OBJECTIVE: To conduct a descriptive systematic review into the nature and effectiveness of family involvement in weight control, weight maintenance and weight-loss interventions.
METHOD: We searched Medline and Psyclit for English language papers describing randomised trials with at least 1-y follow-up that evaluated interventions incorporating a family-based component. Studies involving people with eating disorders, learning disabilities and undernutrition or malnutrition were excluded. Data were extracted on characteristics of the participants, study design, target behaviours, nature of the intervention and study outcomes. A taxonomy was developed and used to classify family involvement in behaviour change interventions. Interventions were also classified according to an existing taxonomy that characterised the behaviour change techniques employed.
RESULTS: A total of 21 papers describing 16 intervention studies were identified. Studies were small (mean sample size: 52), heterogeneous, poorly described but with few losses to follow-up (median 15%). The majority were North American and aimed at weight loss. Few studies described a theoretical underpinning to the behaviour change techniques employed. There was a suggestion that spouse involvement increased effectiveness but that adolescents achieved greater weight loss when treated alone. In studies including children, beneficial effects were seen when greater numbers of behaviour change techniques were taught to both parents and children.
CONCLUSION: Relatively few intervention studies exist in this important area, particularly studies targeting adolescents, and they highlight continued uncertainty about how best to involve family members. The studies provide limited support for the involvement of spouses. They suggest that parental involvement is associated with weight loss in children, and that use of a greater range of behaviour change techniques improves weight outcomes for both parents and children. The development of future interventions and assessment of factors influencing effectiveness may be improved by paying careful attention to which family members are targeted and how they are involved in the intervention in terms of setting goals for behaviour change, providing support and training in behaviour change techniques.
Effective prevention and management of obesity incorporates the behavioural modification of food intake and physical activity.1,2 Greater involvement of family members has been suggested as a way of increasing the effectiveness of interventions aimed at weight control, weight maintenance and weight loss.3,4 Social support, where family members are cognisant of appropriate behaviours to maintain, control or lose weight, and can model and reinforce these to the benefit of the target individual, should help the achievement of long-term goals.5
Three reviews have evaluated the effect of family involvement in this area and their conclusions are mixed. A meta-analysis by Black et al6 suggested that at 9–14 months follow-up, a nonsignificant positive weight loss trend was achieved by treating couples rather than individuals; while Haddock et al7 concluded that parental involvement in the treatment of childhood and adolescent obesity did not significantly improve weight loss. However, the review of Glenny et al 8 reported that family therapy in the prevention of obesity was effective, as was treating obese children and their parents together. However, parental involvement in the treatment of childhood obesity, where only children were aiming for weight control, maintenance or loss and parents supported behaviour change, required further evaluation. Glenny et al8 suggested that the effectiveness of spouse involvement in the treatment of adult obesity could not be established because results were conflicting and sample sizes small.
We aimed to identify trials evaluating family involvement in weight control, weight maintenance and weight-loss interventions targeting food intake and/or physical activity, to describe in detail the nature of the interventions and to describe the different ways in which family members could be involved and their relative effectiveness.
Inclusion and exclusion criteria
We included published, randomised trials with at least 1-y follow-up that targeted either children or adults alone, or children and adults together. Included studies compared a family-based component to another type of family-based or nonfamily-based component. Family-based was defined as the involvement of first- or second-degree relatives or those cohabiting under one roof. Interventions were aimed at changing food intake, physical activity or both in order to control weight, prevent weight gain or achieve weight loss. Studies were excluded in which participants had eating disorders,9 learning disabilities,10 and undernutrition or malnutrition,9,10 as it would have been difficult to disentangle the effectiveness of behaviour change interventions targeting such heterogeneous populations.11
We searched Medline (1966–2000) and Psyclit (1971–2000) using search terms listed in Appendix A. The Medline search terms were combined with the first two parts of the Cochrane Collaboration strategy for identifying randomised trials.12 Retrieval was limited to articles in English. The search strategy identified 1121 studies that were initially assessed for inclusion. In total, 143 abstracts were reviewed and 47 apparently relevant papers were selected. All 47 papers were assessed in full against inclusion criteria (NM). Of these, 15 randomly selected papers were also independently assessed by KT. There was agreement about inclusion or exclusion for 14 of the 15 papers. Disagreement concerning one study was resolved by discussion (NM/WH/SG). Of the 47 papers, 18 met the inclusion criteria and were entered onto Reference Manager Version 7.13 A manual citation search of included papers yielded further three relevant studies.
The following data were extracted: study aim, target behaviour, characteristics of the family and index member (main family member targeted for behaviour change), entry criteria, duration of intervention and follow-up, sample size, losses to follow-up from evaluation, study outcomes, dropouts from the intervention and the nature of the intervention.
A preliminary taxonomy (Table 1) was developed to classify the different ways family members could be involved in behaviour change interventions aimed at weight control, weight maintenance and weight loss. The taxonomy was divided into two sections summarising ‘family characteristics’ and ‘intervention characteristics’, which included family involvement, format, attendance at sessions, goal and behaviour change technique categories. The behaviour change techniques were classified according to an existing taxonomy developed by Hardeman et al14 and independently validated by two authors. Disagreements were resolved by discussion.
Search results (Table 2)
Overall, the combined search strategy identified 21 papers describing 16 intervention studies.4,15,16,17,18,19,20,21,22,23,24,25,26,27,28,29,30,31,32,33,34 In all, 14 studies were conducted in the USA, one in Sweden and one in Canada. All were published between 1975 and 1994. The specified aim in 15 studies was weight loss, and in one study weight control.4 In total, 15 interventions aimed to change both food intake and physical activity levels of participants and one intervention targeted food intake alone.31 Four studies included a randomised waiting-list control group.26,29,30,32,33 The remaining 12 studies had no control arm but compared two or more interventions. Mean sample size of studies was 52 (range 33–97). The median intervention time was 16 weeks (range 9–104 weeks). Median duration of follow-up was 18 months (range 12 months–10 years) (Table 2).
Methodological quality (Table 2)
Losses to follow-up were reported for all the trials (median 15%, range 3–58%) and the intervention dropout rate was described in 10 trials (median 18%, range 0–40%). Allocation concealment at outcome assessment, techniques of randomisation and analytic strategy (for example, use of intention to treat analysis) were not well described in any of the studies.
Seven studies recruited school age children,4,15,20,21,22,23,24,25,26,27,28 one study adolescents16 and eight studies adults.17,18,19,29,30,31,32,33,34 In 14 studies where gender was specified, at least 70% of index members were female subjects.
Eight interventions targeted both parents and child or a parent and child dyad.4,15,16,20,21,22,23,24,25,26,27,28 Seven interventions targeted married couples,17,18,19,29,30,31,34 and one targeted the index member and a significant other, usually a spouse.32,33
All studies incorporated a face-to-face component within each intervention arm. A total of 13 studies involved group sessions15,16,18,20,21,22,23,24,25,26,27,28,29,30,31,32,33,34 and three incorporated individual or couple sessions.4,17,19 The median number of contacts with the index member was 11 (range 5–32). In all, 11 studies included a distant component, such as telephone calls and educational materials.
Attendance at sessions
In 10 studies, attendance of the index member was compared to attendance of both the index and family member(s).17 In two of these studies, the partial attendance of family member(s) (attending some designated sessions) was compared with full attendance31 or no attendance31,32,33 and one study specifically compared index and family member(s) attending sessions together and separately.16 In the remaining six studies, both the index member and family member(s) were invited to attend all sessions.15,16,18,19,28,29,30,31,32,33,34
Goals for index and family members
All studies aimed to change the index member's target behaviour and six studies aimed to change both the index member's and family members' behaviour.15,16,20,21,22,23,24,25,28,34 Family member(s) gave active support to index members in each intervention arm in seven studies.15 Other studies4,20,21,22,23,24,25,26,27,28 compared active support with either passive support,16 minimising negative support30 or no support17 to index members in different intervention arms.16,18,19,29,30,31,32,33,34 In nine studies, a monetary deposit was requested. This was returned dependent on attendance,17,16,18,23,24,28,30,31,32,33,34 keeping to a contract,17 completion of homework assignments28 and either weight loss or appropriate eating behaviour.32,33 In six studies, the index or family member was given a contract15 related to the change in target behaviour(s).17,19,20,21,22,25,28,29
Behaviour change techniques
All studies involving adults and adolescents, and one study involving children, compared teaching behaviour change techniques to index members alone to teaching behaviour change techniques to both index members and family members.16,17,18,19,28,28,29,30,31,32,33,34 Otherwise different amounts and types of behaviour change techniques taught to index members and family member(s) were compared.4,15,20,21,22,23,24,25,26,27 Hardeman et al14 cited 19 behaviour change techniques (Table 1). Studies incorporated a range of four4,23,24 to 1119,30 of these techniques. Behaviour change techniques most frequently used were (1) goal or target specified; (2) (self)monitoring; (3) contingencies or incentives for target behaviour or attendance; (4) increasing skills (5) social encouragement and support.
Effectiveness of family involvement (Table 4)
Involvement of spouses in weight loss, weight control and weight maintenance interventions tended to improve effectiveness. In three studies treating index members and spouses together produced significantly bigger effects at 1-y follow-up compared to treating index members alone.30,29,33 This trend did not achieve statistical significance in two further studies.18,31 However, in Saccone and Israel's study,33 the apparent benefit of spouse participation was only evident when eating behaviours were targeted rather than weight loss. The overall difference in weight loss between intervention groups in these five trials ranged from 0.318 to 6.1?kg.30
Conversely, three other studies17,19,34 suggested treating index members alone produced greater weight loss than treating index members and spouses together, at 1-y follow-up. One of these studies17 achieved statistical significance. The overall difference in weight loss between intervention groups in these three studies ranged from 1.317 to 5.9?kg.19 Only one study targeted both the index member and overweight spouse together.34 Spouses lost significantly more weight when treated alongside index members than when not receiving treatment (−7.6 vs 1.7?kg).
Brownell et al16 demonstrated that, at 1-y follow-up, adolescents targeted separately from their mothers lost significantly more weight than when targeted together with their mothers (10.6?kg).
Targeting both parents and children for weight loss seems to yield positive results for children. One study demonstrated significant results at 10-y follow-up,15,20,21,22 and another nonsignificant results at 1-y follow-up.28 The overall effect ranged from 1.428 to 11.715,20,21,22 drop in the percentage overweight. Results were conflicting for parental weight loss. The differential effect of family involvement dependent on children's age or gender could not be established. Studies did not analyse the effect of family involvement according to age or gender and no study targeted children under the age of 6?y.
Parent training in behaviour change techniques appears conducive to child weight loss. Two studies showed a trend in this direction at 1-y follow-up, although not achieving statistical significance.23,24,26 Parents were taught more behaviour change techniques in one intervention group compared to the other.
Generally, the greater the number of behaviour change techniques taught to both parents and children, the more successful the weight loss or weight control programme. Epstein et al25 showed a significant decrease in percentage overweight in the intervention group taught additional behaviour change techniques (9.8%).25 In this group, participants were also tested to ensure their understanding of behaviour change techniques taught. In Israel's study,27 seven more behaviour change techniques were taught to children in the Enhanced Child Involvement (ECI) group than in the standard treatment (ST) group. Children in the ECI group showed a nonsignificant decrease in percentage overweight (5.1%). Flodmark's prevention of weight gain (weight control) study showed a greater reduction in body mass index (BMI) (0.5%) in the group attending family therapy sessions, albeit not statistically significant.4
Despite a worldwide increase in the prevalence of obesity and the potential importance of family support for behaviour change, only 16 randomised studies on family involvement in weight control, weight maintenance and weight-loss interventions were identified in this review. Indeed, no studies were identified after 1994. The majority of studies were conducted in the USA and were concerned with weight loss; only one weight control study was identified, which was surprising considering the increasing need for strategies to prevent obesity. Three out of seven interventions targeting children and one spouse intervention were conducted at the same research centre.15,20,21,22,23,24,25,34 This may have introduced a bias in the results of this review, although the effectiveness of family involvement appeared to vary across the studies, and each of the children's interventions measured a different aspect of parent and child involvement and has been separately compared to research from other sources. Sample sizes were small and few studies conducted an intention-to-treat analysis. In studies where there were fairly subtle differences between intervention groups, such as teaching one or two additional skills, the power of the studies might not have been sufficient to detect clinically important differences in outcome. Losses to follow-up and dropouts from interventions were fairly low. Outcomes were heterogeneous within and between studies. Future studies might report standardised criteria, for example, weight in kilograms and BMI to aid interpretation.
The taxonomy was developed to classify the different ways in which family members could be involved in behaviour change interventions aimed at weight control, weight maintenance and weight loss. It was divided into two sections summarising (1) age and sex of the family member targeted for behaviour change and (2) how family members were involved in various intervention components. It aided this review by systematically gathering information on family involvement in interventions, such as classifying attendance at sessions and goals set by family members, and linking this to study effectiveness. It also provided sufficient information from which gaps in research may be ascertained. The taxonomy highlighted the even split of studies between those recruiting adults and those recruiting children, although only one study involved adolescents. Overall, studies most frequently included female subject's involved the index and family member attending face-to-face sessions compared to the index member attending face-to-face sessions alone, and had a goal of behaviour change by the index member with active support from the family. Most adult studies compared teaching behaviour change techniques to the index member alone to teaching both the index member and family member. In all but one of the child/parent studies, different amounts and types of behaviour change techniques were taught to index and family member(s). The review has highlighted the lack of studies including men, preschool children, adolescents and older adults, and interventions using an individual, dyad or family face-to-face format or a distance format, such as by telephone or letter. The results of this review support the conclusions of other similar studies, which indicate that the more behavioural change techniques used the greater the effectiveness of the intervention.14
Effectiveness of interventions
Involving family members in weight control, weight maintenance and weight loss programmes may improve their effectiveness. In studies involving spouses, there is generally more support for couples being treated together. One study suggested that this effect may be enhanced by setting goals related to specific behaviours (eg eating behaviours) rather than goals related to weight.33 Only one study targeted overweight spouses as well as the index member, and more research in this area would be informative. Many studies included spouses' willingness to attend sessions and support index members in the entry criteria; however, the degree to which spouses want to support index members could vary greatly both within and between studies. The nonsignificant positive effect of spouse involvement in this review is similar to the conclusion drawn by Black et al6 in their meta-analysis. Glenny et al8 could not establish the effectiveness of spouse involvement in the treatment of adult obesity because results were conflicting and sample sizes small; however, this review identified more studies, which enabled us to draw conclusions.
The one study including adolescents suggested that it may be more effective to treat them separately from their mothers, where mothers provide passive rather than active support.
In trials involving children supported by parental involvement, effectiveness of interventions tended to be positively associated with the number of behaviour change techniques taught to both parents and children, with parent training in behaviour change techniques and with targeting both parents and children together for weight loss. Epstein et al's25 study suggested that effectiveness may be increased when behavioural modification techniques are not only taught to participants, but their mastery of the techniques is also assessed. Future studies may establish whether the effects of parent involvement differ according to age or gender of the children. The positive effect of parent involvement on childhood obesity is similar to Glenny et al's8 conclusion that family therapy in the prevention of obesity and treating obese children and their parents together was effective. Glenny et al8 were unable to draw conclusions where only children were targeted for weight control and parents supported behaviour change; whereas, use of the taxonomy enabled us to establish that the number of behaviour change techniques taught to both parents and children and training parents in behaviour change techniques were positively associated with children's weight loss.8 Our conclusions conflict with those drawn by Haddock et al,7 who found no effect of family involvement on childhood obesity. The differences may be because the present review used randomised trials and length of follow-up as inclusion criteria.
There was no obvious link between length of intervention and effectiveness. In addition, it proved difficult to relate initial levels of obesity to weight loss, as studies used divergent criteria for obesity and criteria were not always specified. However, most adult studies used Metropolitan Life Insurance norms, and in those studies no association was found between initial levels of obesity and weight loss.
The conclusions drawn from this review have face validity. For children the support of a parent, and for adults the support of a spouse, would be expected to enhance effectiveness, but adolescents striving for independence might be expected to respond better when treated individually.
Implications for future research
The results of this systematic review underline the need for further well-designed interventions and evaluations. Future interventions could focus more on achieving weight control and weight maintenance, as opposed to simply weight loss. Considering the well-documented familial link in obesity,15 it may be sensible to encourage both children and parents to lose weight. Interventions for adults might be more effective if they target specific behaviours rather than the distal outcome of weight.
In all studies, some attempts to assure the quality of the intervention, for example, ensuring that behavioural change techniques have been taught, would enhance understanding of the causal mechanisms and reasons for differential effectiveness of interventions. A qualitative component would also enhance studies and provide insights into factors that could impact on the effectiveness of interventions, such as the degree of weight-loss spouses wish for their partners. Further studies in adolescents need to be conducted, as this is an under-researched population group in whom obesity and associated behaviour patterns are increasingly already established.35 Studies may assess whether the effectiveness of family involvement differs with age groups and gender.
The literature search was not exhaustive. The bibliographic search strategy was limited to just two databases Medline and Psyclit, with a manual check of the reference lists of included papers, articles were limited to those in the English language, unpublished trials and grey literature were not included and authors of the included papers were not contacted. Consequently, it is possible that publication bias has influenced the findings of this review.
Weight-loss interventions targeting food intake and/or physical activity might be most effective if they incorporate psychological and educational theory and involve family members appropriately. The taxonomy we have developed has assisted in classifying and comparing interventions and participants, particularly relating to the nature of family involvement, and may aid the development and specification of future interventions. However, there is continuing uncertainty about the most appropriate involvement of family members. The increasing worldwide burden of obesity should provide an impetus for further and better research into strategies for prevention at the individual, family and population level.
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This review was undertaken as part of a study funded by the NHS Executive Anglia, Medical Research Council and Royal College of General Practitioners. The views expressed in this publication are those of the researchers. We wish to thank Ann-Louise Kinmonth, Department of Public Health and Primary Care, University of Cambridge for her helpful comments. We also thank Janet Cade and Mike Robinson, Nuffield Institute, University of Leeds for supervising NM's Masters degree in Public Health dissertation, which contributed to this paper.
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McLean, N., Griffin, S., Toney, K. et al. Family involvement in weight control, weight maintenance and weight-loss interventions: a systematic review of randomised trials. Int J Obes 27, 987–1005 (2003). https://doi.org/10.1038/sj.ijo.0802383
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