Video Abstract
Our aim was to compare the effect of 2 treatment models on attendance and child weight status: a less intense guided self-help (GSH) program delivered in the primary care setting versus traditional family-based behavioral treatment (FBT) delivered in an academic center.
We conducted a randomized clinical trial among 164 children between 5 and 13 years old with a BMI ≥85th percentile and their parents. The intervention group (GSH) received 14 individual sessions over 6 months, with 5.3 hours of treatment. The control group (FBT) received 20 group-based sessions over 6 months, with 20 hours of treatment. Main outcomes included proportion of sessions families attended and change in child BMI z-score (BMIz), percentage from the 95th BMI percentile, difference from the 95th BMI percentile at the end of treatment, and 6-month follow-up.
Mean age of children was 9.6 years, BMI z-score 2.1, 49% female, and >90% Latino. The odds of attending GSH compared to FBT was 2.2 (P < 0.01). Those assigned to GSH had a 67% reduced risk of attrition (hazard ratio = 0.33, 95% confidence interval 0.22–0.50, P < .001). Intent-to-treat analysis showed no between-group differences in change in BMIz and percentage from the 95th BMI percentile over time. Combined, there was a significant reduction in BMIz from baseline to posttreatment (β = −0.07 (0.01), P < .01, d: 0.60) and a slight increase from posttreatment to follow-up (β = 0.007 (0.13), P = .56).
This study provides support for a novel, less intense GSH model of obesity treatment, which can be implemented in the primary care setting. Future studies should examine effective approaches to dissemination and implementation of GSH in different settings to increase access to treatment.
Second, this differential attrition raises the question of how to define an efficacious “dosage” of these treatments. GSH provided not only fewer visits (14 sessions versus 20 sessions) but also sessions that were shorter in length (the first lasting 60 minutes and all remaining lasting 20 minutes versus 60 minutes for every session in the FBT arm). Even though GSH participants attended more sessions, on average (7.4 versus 4.5), the total time they received nutritional coaching and counseling was significantly lower at 188 minutes (60 minutes + 6.4*20minutes) relative to the FBT arm (4.5 visits*60 minutes = 270 minutes). Thus, the question is whether the frequency of visits or the length of the visits is what matters. Although it appears that patients are more likely to complete visits that are shorter in duration (e.g. lower attrition among GSH), those visits were also happening at the primary care site as compared to an academic center, which could also explain differences in attrition.
Although this trial cannot tell us much about the effect of these treatment modes on health outcomes at this point, we may be able to learn more about structuring such treatment in a way that will increase compliance.