The shift towards use ofbehaviour change theory within a child developmentframework (i.e. understanding how children’s lifestylebehaviours develop via parent–child interactions and thechild’s environment) is promising (37). While a number ofreviews now also support behaviour theory based interven-tion development (5,7,39), the findings of this review high-light the need to consider how theory is operationalized asintervention behavioural techniques. This step of translat-ing theory into practice is likely to impact on the interven-tion effectiveness potential.

This review systematically described the behaviourchange techniques reported in child obesity preventioninterventions using a standardized and validated tax-onomy. The number of behaviour change techniquesidentified in this review (median of eight) was similar tothose identified in systematic reviews of healthy eating(average 6, range 1–13) and physical activity (average 8,range 1–14) interventions in free living adults (9). For thefirst time, reported behaviour change techniques weremapped against processes considered best practice forfacilitating lifestyle behaviour change. In doing so, gaps inthe application of behaviour change theory into practiceare highlighted. In particular, attention is needed to ensurebehaviour change techniques that support prevention andmanagement of relapse are included in future interventions.This is likely to enhance both the initial effectivenessand long-term sustainability of behavioural lifestyleinterventions.

Kamath and colleagues recently undertook a meta-analysis of 29 randomized controlled trials of behaviouralinterventions to prevent childhood obesity. This reviewdiffered from the present review as the studies includedinterventions that did not target parents or targeted parentsin combination with settings such as schools (7). Kamathand colleagues found that intervention effectiveness wasassociated with use of multiple cognitive components (e.g.goal setting, problem solving/relapse prevention) and inclu-sion of reinforcement in interventions to increase physicalactivity, decrease sedentary activity or promote healthy

obesity reviews Content analysis of child obesity interventions R. K. Golley et al. 127

© 2010 The Authorsobesity reviews © 2010 International Association for the Study of Obesity 12, 114–130

eating. Intervention effectiveness was not associated withinclusion of informational, environmental or social supportcomponents. The present review also supports inclusion ofintervention content that extends beyond information, suchas use of cognitive and behavioural strategies (e.g. specificgoal setting, prompt barrier identification, prompt self-monitoring). However, in the group of studies reviewedhere, environmental restructuring was more commonlyused in effective interventions. The differences between thepresent review and Kamath and colleagues may reflectthe different group of studies reviewed, and the approachtaken in categorizing intervention content. It may alsohighlight the difference in intervention approaches neededin targeting families, and specifically parents, comparedwith school-based or child-focused interventions.

In considering which lifestyle behaviours should be thetarget of family-focused child obesity interventions, thisreview suggests that intervention effectiveness was not influ-enced by the number of nutrition and activity behaviours.This is encouraging as interventions may choose to focus ona few targeted behaviours or a range of complex and inter-related behaviours with equal opportunity for effectiveness.

Variation was observed in the specific food and activitybehaviours targeted by interventions. While most interven-tions achieved a change in the intended behaviour, moreresearch is needed on the ability of different behaviourtargets to have a discrete and cumulative or synergisticimpact on energy balance. For example, the promotion offruit and vegetable intake is a common target in childobesity prevention interventions. However, if the nutritionbehaviour of increased fruit and vegetable intake is notcoupled with a reduction in overall food, or specificallyenergy intake, then an ‘effective’ intervention couldincrease fruit and vegetable intake without any impact onweight status or rate of weight gain.

The strength of this review is in the systematic use of ataxonomy to describe studies in terms of interventioncontent. While this has been undertaken in adults (39) andrecently in children (7), the taxonomy used here is compre-hensive and validated (9). Other strengths include thebroad search focus (i.e. interventions targeting obesityprevention and translatable healthy lifestyle promotioninterventions were included for review), focus on recentliterature and interventions that incorporate ‘best practice’cornerstone, combining nutrition and/or activity withbehaviour modification and family involvement led byparents. Finally, a comprehensive but stringent evaluationof intervention effectiveness was undertaken. Interventioneffectiveness was considered across all study outcomesassessed (e.g. health, lifestyle behaviours and determinantsof lifestyle behaviours). However, the quality of outcomemeasurement and results across outcome categories werealso considered, to avoid an intervention being deemedeffective on the basis of a single outcome.

This review is not without limitations. The review doesdraw on evidence from a range of studies which vary inmethodological quality, intervention and follow-up dura-tion. In terms of follow-up direction, there was a tendencyin included studies to focus on end of intervention effectsonly. As a result of the limitations in available resources,intervention content was only categorized based on thedescription provided in published articles. While it is likelythat this means that intervention content reported here mayunderestimate the true intervention content, this in itself isan important lesson for researchers. In line with improve-ments in the reporting of the design and methodology ofintervention studies, there is a need to improve the report-ing of intervention content, to inform both researchers andpractice. The development and use of taxonomies such asthat utilized in this review would aid synthesis of researchfindings in a way which is relevant to practice. Anotherconsideration is the definition of intervention effective-ness, while it tried to capture overall effectiveness, studieswithout an objective measure or studies that only measuredone aspect of children’s behaviour did not meet the criteriafor effectiveness. While beyond the scope of the presentreview, the specific intervention content best suited to inter-ventions with younger vs. older children would be worthexploring in future reviews and as more family-targetedstudies become available.

Conclusion

The current review makes a useful contribution to theexisting body of reviews on child obesity prevention andtreatment. It critically analysed the content of family-basedobesity prevention interventions involving parents. It pro-vides a comprehensive understanding of the interventionfeatures associated with effective behaviour change inchildren. Table 4 provides a summary of key points forresearchers and practitioners, designing and implementingbehaviour change interventions involving parents. Theresults remind us of the importance of engaging and sup-porting parents as part of a multi-level approach to promot-ing healthy weight and lifestyle behaviours in children.Detailed synthesis of this broad literature will support policymakers and developers of interventions in making informeddecisions on how to best utilize resources and prioritizeintervention content. To maximize intervention effective-ness, the behaviour change techniques used should be care-fully considered to ensure they are linked to behaviourchange theory, are associated with effective interventions(e.g. specific goal setting, monitoring, performance feedbackand environmental restructuring) and span best practicebehaviour change processes. This should improve childobesity prevention intervention effectiveness, and perhapsthe development of effective but lower intensity interven-tions better suited to delivery in public health settings.

128 Content analysis of child obesity interventions R. K. Golley et al. obesity reviews

© 2010 The Authorsobesity reviews © 2010 International Association for the Study of Obesity 12, 114–130

Conflicts of Interest Statement

Gilly A Hendrie, Amy Slater and Nadia Corsini areemployees of CSIRO Food and Nutritional Sciences.Rebecca K Golley is supported by a NHMRC PostdoctoralFellowship.

Acknowledgements

Thanks to Ms Mikaela Lawrence (Information Specialist)for assisting with the development and execution of thereview search strategy. RK Golley is supported by aNHMRC Public Health Training Award (478115).

References

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Table 4 Key points for researchers and practitioners designing andevaluating behaviour change interventions involving parents in anobesity prevention setting

Key points for interventionevaluation

Key points for intervention design

Improve reporting of study qualityand design including selectionbias, confounders and wherepossible drop out rates.

Include strategies that span thespectrum of the behaviourchange process.

Improve reporting of interventioncontent to include underlyingtheory, target of the intervention,behaviour change componentsincluding techniques andstrategies used.

Behaviour change techniques toconsider include specific goalsetting, prompt self-monitoringand self-talk, encourage barrieridentification, restructure thehome environment, set gradedtask and provide contingentrewards.

Recommend using taxonomy forconsistent vocabulary to aid instudy comparisons.

Targeting one or multiplebehaviours to change can beeffective.

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