Article | Published:


Addressing childhood obesity in low-income, ethnically diverse families: outcomes and peer effects of MEND 7–13 when delivered at scale in US communities

International Journal of Obesity (2018) | Download Citation



Implementation of a large-scale, child weight management program in low-income, ethnically diverse communities provided an important opportunity to evaluate its effectiveness under service level conditions (i.e. provision as a primary care child weight management service).


MEND 7–13 is a community-based, multi-component, childhood obesity intervention designed to improve dietary, physical activity and sedentary behaviors. It comprises twice weekly sessions for 10 consecutive weeks (35 contact hours) and is delivered to groups of children and accompanying parents/caregivers. The evaluation used an uncontrolled, repeated measures design. Overall, 3782 children with overweight or obesity attended 415 MEND 7–13 programs in eight US states, of whom 2482 children (65.6%) had complete data for change in zBMI. The intervention targeted low-income, ethnically diverse families. Changes in anthropometric, cardiovascular fitness and psychological outcomes were evaluated. A longitudinal multivariate imputation model was used to impute missing data. Peer effects analysis was conducted using the instrumental variables approach and group fixed effects.


Mean changes in BMI and zBMI at 10 weeks were −0.49 kg/m2 (95% CI: −0.67, −0.31) and −0.06 (95% CI: −0.08, −0.05), respectively. Benefits were observed for cardiovascular fitness and psychological outcomes. Mean peer reduction in zBMI was associated with a reduction in participant zBMI in the instrumental variables model (B = 0.78, P = 0.04, 95% CI: 0.03, 1.53). Mean program attendance and retention were 73.9% and 88.5%, respectively.


Implementing MEND 7–13 under service level conditions was associated with short-term improvements in anthropometric, fitness and psychological indices in a large sample of low-income, ethnically diverse children with overweight and obesity. A peer effect was quantified showing that benefits for an individual child were enhanced, if peers in the same group also performed well. To our knowledge, this is the first US study to evaluate outcomes of an up-scaled community-based, child weight management program and to show positive peer effects associated with participation in the intervention.

Access optionsAccess options

Rent or Buy article

Get time limited or full article access on ReadCube.


All prices are NET prices.


  1. 1.

    Harvey JR, Ogden DE. Obesity treatment in disadvantaged population groups: where do we stand and what can we do? Prev Med. 2014;68:71–5.

  2. 2.

    Wang Y, Beydoun MA. The obesity epidemic in the United States—gender, age, socioeconomic, racial/ethnic, and geographic characteristics: a systematic review and meta-regression analysis. Epidemiol Rev. 2007;29:6–28.

  3. 3.

    Fagg J, Cole TJ, Cummins S, Goldstein H, Morris S, Radley D, et al. After the RCT: who comes to a family-based intervention for childhood overweight or obesity when it is implemented at scale in the community? J Epidemiol Community Health. 2015;69:142–8.

  4. 4.

    Lucas PJ, Curtis-Tyler K, Arai L, Stapley S, Fagg J, Roberts H. What works in practice: user and provider perspectives on the acceptability, affordability, implementation, and impact of a family-based intervention for child overweight and obesity delivered at scale. BMC Public Health. 2014;14:614.

  5. 5.

    Hardy LL, Mihrshahi S, Gale J, Nguyen B, Baur LA, O’Hara BJ. Translational research: are community-based child obesity treatment programs scalable? BMC Public Health. 2015;15:652.

  6. 6.

    NICE. Weight management: lifestyle services for overweight or obese children and young people. 2013. Accessed 11 July 2018.

  7. 7.

    Christakis NA, Fowler JH. The spread of obesity in a large social network over 32 years. N Engl J Med. 2007;357:370–9.

  8. 8.

    Renna F, Grafova IB, Thakur N. The effect of friends on adolescent body weight. Econ Hum Biol. 2008;6:377–87.

  9. 9.

    Trogdon JG, Nonnemaker J, Pais J. Peer effects in adolescent overweight. J Health Econ. 2008;27:1388–99.

  10. 10.

    Sacher PM, Chadwick P, Wells JC, Williams JE, Cole TJ, Lawson MS. Assessing the acceptability and feasibility of the MEND Programme in a small group of obese 7-11-year-old children. J Hum Nutr Diet. 2005;18:3–5.

  11. 11.

    Sacher PM, Kolotourou M, Chadwick PM, Cole TJ, Lawson MS, Lucas A, et al. Randomized controlled trial of the MEND program: a family-based community intervention for childhood obesity. Obesity. 2010;18:S62–8.

  12. 12.

    Kolotourou M, Radley D, Gammon C, Smith L, Chadwick P, Sacher PM. Long-term outcomes following the MEND 7-13 child weight management program. Child Obes. 2015;11:325–30.

  13. 13.

    Law C, Cole T, Cummins S, Fagg J, Morris S, Roberts, H. A pragmatic evaluation of a family-based intervention for childhood overweight and obesity. Public Health Research. Southampton, UK: NIHR Journals Library; 2014.

  14. 14.

    Butte NF, Hoelscher DM, Barlow SE, Pont S, Durand C, Vandewater EA, et al. Efficacy of a community- versus primary care-centered program for childhood obesity: TX CORD RCT. Obesity. 2017;25:1584–93.

  15. 15.

    Kuczmarski RJ, Ogden CL, Grummer-Strawn LM, Flegal KM, Guo SS, Wei R, et al. CDC growth charts: United States. Adv Data 2000;314:1–27.

  16. 16.

    NEF. The social and economic value of the Mend 7-13 programme. 2010. Accessed 12 March 2018.

  17. 17.

    O’Connor EA, Evans CV, Burda BU, Walsh ES, Eder M, Lozano P. Screening for obesity and intervention for weight management in children and adolescents: evidence report and systematic review for the US Preventive Services Task Force. JAMA. 2017;317:2427–44.

  18. 18.

    Hoelscher DM, Kirk S, Ritchie L, Cunningham-Sabo L, Academy Positions Committee. Position of the Academy of Nutrition and Dietetics: interventions for the prevention and treatment of pediatric overweight and obesity. J Acad Nutr Diet. 2013;113:1375–94..

  19. 19.

    Lohman TG. Anthropometric standardization reference manual. Champaign, IL: Human Kinetics;1988.

  20. 20.

    Rudolf MC, Walker J, Cole TJ. What is the best way to measure waist circumference? Int J Pediatr Obes. 2007;2:58–61.

  21. 21.

    Flegal KM, Wei R, Ogden CL, Freedman DS, Johnson CL, Curtin LR. Characterizing extreme values of body mass index-for-age by using the 2000 Centers for Disease Control and Prevention growth charts. Am J Clin Nutr. 2009;90:1314–20.

  22. 22.

    Woo JG, Cole TJ. Assessing adiposity using BMI z-score in children with severe obesity. Obesity. 2017;25:662.

  23. 23.

    Freedman DS, Butte NF, Taveras EM, Lundeen EA, Blanck HM, Goodman AB, et al. BMI z-scores are a poor indicator of adiposity among 2- to 19-year-olds with very high BMIs, NHANES 1999-2000 to 2013-2014. Obesity. 2017;25:739–46.

  24. 24.

    Golding LA. YMCA fitness testing and assessment manual. Champaign, IL: Human Kinetics; 2000.

  25. 25.

    Yin Z, Gutin B, Johnson MH, Hanes J Jr., Moore JB, Cavnar M, et al. An environmental approach to obesity prevention in children: Medical College of Georgia FitKid Project year 1 results. Obes Res. 2005;13:2153–61.

  26. 26.

    Yin Z, Hanes J Jr., Moore JB, Humbles P, Barbeau P, Gutin B. An after-school physical activity program for obesity prevention in children: the Medical College of Georgia FitKid Project. Eval Health Prof. 2005;28:67–89.

  27. 27.

    Goodman R. The strengths and difficulties questionnaire: a research note. J Child Psychol Psychiatry. 1997;38:581–6.

  28. 28.

    Mendelson BK, White DR. Relation between body-esteem and self-esteem of obese and normal children. Percept Mot Skills. 1982;54:899–905.

  29. 29.

    Harter S. Manual of the self-perception profile for children. Denver: University of Denver; 1985.

  30. 30.

    Rosenberg M. Society and the adolescent self-image. Princeton, NJ: Princeton University Press; 1965.

  31. 31.

    Modi AC, Zeller MH. Validation of a parent-proxy, obesity-specific quality-of-life measure: sizing them up. Obesity. 2008;16:2624–33.

  32. 32.

    Varni JW, Seid M, Kurtin PS. PedsQL 4.0: reliability and validity of the Pediatric Quality of Life Inventory version 4.0 generic core scales in healthy and patient populations. Med Care. 2001;39:800–12.

  33. 33.

    Tsiros MD, Olds T, Buckley JD, Grimshaw P, Brennan L, Walkley J, et al. Health-related quality of life in obese children and adolescents. Int J Obes. 2009;33:387–400.

  34. 34.

    Ware J Jr., Kosinski M, Keller SD. A 12-Item Short-Form Health Survey: construction of scales and preliminary tests of reliability and validity. Med Care. 1996;34:220–33.

  35. 35.

    US Census. Accessed 12 March 2018.

  36. 36.

    Fagg J, Chadwick P, Cole TJ, Cummins S, Goldstein H, Lewis H, et al. From trial to population: a study of a family-based community intervention for childhood overweight implemented at scale. Int J Obes (Lond). 2014;38:1343–9.

  37. 37.

    Fleming S, Thompson M, Stevens R, Heneghan C, Pluddemann A, Maconochie I, et al. Normal ranges of heart rate and respiratory rate in children from birth to 18 years of age: a systematic review of observational studies. Lancet. 2011;377:1011–8.

  38. 38.

    Rubin DB. Multiple imputation for nonresponse in surveys. Chichester: John Wiley and Sons; 1987.

  39. 39.

    Sterne JA, White IR, Carlin JB, Spratt M, Royston P, Kenward MG, et al. Multiple imputation for missing data in epidemiological and clinical research: potential and pitfalls. BMJ. 2009;338:b2393.

  40. 40.

    Manski CF. Identification of endogenous social effects: the reflection problem. Rev Econ Stud. 1993;60:531–42.

  41. 41.

    Gaviria A, Raphael S. School-based peer effects and juvenile behavior. Rev Econ Stat. 2001;83:257–68.

  42. 42.

    Norton EC, Lindrooth RC, Ennett ST. Controlling for the endogeneity of peer substance use on adolescent alcohol and tobacco use. Health Econ. 1998;7:439–53.

  43. 43.

    Powell LM, Tauras JA, Ross H. The importance of peer effects, cigarette prices and tobacco control policies for youth smoking behavior. J Health Econ. 2005;24:950–68.

  44. 44.

    Von Hinke S, Leckie G, Nicoletti C. The use of instrumental variables in peer effects models with group fixed effects. Mimeo: University of Bristol; 2015.

  45. 45.

    Guzman GG. Household Income. 2016. Accessed 12 March 2018.

  46. 46.

    Davis MM, Aromaa S, McGinnis PB, Ramsey K, Rollins N, Smith J, et al. Engaging the underserved: a process model to mobilize rural community health coalitions as partners in translational research. Clin Transl Sci. 2014;7:300–6.

  47. 47.

    Nobles J, Griffiths C, Pringle A, Gately P. Design programmes to maximise participant engagement: a predictive study of programme and participant characteristics associated with engagement in paediatric weight management. Int J Behav Nutr Phys Act. 2016;13:76.

  48. 48.

    Skelton JA, Beech BM. Attrition in paediatric weight management: a review of the literature and new directions. Obes Rev. 2011;12:e273–81.

  49. 49.

    Davis AM, Daldalian MC, Mayfield CA, Dean K, Black WR, Sampilo ML, et al. Outcomes from an urban pediatric obesity program targeting minority youth: the Healthy Hawks program. Child Obes. 2013;9:492–500.

  50. 50.

    Janicke DM, Sallinen BJ, Perri MG, Lutes LD, Huerta M, Silverstein JH, et al. Comparison of parent-only vs family-based interventions for overweight children in underserved rural settings: outcomes from project STORY. Arch Pediatr Adolesc Med. 2008;162:1119–25.

  51. 51.

    Sacher P. Randomised controlled trial of the MEND Programme: a family-based community intervention for childhood obesity. Obesity. 2010;Suppl 1:S62–8. Accessed 12 March 2018.

  52. 52.

    Kolotourou M, Radley D, Chadwick P, Smith L, Orfanos S, Kapetanakis V, et al. Is BMI alone a sufficient outcome to evaluate interventions for child obesity? Child Obes. 2013;9:350–6.

  53. 53.

    Cason-Wilkerson R, Goldberg S, Albright K, Allison M, Haemer M. Factors influencing healthy lifestyle changes: a qualitative look at low-income families engaged in treatment for overweight children. Child Obes. 2015;11:170–6.

  54. 54.

    Datar A, Nicosia N. Association of exposure to communities with higher ratios of obesity with increased body mass index and risk of overweight and obesity among parents and children. JAMA Pediatr. 2018;172:239–46.

  55. 55.

    Aarts F, Radhakishun NN, van Vliet M, Geenen R, von Rosenstiel IA, Hinnen C, et al. Gastric bypass may promote weight loss in overweight partners. J Am Board Fam Med. 2015;28:90–6.

  56. 56.

    Singh GK, Kogan MD, Siahpush M, van Dyck PC. Prevalence and correlates of state and regional disparities in vigorous physical activity levels among US children and adolescents. J Phys Act Health. 2009;6:73–87.

  57. 57.

    Eime RM, Young JA, Harvey JT, Charity MJ, Payne WR. A systematic review of the psychological and social benefits of participation in sport for children and adolescents: informing development of a conceptual model of health through sport. Int J Behav Nutr Phys Act. 2013;10:98.

  58. 58.

    Kalra G, De Sousa A, Sonavane S, Shah N. Psychological issues in pediatric obesity. Ind Psychiatry J. 2012;21:11–7.

  59. 59.

    Wallander JL, Fradkin C, Chien AT, Mrug S, Banspach SW, Davies S, et al. Racial/ethnic disparities in health-related quality of life and health in children are largely mediated by family contextual differences. Acad Pediatr. 2012;12:532–8.

  60. 60.

    Christakis NA, Fowler JH. Social contagion theory: examining dynamic social networks and human behavior. Stat Med. 2013;32:556–77.

  61. 61.

    Salvy SJ, de la Haye K, Bowker JC, Hermans RC. Influence of peers and friends on children’s and adolescents’ eating and activity behaviors. Physiol Behav. 2012;106:369–78.

  62. 62.

    Salvy SJ, Bowker JC. Peers and obesity during childhood and adolescence: a review of the empirical research on peers, eating, and physical activity. J Obes Weight Loss Ther. 2014;4:207.

  63. 63.

    Gorin AA, Lenz EM, Cornelius T, Huedo-Medina T, Wojtanowski AC, Foster GD. Randomized controlled trial examining the ripple effect of a nationally available weight management program on untreated spouses. Obesity. 2018;26:499–504.

  64. 64.

    Gwozdz W, Sousa-Poza A, Reisch LA, Bammann K, Eiben G, Kourides Y, et al. Peer effects on obesity in a sample of European children. Econ Hum Biol. 2015;18:139–52.

  65. 65.

    Skelton JA, Martin S, Irby MB. Satisfaction and attrition in paediatric weight management. Clin Obes. 2016;6:143–53.

Download references


MEND 7–13 was provided free to all attending families. Program funding was received from a number of public and private organizations, including: American Council on Exercise, Anthem/Wellpoint, BG Group, Blue Cross Blue Shield Illinois, Blue Cross Blue Shield Kansas City, Blue Cross Blue Shield Texas, Chicago Community Foundation, City of Amarillo Public Health Department, Colorado Health Foundation, Corpus Christi Nueces County Public Health Department, General Mills Foundation, Harlem Children’s Zone, Houston Endowment Inc., Kaiser Permanente, Lawndale Christian Healthcare Centre, Lexington Hospital, OSI Pharmaceuticals Foundation, RGK Foundation, Rose Hills Foundation, Scott & White Foundation, Sequoia Healthcare District, St. David’s Foundation, United Way, University of Texas Brownsville School of Public Health.

Author information


  1. Childhood Nutrition Research Centre, University College London, London, UK

    • Paul M. Sacher
  2. Healthy Weight Partnership Inc., Boston, MA, USA

    • Paul M. Sacher
    •  & Maria Kolotourou
  3. Department of Economics, University College London, London, UK

    • Stavros Poupakis
  4. Department of Diabetes, Royal Free Hampstead NHS Trust, Pond Street, London, UK

    • Paul Chadwick
  5. School of Sport, Leeds Beckett University, Leeds, UK

    • Duncan Radley
  6. Centre for Paediatric Epidemiology and Biostatistics, University College London, London, UK

    • Jamie Fagg


  1. Search for Paul M. Sacher in:

  2. Search for Maria Kolotourou in:

  3. Search for Stavros Poupakis in:

  4. Search for Paul Chadwick in:

  5. Search for Duncan Radley in:

  6. Search for Jamie Fagg in:

Conflicts of interest

PMS, MK, SP and JF are consultants for Healthy Weight Partnership, a for profit organization that delivers MEND in North America. In addition, PMS is a shareholder of Healthy Weight Partnership Inc. The remaining authors declare that they have no conflict of interest.

Corresponding author

Correspondence to Paul M. Sacher.

About this article

Publication history