Family-based Counseling to Reduce Childhood Overweight (2006)
Goldfield GS, Epstein LH, Kilanowski CK, Paluch RA, Kogut-Bossler B. Cost-effectiveness of group and mixed family-based treatment for childhood obesity. Int J Obes Relat Metab Disord. 2001 Dec;25(12):1843-9.PubMed ID: 11781766
The goal of this study was to compare the cost-effectiveness of two protocols (individual plus group therapy versus group therapy alone) for the delivery of family-based behavioral treatment.
child between 20% and 100% overweight
neither parent greater than 100% overweight
one parent willing to attend treatment meetings
no family member participating in an alternative weight control program
no child or parent having current psychiatric problems
no dietary or exercise restrictions on the participating parent or child
Subjects recruited by newspaper advertisements and physician referrals.
Families randomized into two groups:
Mixed treatment group: recieved part of their behavioral therapy treatment in an individual family session with the therapist and part in a group setting.
Group treatment only group: received treatment only in group setting--no individual meeting with the treatment therapist.
Both groups received the same treatment program from the same therapists, and the Group treatment only group received an additional 20 minutes of group therapy to equalize the time in treatment to that of the Mixed treatment group.
Blinding used (if applicable)
Intervention (if applicable)
Interventions for this study followed the standard treatment program used by Epstein and his colleagues in a number of other studies. Interventions for Epstein's weight loss program are described in the evidence summary, The Traffic Light Diet and Treating Childhood Overweight.
One-way analyses of variance (ANOVAs) were conducted to make comparisons between groups.
Timing of Measurements
Baseline, 6 and 12 months
- Unit weight lost per dollar expended
Form and cost of program delivery: Individual plus group treatment versus group treatment only.
Costs were calculated by adding Orientation costs and Treatment costs and dividing change in Z-BMI or percentage overweight by the total cost of treatment at the 12 month follow-up.
Initial N: 31 families randomized to two treatment groups.
Attrition (final N): 2 families dropped out before treatment, five families refused to participate in follow-up assessments, leaving 24 families with complete data.
Children: Mixed treatment: 9.8±1.3 Group treatment only: 10.3±1.3
Parents: Mixed treatment: 40.9±3.8 Group treatment only: 41.7±7.1
Ethnicity: all white.
Other relevant demographics:
Family socioeconomic status (using Hollingshead Four Factor Index) Mixed treatment: 44.6±9.3; Group treatment only: 44.8±8.02 (on a range from 8 (low) to 66 (high)).
Baseline weight in kg (children): Mixed treatment: 56.5±15.1 Group treatment only: 57.8±9.6
Baseline weight in kg (parents): Mixed treatment: 86.2±24.4 Group treatment only: 82.5±22.9
The only demographic characteristic on which there was significant difference between treatment groups was parental height. Parents in the mixed treatment group tended to be slightly taller.
Both children and parents in the study showed a significant decrease in percent overweight (F(2,88)=18.01, P<0.001) and Z-BMI (F(2,88)=19.16, P<0.001) over time (baseline to 6 months and 6 months to 12 months). Weight loss was as follows:
|Baseline to 6 months||Baseline to 12 months|
% overweight: -9.97±8.74
BMI Z score: -0.59±0.49
% overweight: -8.04±10.27
BMI Z score: -0.64±0.63
% overweight: -6.67±10.3
BMI Z score: -0.31±0.63
% overweight: -5.31±14.13
BMI Z score: -0.29±0.78
|Obese Parents (n=18)||
% overweight: -7.03±11.65
BMI Z score: -0.39±0.64
% overweight: -5.70±16.08
BMI Z score: -0.31±0.88
Cost of Treatment
The cost of group treatment ($491.51) was significantly less expensive than the cost of the mixed group (US$1390.70; F(1,22)=13 680.60).
The group treatment was associated with larger decreases in percentage overweight (F(1,44)=4.69, P<0.05) or Z-BMI (F(1,44)=7.61, P<0.01) per dollar spent at 12 months.
The mixed treatment approach (individual and group treatment) was approximately 2.8 times more expensive per family ($1390 vs $491) and, given equivalent weight control results, the group intervention was significantly less expensive per unit of BMI or percentage overweight change.
According to the authors, "[F]amily-based behavioral treatment for childhood obesity is more cost-effective when provided in group format compared to the combination of group plus individualized treatment, and the cost-efectiveness extends to parents."
However, the authors do point out that these findings only apply to the subjects studied. Children who are morbidly obese, families of different racial, ethnic, or socioeconomic status backgrounds may require an approach other than group only therapy for success.
Study population was mildly to moderately obese and it is not clear whether the findings generalize to more obese children. The authors note that "It is possible that more obese children may require individualized treatment."
Self-selection by recruiting families
Limited demographic group (all white and solidly middle class) makes it unclear the extent to which the results generalize to other demographic groups.
Quality Criteria Checklist: Primary Research
|1.||Would implementing the studied intervention or procedure (if found successful) result in improved outcomes for the patients/clients/population group? (Not Applicable for some epidemiological studies)||Yes|
|2.||Did the authors study an outcome (dependent variable) or topic that the patients/clients/population group would care about?||Yes|
|3.||Is the focus of the intervention or procedure (independent variable) or topic of study a common issue of concern to dieteticspractice?||Yes|
|4.||Is the intervention or procedure feasible? (NA for some epidemiological studies)||Yes|
|1.||Was the research question clearly stated?||Yes|
|1.1.||Was (were) the specific intervention(s) or procedure(s) [independent variable(s)] identified?||Yes|
|1.2.||Was (were) the outcome(s) [dependent variable(s)] clearly indicated?||Yes|
|1.3.||Were the target population and setting specified?||Yes|
|2.||Was the selection of study subjects/patients free from bias?||Yes|
|2.1.||Were inclusion/exclusion criteria specified (e.g., risk, point in disease progression, diagnostic or prognosis criteria), and with sufficient detail and without omitting criteria critical to the study?||Yes|
|2.2.||Were criteria applied equally to all study groups?||Yes|
|2.3.||Were health, demographics, and other characteristics of subjects described?||Yes|
|2.4.||Were the subjects/patients a representative sample of the relevant population?||No|
|3.||Were study groups comparable?||Yes|
|3.1.||Was the method of assigning subjects/patients to groups described and unbiased? (Method of randomization identified if RCT)||Yes|
|3.2.||Were distribution of disease status, prognostic factors, and other factors (e.g., demographics) similar across study groups at baseline?||Yes|
|3.3.||Were concurrent controls or comparisons used? (Concurrent preferred over historical control or comparison groups.)||Yes|
|3.4.||If cohort study or cross-sectional study, were groups comparable on important confounding factors and/or were preexisting differences accounted for by using appropriate adjustments in statistical analysis?||N/A|
|3.5.||If case control study, were potential confounding factors comparable for cases and controls? (If case series or trial with subjects serving as own control, this criterion is not applicable.)||N/A|
|3.6.||If diagnostic test, was there an independent blind comparison with an appropriate reference standard (e.g., "gold standard")?||N/A|
|4.||Was method of handling withdrawals described?||No|
|4.1.||Were follow-up methods described and the same for all groups?||???|
|4.2.||Was the number, characteristics of withdrawals (i.e., dropouts, lost to follow up, attrition rate) and/or response rate (cross-sectional studies) described for each group? (Follow up goal for a strong study is 80%.)||No|
|4.3.||Were all enrolled subjects/patients (in the original sample) accounted for?||Yes|
|4.4.||Were reasons for withdrawals similar across groups?||No|
|4.5.||If diagnostic test, was decision to perform reference test not dependent on results of test under study?||N/A|
|5.||Was blinding used to prevent introduction of bias?||No|
|5.1.||In intervention study, were subjects, clinicians/practitioners, and investigators blinded to treatment group, as appropriate?||No|
|5.2.||Were data collectors blinded for outcomes assessment? (If outcome is measured using an objective test, such as a lab value, this criterion is assumed to be met.)||???|
|5.3.||In cohort study or cross-sectional study, were measurements of outcomes and risk factors blinded?||N/A|
|5.4.||In case control study, was case definition explicit and case ascertainment not influenced by exposure status?||N/A|
|5.5.||In diagnostic study, were test results blinded to patient history and other test results?||N/A|
|6.||Were intervention/therapeutic regimens/exposure factor or procedure and any comparison(s) described in detail? Were interveningfactors described?||Yes|
|6.1.||In RCT or other intervention trial, were protocols described for all regimens studied?||Yes|
|6.2.||In observational study, were interventions, study settings, and clinicians/provider described?||N/A|
|6.3.||Was the intensity and duration of the intervention or exposure factor sufficient to produce a meaningful effect?||Yes|
|6.4.||Was the amount of exposure and, if relevant, subject/patient compliance measured?||No|
|6.5.||Were co-interventions (e.g., ancillary treatments, other therapies) described?||Yes|
|6.6.||Were extra or unplanned treatments described?||N/A|
|6.7.||Was the information for 6.4, 6.5, and 6.6 assessed the same way for all groups?||No|
|6.8.||In diagnostic study, were details of test administration and replication sufficient?||N/A|
|7.||Were outcomes clearly defined and the measurements valid and reliable?||Yes|
|7.1.||Were primary and secondary endpoints described and relevant to the question?||Yes|
|7.2.||Were nutrition measures appropriate to question and outcomes of concern?||Yes|
|7.3.||Was the period of follow-up long enough for important outcome(s) to occur?||Yes|
|7.4.||Were the observations and measurements based on standard, valid, and reliable data collection instruments/tests/procedures?||Yes|
|7.5.||Was the measurement of effect at an appropriate level of precision?||Yes|
|7.6.||Were other factors accounted for (measured) that could affect outcomes?||No|
|7.7.||Were the measurements conducted consistently across groups?||Yes|
|8.||Was the statistical analysis appropriate for the study design and type of outcome indicators?||Yes|
|8.1.||Were statistical analyses adequately described and the results reported appropriately?||Yes|
|8.2.||Were correct statistical tests used and assumptions of test not violated?||Yes|
|8.3.||Were statistics reported with levels of significance and/or confidence intervals?||Yes|
|8.4.||Was "intent to treat" analysis of outcomes done (and as appropriate, was there an analysis of outcomes for those maximally exposed or a dose-response analysis)?||N/A|
|8.5.||Were adequate adjustments made for effects of confounding factors that might have affected the outcomes (e.g., multivariate analyses)?||No|
|8.6.||Was clinical significance as well as statistical significance reported?||Yes|
|8.7.||If negative findings, was a power calculation reported to address type 2 error?||N/A|
|9.||Are conclusions supported by results with biases and limitations taken into consideration?||Yes|
|9.1.||Is there a discussion of findings?||Yes|
|9.2.||Are biases and study limitations identified and discussed?||Yes|
|10.||Is bias due to study's funding or sponsorship unlikely?||Yes|
|10.1.||Were sources of funding and investigators' affiliations described?||Yes|
|10.2.||Was the study free from apparent conflict of interest?||Yes|