JAMA Pediatrics Journal Club Slides: Effect of Attendance of the Child in Childhood Obesity Treatment Boutelle KN, Rhee KE, Liang J, et al. Effect of attendance of the child on body weight, energy intake, and physical activity in childhood obesity treatment: a randomized clinical trial. JAMA Pediatr. Published online May 30, 2017. doi:10.1001/jamapediatrics.2017.0651

Introduction Background Two-thirds of children who complete family-based therapy (FBT) for pediatric obesity are still obese in adulthood. FBT is intensive, requiring the parent and child to attend weekly groups and behavioral coaching, and is typically offered only in academic centers. Parent-only treatments (parent-based therapy [PBT]) are developmentally appropriate for the child and would be easier to disseminate and could be more cost-effective. Primary Objective To examine whether PBT is noninferior to FBT on child weight outcomes at 6, 12, and 24 months. Secondary Objective To compare the 2 programs on parent weight, child and parent energy intake, child and parent physical activity, parenting style, and parent feeding behaviors.

Methods Study Design Randomized clinical noninferiority trial that evaluated two 6-month treatments for childhood obesity: FBT, provided to parent and child. PBT, provided to parent only. Setting Academic medical center. Patients 150 overweight and obese children aged 8 to 12 years and their parents.

Methods Outcome Measures Anthropometry (child and parent). Energy intake (child and parent). Physical activity (child and parent). Children’s Report of Parenting Behavior Inventory (child). Birch Child Feeding Questionnaire (parent). Statistical Analyses Noninferiority analysis of child body mass index (BMI) z score to determine if a 2-tailed upper bound of the 90% CI of the treatment effect would rule out our prespecifed difference in BMI z scores across treatments. Superiority analyses were conducted for the other variables, using linear mixed effects models with planned covariates, including age, sex, the linear effect of time, and corresponding baseline values.

Results CONSORT Flow Diagram Describing Recruitment, Study Flow, and Follow-up of the Participants There were 794 parents who called in response to marketing, but only 192 were considered for further screening.

Sample Characteristics Results Sample Characteristics

Results Main Effect of Treatment Group Assignment on Primary and Secondary Outcomes

Child and Parent Weight Changes Over the 24-Month Period Results Child and Parent Weight Changes Over the 24-Month Period

Comment To our knowledge, this is the first large-scale clinical study to test the noninferiority of a PBT program compared with an FBT program for children with overweight or obesity over a 24-month period. This study showed that the PBT program was noninferior to FBT on child weight outcomes, child and parent energy intake, child and parent physical activity, and parenting measures at 6-, 12-, and 24-month follow-ups. Although the PBT program was noninferior to FBT on parent weight outcomes at 6-month follow-up, parents enrolled in PBT gained more weight over time following treatment. Additionally, there was greater attrition and lower acceptability ratings in the PBT compared with the FBT group.

Comment Strengths of PBT Similar outcomes to FBT. Could be useful for flexible scheduling. Reliable and caring adult provides information and reinforcement. Emphasizes the role of the parent. Strengths of FBT Children learn the material from multiple sources. Could be useful for children who need social support. Less dropout and higher acceptability than PBT.

Comment Strengths of Study Randomized design. Noninferiority testing. Racial/ethnic diversity of the families. Use of a validated treatment protocol. 24-month observation period. Summary This study provides sound empirical evidence supporting a PBT model for the delivery of childhood obesity treatment. Reasons for parents’ preference of model delivery should be explored in future research.

Conflict of Interest Disclosures Contact Information If you have questions, please contact the corresponding author: Kerri Boutelle, PhD, Department of Pediatrics, University of California, San Diego, 9500 Gilman Dr, MC 0874, La Jolla, Ca 92093-0874 (kboutelle@ucsd.edu) Funding/Support This project was supported by grants R01DK075861 and K02HL112042 from the National Institutes of Health to Dr Boutelle. Conflict of Interest Disclosures Dr Boutelle is funded by a grant from the Egg Nutrition Center.