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Obesity Prevention/Treatment

Family-focused physical activity, diet and obesityinterventions in African–American girls:a systematic review

D. J. Barr-Anderson1, A. W. Adams-Wynn2, K. I. DiSantis3 and S. Kumanyika4

1Arnold School of Public Health, University of

South Carolina, Columbia, SC, USA; 2School

of Kinesiology, University of Minnesota,

Minneapolis, MN, USA; 3College of Health

Sciences, Arcadia University, Glenside, PA,

USA; 4Perelman School of Medicine,

University of Pennsylvania, Philadelphia, PA,

USA

Received 8 May 2012; revised 28 August

2012; accepted 30 August 2012

Address for correspondence: DJ

Barr-Anderson, Public Health Research

Center, 921 Assembly Street, Room 135,

Columbia, SC 29208, USA.

E-mail: [email protected]

SummaryObesity interventions that involve family members may be effective with racial/ethnic minority youth. This review assessed the nature and effectiveness of familyinvolvement in obesity interventions among African–American girls aged 5–18years, a population group with high rates of obesity. Twenty-six databases weresearched between January 2011 and March 2012, yielding 27 obesity pilot orfull-length prevention or treatment studies with some degree of family involve-ment and data specific to African–American girls. Interventions varied in type andlevel of family involvement, cultural adaptation, delivery format and behaviourchange intervention strategies; most targeted parent–child dyads. Some similari-ties in approach based on family involvement were identified. The use of theo-retical perspectives specific to African–American family dynamics was absent.Across all studies, effects on weight-related behaviours were generally promisingbut often non-significant. Similar conclusions were drawn for weight-relatedoutcomes among the full-length randomized controlled trials. Many strategiesappeared promising on face value, but available data did not permit inferencesabout whether or how best to involve family members in obesity prevention andtreatment interventions with African–American girls. Study designs that directlycompare different types and levels of family involvement and incorporate relevanttheoretical elements may be an important next step.

Keywords: Adolescents, caregiver, nutrition, physical activity.

obesity reviews (2013) 14, 29–51

Introduction

In the United States, disparities in obesity are evidencedby elevated obesity rates within racial/ethnic minoritiesrelative to those seen in Caucasians (non-Hispanic white)(1). This disparity affects African–American (non-Hispanicblack) girls aged 6–19 years, whose prevalence of obesity(�95th percentile) in 2007–2008 was 26%, compared to16% in their Caucasian counterparts (2), and remainedsteady in 2009–2010 (3). A striking disparity was also seenin an analysis of severe obesity (�120% of 95th percentile):

African–American girls had doubled the prevalence com-pared to Caucasian girls (18% vs. 9%, respectively) (4). Aneed for specially designed interventions to address obesityin African–American females is suggested by the disparityin prevalence and also by evidence of lesser effectiveness ofweight loss interventions in black compared to Caucasianpopulations. African Americans tend to lose less weightthan Caucasians when offered the same intervention (5–7),and this difference is particularly pronounced in females(5,7). These dissimilarities have been attributed to bothcultural and contextual issues, i.e. possible variations in

obesity reviews doi: 10.1111/j.1467-789X.2012.01043.x

29© 2012 The Authorsobesity reviews © 2012 International Association for the Study of Obesity 14, 29–51, January 2013

factors that influence the motivation or ability of partici-pants to adhere to behavioural change advice.

Family-based behavioural interventions are among themost successful for addressing childhood obesity (8), andmay have particular relevance to racial/ethnic minorityyouth (9). When targeting youth using behavioural changestrategies, it makes practical sense to engage the familyand not just the child. The child is not in sole control ofdecision-making related to healthy lifestyle choices.Rather, family dynamics (i.e. family rules, emotionalsupport, encouragement, positive reinforcement andfamily involvement) work as a unit, with parents influenc-ing their children and vice versa (8). Sociological researchsuggests that African–American households exhibit aninherent strength in their supportive, interpersonal parent–child and extended family bonds, in response to historicaldiscrimination (10). Thus, in addition to the generalfinding that a focus on family and home environmentsis important in child-focused obesity interventions,the inclusion of family members and using familiar sur-roundings such as neighbourhood community centresor homes as the setting for the interventions may alsobe forms of cultural adaptation for African–Americanchildren (10).

Although several reviews have focused on effects offamily involvement on outcomes (11–14), findings of thesereviews have pointed out the need for more evidence aboutthe effectiveness of such approaches on racial/ethnicminorities (12,14), and it is still unclear what level offamily involvement yields the largest impact on youthbehaviours and weight outcomes. Therefore, this reviewwas undertaken to examine evidence available for inter-vention studies with a family component for African–American girls. Based on an Institute of Medicine reportthat encouraged an inclusive approach to locating andassessing evidence about obesity prevention (15), all poten-tially relevant evidence was considered in order to obtaininsights about strategies used, how comprehensive theywere, and how they were conducted as well as impact onoutcomes. The overall objective was to gather a compre-hensive picture of the evidence available for this particulartype of intervention for a vulnerable population, African–American girls. Specific aims of the review were to (i)examine intervention strategies related to level of familyinvolvement and cultural adaptation and (ii) assess theeffectiveness of studies with different types and levels offamily involvement.

Methods

Data sources

In January and February 2011, relevant peer-reviewedjournal articles and abstracts from databases (AGRICOLA,

AMED, Biological Abstracts, BIOSIS Previews, CDSR[Cochrane], CENTRAL/CCTR, CINAHL, CochraneLibrary, DARE, ERIC, EMBASE, Health Source: Nursing/Academic Edition, PsycARTICLES, PsycINFO, PubMed orMEDLINE, Population Index, Proquest Digital Disserta-tion Abstracts Int’l, Proquest Digital Dissertations andTheses, Science Citation Index [Web of Science], Science-Direct, SCOPUS, Social Science Citation Index [Web ofScience], SPORTDiscus, TRIS, TRIP, Web of Science) wereretrieved during a systematic search of interventions forAfrican–American girls that included a family componentand incorporated weight change, physical activity and/ornutrition components. The following strategy and searchterms were applied: (adolescent OR girl OR teen OR childOR youth) AND (African-American OR black) AND(obesity OR weight OR overweight) AND intervention.Bibliographies from pertinent articles were also reviewedfor additional applicable interventions. In November 2011and March 2012, the electronic search was updated. Therewas no limit on publication year, except for the restrictionsof the databases. The earliest searchable year was 1887(PsycINFO).

Study inclusion and exclusion criteria

The inclusion criteria used for all articles and abstractswere (i) samples that included any African–American girlsaged 5–18 years; (ii) some degree of family involvement;(iii) intervention studies only; (iv) intervention strategiestargeting physical activity, eating/nutrition or weight; (v)any study design (e.g. randomized controlled trial [RCT],quasi-experimental or other); (vi) primary outcome relatedto physical activity, healthy eating (i.e. fruit, vegetable,water, sweetened beverage) or weight; (vii) availability ofdescription of intervention; (viii) studies conducted in theUnited States only; and (ix) intervention took place ineither a home or community setting (i.e. school, localtheatre, clinic, park or recreational centre, etc.).

There were no restrictions on the length of the interven-tion, year in which the intervention took place, or theweight of participants at study entry. Included articles werenot restricted to studies with African American-only orgirl-only samples. However, results for African Americansand girls had to be reported or considered separately (i.e.stratification or assessment of interaction) from other racialgroups and from boys. From the electronic searches, 8,709citations matched the initial search criteria. Each articletitle and abstract were reviewed independently by tworesearchers for duplicates and relevancy. Excluded werenon-English publications, news reports, review articles andsecondary data analyses. The remaining articles (n = 67)were then obtained for independent review by the sameauthors.

30 Family interventions in African–American girls D. J. Barr-Anderson et al. obesity reviews

© 2012 The Authorsobesity reviews © 2012 International Association for the Study of Obesity14, 29–51, January 2013

Identification of eligible studies

Of the 67 articles thoroughly reviewed (Fig. 1), many wereexcluded because their results did not stratify for ethnicityand/or gender (n = 31), precluding assessment of interven-tion effects for African–American girls. No attempt wasmade to contact the authors of these studies to providesubgroup analysis for African–American girls. Otherreasons for exclusion were: the intervention did notinclude a family component (n = 5); baseline data but notpost-intervention data were reported (n = 4); the article

was a review or secondary data analysis (n = 4); and thetargeted child was less than 5 years of age (n = 1), result-ing in 22 articles. In November 2011, the databases weresearched again and five articles were found that met theinclusion and exclusion criteria. No additional articleswere identified after a further update of the search inMarch 2012, resulting in a final number of 27 articlesincluded in this systematic review. Of the studies included,four were pilot studies (16–19) for RCTs of 2-yearinterventions (20–23) that are also represented in thisreview.

Potentially relevant citations identified through systematic

searches in SEARCH ENGINES* (n = 8709)

Excluded citations that were duplicates or unrelated

(n = 8644)

Publications included from first literature search February 2011 (n = 22)

Articles carefully examined for inclusion (n = 67)

Excluded citations that did

not stratify by race/ethnicity

and/or gender(n = 31)

Excluded citations that

did not include a family

component (n = 5)

Excluded citations that

did not report post-intervention data (n = 4)

Excluded citations that were a review or secondary data analysis

(n = 4)

Five additional publications included from November 2011 literature search (n = 27)

Excluded citation that targeted a child less than 5(n = 1)

Figure 1 Flow chart of systematic search findings.*Search engines: AGRICOLA, AMED, Biological Abstracts, BIOSIS Previews, CDSR (Cochrane), CENTRAL/CCTR, CINAHL, Cochrane Library, DARE,ERIC, EMBASE, Health Source: Nursing/Academic Edition, PsycARTICLES, PsycINFO, PubMed or MEDLINE, Population Index, Proquest DigitalDissertation Abstracts Int’l, Proquest Digital Dissertations and Theses, Science Citation Index (Web of Science), ScienceDirect, SCOPUS, SocialScience Citation Index (Web of Science), SPORTDiscus, TRIS, TRIP, Web of Science.

obesity reviews Family interventions in African–American girls D. J. Barr-Anderson et al. 31

© 2012 The Authorsobesity reviews © 2012 International Association for the Study of Obesity 14, 29–51, January 2013

Data extraction and analysis

Variables of interest included the intervention behaviouralchange strategies, level of family involvement, culturaladaptations, and the effectiveness of the studies on diet,physical activity, and weight change. Data extracted fromeach article include data collection year, study populationdescription, study setting, study design, theoretical frame-work, key intervention components, intervention durationand follow-up periods, assessment measures for treatmenteffects, key intervention findings related to outcome vari-ables, strengths and limitations of the study, recommenda-tions for future research, and criteria related to internal andexternal validity.

Assessment of intervention components

Assessment of family participation or involvement wasadapted from previous work that evaluated the nature andeffectiveness of family involvement in weight control,weight maintenance and weight loss interventions (24).Family involvement was described according to (i) familymember involvement (i.e. parent–child only, multiplefamily members that included parent–child pair plus addi-tional family member[s], or whole family involvementdefined as entire household where child lives most of thetime); (ii) index member (i.e. targeted participant) of theintervention; (iii) format of intervention delivery (i.e.distant, face-to-face and/or other delivery); (iv) expectedjoint attendance by index and family member (i.e. single/partial/all sessions attended jointly/separately); (v) goal forthe family member (i.e. no specific goal, support-relatedgoal or change in own behaviour goal); and (vi) behaviourtargeted for change (i.e. physical activity and/or diet).

Cultural adaptation was described as (i) no culturaladaptation mentioned; (ii) adaptation limited to targetedrecruitment of African–American participants or conductof intervention in culturally familiar setting; or (iii) specificattempts to tailor intervention components (25).

Assessment of methodological quality

Internal validity was evaluated using six criteria adaptedfrom the Delphi list (26): (i) randomization performed; (ii)treatment allocation concealed for baseline data collection;(iii) groups similar at baseline; (iv) eligibility criteria speci-fied; (v) point estimates presented; and (vi) intention-to-treat analysis included. Criteria related to blinding werenot assessed because the nature of behavioural changeinterventions prevents research staff and participants frombeing blinded to treatment assignment. External validitywas assessed using seven criteria outlined by Green andGlasgow most applicable to behaviour change intervention

research (27): staff expertise, programme adaptation,long-term effects, institutionalization, attrition, consistentimplementation, and quality of implementation of differentprogramme components and mechanisms. A total meth-odological quality score was created by summing thenumber of internal and external validity criteria met (seeSupporting Information Appendix S1 for methodologicalquality assessment table).

Behavioural and weight change outcomes

Studies identified included some that recruited only over-weight or obese participants and were treatment orientedas well as those that focused on or included girls in thehealthy weight range and were prevention oriented. Westratified studies into treatment and prevention subsetswhen considering outcomes given the differences in studyparticipants, goals and participant motivations related totreatment vs. prevention. In particular, prevention studiestend to focus more on shaping lifelong habits than onweight loss strategies, and participant motivations foradherence may be much more heterogeneous than in treat-ment study populations. Both types of studies would beexpected to result in similar behaviour changes, but effectson weight are often smaller in prevention studies and maynot be detectable in the short term. We were also cognizantof the complexities of evaluating weight change outcomesin growing children and adolescents among whom weight,height and body mass index (BMI) increase with age andare evaluated on growth charts (28,29). Improvements inweight of active intervention vs. control groups may bereflected in various scenarios (weight loss, no change inweight or less weight gain; or reduced, stable, or less ofan increase in age and gender-specific BMI z-scores) inthe active intervention relative to control group. Takentogether, these issues led us to consider the direction of netweight change outcomes only in controlled trials (RCTs) oftreatment (any duration) and only in full-length RCTsof prevention. We considered the direction and significanceof behavioural change outcomes for all studies.

Results

Description of studies

Table 1 provides a general description of the study popu-lation, study setting and state location, study design andtheoretical framework, nature of comparison group (ifapplicable), and duration of intervention and post-intervention follow-up, grouped by age of participants (i.e.�12 years, �13 years or across both age groups). Studiesare grouped by participant age because studies that targetdifferent developmental stages likely require differentapproaches. Therefore, some of the results discussing the



Tab

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ilot,

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inte

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afa

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hor

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dy

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retic

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ure

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roup

Dur

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nof

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and

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here

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le)

Ag

e�

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bon

etal

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05(1

9)(1

999)

(Not

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icle

s:Fi

tzg

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2002

(57)

and

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03(4

9))

409

pre

-sch

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ge

child

ren

(50.

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mal

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ajor

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(99%

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80.7

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300

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old

girl

san

dth

eir

par

ents

§

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mun

ityb

ased

(low

-inco

me

com

mun

ityce

ntre

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dho

me

bas

edC

alifo

rnia

Two-

gro

upp

aral

lelR

CT

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ialc

ogni

tive

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ryM

onth

lyne

wsl

ette

rsan

dq

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erly

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mun

ityce

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ting

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rmat

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edhe

alth

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atio

non

nutr

ition

,p

hysi

cala

ctiv

ity,

and

red

ucin

gca

rdio

vasc

ular

dis

ease

and

canc

erris

k

2ye

ars



Tab

le1

Con

tinue

d

Aut

hor

pub

licat

ion

year

(yea

rst

udy

star

ted

)S

tud

yp

opul

atio

n†S

tud

yse

tting

‡an

dst

ate

loca

tion

Stu

dy

des

ign

and

theo

retic

alfr

amew

ork

Nat

ure

ofco

mp

aris

ong

roup

Dur

atio

nof

inte

rven

tion

and

FU(w

here

app

licab

le)

Sto

ryet

al.

2003

(35)

(200

1)54

8–10

-yea

r-ol

dg

irls

and

thei

rp

aren

ts§

Com

mun

ityb

ased

(nei

ghb

ourh

ood

loca

tions

and

afte

r-sc

hool

pro

gra

mm

e)an

dho

me

bas

edM

inne

sota

Pilo

t;tw

o-g

roup

par

alle

lRC

TS

ocia

lcog

nitiv

eth

eory

Non

-nut

ritio

n/p

hysi

cala

ctiv

ityp

rog

ram

me

focu

sed

onp

rom

otin

gp

ositi

vese

lf-es

teem

and

cultu

rale

nric

hmen

t;th

ree

mon

thly

Sat

urd

aym

orni

ngm

eetin

gs

incl

udin

gar

tsan

dcr

afts

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lf-es

teem

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ities

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eatin

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yb

ooks

and

aw

orks

hop

onA

fric

anp

ercu

ssio

nin

stru

men

ts

12w

eeks

Bar

bea

uet

al.

2007

(31)

(not

spec

ified

)27

88–

12-y

ear-

old

girl

s(3

rd–5

thg

rad

e)Tr

eatm

ent

gro

up(n

=11

8)C

ontro

lgro

up(n

=83

)

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mun

ityb

ased

(sev

enel

emen

tary

scho

ols)

Geo

rgia

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gro

upp

aral

lelR

CT

Fram

ewor

kno

tsp

ecifi

edN

oin

terv

entio

nfo

rco

mp

aris

ong

roup

10m

onth

s

Fitz

gib

bon

etal

.19

95(3

3)(n

otsp

ecifi

ed)

24w

omen

and

thei

r8–

12-y

ear-

old

dau

ght

ers

Com

mun

ityb

ased

(tut

orin

gp

rog

ram

me

adja

cent

toho

usin

gp

roje

ctco

mp

lex)

Illin

ois

Pilo

t;tw

o-g

roup

par

alle

lRC

TS

ocia

llea

rnin

gth

eory

No

inte

rven

tion

for

com

par

ison

gro

up6

wee

ks

Ram

anet

al.

2010

(44)

(200

5)16

59–

11-y

ear-

old

girl

san

db

oys

(�85

thB

MI

per

cent

ilefo

rag

ean

dg

end

er)

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mun

ityb

ased

(sum

mer

cam

plo

cate

dat

YM

CA

)C

alifo

rnia

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t;tw

o-g

roup

,no

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ndom

ized

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uasi

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erim

enta

lS

ocia

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nitiv

eth

eory

Chi

ld:

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entio

nalY

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erca

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ent§ :

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ition

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phy

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tivity

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)

12m

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Bur

net

etal

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11(4

0)(n

otsp

ecifi

ed)

(Not

e:su

pp

lem

enta

lart

icle

:B

urne

tet

al.

2002

(9))

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artic

ipan

ts(2

9fa

mili

es)

incl

udin

g30

9–12

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ht(�

85th

BM

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erce

ntile

for

age

and

gen

der

)g

irls

and

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d32

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mun

ityb

ased

(sp

ecifi

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ed)

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ois

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ent

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tal

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lthb

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cial

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ning

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ry,

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and

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odel

NA

14w

eeks

(inte

nsiv

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onth

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year

1ye

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aug

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ome

bas

edTe

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eren

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aves

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ialc

ogni

tive

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ry

NA

8w

eeks



Tab

le1

Con

tinue

d

Aut

hor

pub

licat

ion

year

(yea

rst

udy

star

ted

)S

tud

yp

opul

atio

n†S

tud

yse

tting

‡an

dst

ate

loca

tion

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dy

des

ign

and

theo

retic

alfr

amew

ork

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ure

ofco

mp

aris

ong

roup

Dur

atio

nof

inte

rven

tion

and

FU(w

here

app

licab

le)

New

ton

etal

.20

10(4

3)(n

otsp

ecifi

ed)

772n

d–6

thg

rad

est

uden

ts(m

ean

age

of9.

26ye

ars;

50%

girl

s)

Com

mun

ityb

ased

(sch

ool)

and

hom

eb

ased

Loui

sian

a

Pilo

t;on

etre

atm

ent

gro

up,

qua

si-e

xper

imen

tal

Soc

iall

earn

ing

theo

ry

NA

18m

onth

s

Olv

era

etal

.20

10(4

8)(2

006)

(Not

e:su

pp

lem

enta

lart

icle

:O

lver

aet

al.

2008

(60)

)

37g

irls

(85t

h–94

thB

MI

per

cent

ilefo

rag

ean

dg

end

er)

and

thei

rp

aren

ts§

(n=

27La

tina

girl

s;n

=10

AA

girl

s);

mea

nag

e:10

.8�

1.2

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mun

ityb

ased

(uni

vers

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mp

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tting

)an

dho

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edTe

xas

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t;on

etre

atm

ent

gro

up,

qua

si-e

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tal

Soc

ialc

ogni

tive

theo

ry

NA

3w

eeks

Jack

son

etal

.20

10(4

1)(2

006)

15lo

w-in

com

e11

–13-

year

-old

girl

san

db

oys

(n=

12g

irls)

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mun

ityb

ased

(low

-inco

me

urb

anaf

ter-

scho

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tting

)an

dho

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bas

edG

eorg

ia

Pilo

t;on

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ent

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up,

qua

si-e

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talw

ithC

BP

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pro

ach

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ewor

kno

tsp

ecifi

ed

NA

6w

eeks

Ag

e�

13ye

ars

Will

iam

son

etal

.20

06(3

8)(n

otsp

ecifi

ed)

5711

–15-

year

-old

over

wei

ght

girl

san

d1

over

wei

ght

par

ent§

Hom

eb

ased

Loui

sian

aTw

o-g

roup

par

alle

lRC

TFr

amew

ork

not

spec

ified

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lthed

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ion

del

iver

edvi

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ce-t

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nsan

dlin

ksto

ava

riety

ofw

ebsi

tes

pro

mot

ing

ahe

alth

ylif

esty

le

2ye

ars

Fren

net

al.

2003

(45)

(200

0)13

012

–15-

year

-old

mul

ti-et

hnic

girl

san

db

oys

(n=

58A

A;

n=

68g

irls)

Trea

tmen

tg

roup

(n=

67)

Con

trolg

roup

(n=

63)

Com

mun

ityb

ased

(sch

ool

com

put

erla

b)

Wis

cons

in

Two-

gro

up,

non-

rand

omiz

ed,

qua

si-e

xper

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tal

Com

bin

atio

nof

tran

sthe

oret

ical

and

heal

thp

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nm

odel

s

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par

ison

gro

upno

td

escr

ibed

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dem

icsc

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year

~9m

onth

s

Res

nico

wet

al.

2005

(21)

(not

spec

ified

)12

312

–16-

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girl

s(>

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BM

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erce

ntile

for

age

and

gen

der

)

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mun

ityb

ased

(chu

rche

s)G

eorg

iaTw

o-g

roup

par

alle

lRC

TFr

amew

ork

not

spec

ified

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erat

ein

tens

ityco

mp

aris

ong

roup

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ld:

six

mon

thly

sess

ions

sele

ctin

gle

sson

sfro

mhi

gh-

inte

nsity

gro

up;

top

ics

cove

red

incl

uded

fat

fact

s,b

arrie

rsan

db

enefi

tsto

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dd

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ents

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ery

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n

6m

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mon

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rven

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den

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.19

90(3

7)(n

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3612

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year

-old

girl

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dth

eir

mot

hers

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mun

ityb

ased

(clin

icse

tting

)an

dho

me

bas

edP

enns

ylva

nia

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dom

ized

with

thre

etre

atm

ent

gro

ups

Fram

ewor

kno

tsp

ecifi

ed

NA

16w

eeks

6-m

onth

pos

t-in

terv

entio

nFU



Tab

le1

Con

tinue

d

Aut

hor

pub

licat

ion

year

(yea

rst

udy

star

ted

)S

tud

yp

opul

atio

n†S

tud

yse

tting

‡an

dst

ate

loca

tion

Stu

dy

des

ign

and

theo

retic

alfr

amew

ork

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ure

ofco

mp

aris

ong

roup

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atio

nof

inte

rven

tion

and

FU(w

here

app

licab

le)

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pso

n20

10(3

6)(n

otsp

ecifi

ed)

3912

–18-

year

-old

girl

sC

omm

unity

bas

ed(c

hurc

hes)

Nor

thC

arol

ina

Pilo

t;on

etre

atm

ent

gro

up,

qua

si-e

xper

imen

tal

Theo

ryof

reas

oned

actio

n

NA

12w

eeks

Mac

Don

elle

tal.

2011

(42)

(not

spec

ified

)44

13–1

7-ye

ar-o

ldov

erw

eig

ht(�

85th

BM

Ip

erce

ntile

for

age

and

gen

der

)g

irls

and

boy

san

dth

eir

par

ents

§(7

9.5%

girl

s)

Com

mun

ityb

ased

(ad

oles

cent

med

icin

ecl

inic

s)M

ichi

gan

Pilo

t;tw

o-g

roup

par

alle

lRC

TFr

amew

ork

not

spec

ified

Four

60-m

inse

ssio

nsof

nutr

ition

alco

unse

lling

10w

eeks

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oss

bot

hag

eg

roup

s(i.

e.8–

18ye

ars)

Cot

ton

etal

.20

06(3

9)(n

otsp

ecifi

ed)

368–

18-y

ear-

old

girl

and

boy

pat

ient

s(n

=27

girl

s)C

omm

unity

bas

ed(u

rban

prim

ary

care

setti

ng)

Geo

rgia

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t;on

etre

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ent

gro

up,

qua

si-e

xper

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Fram

ewor

kno

tsp

ecifi

ed

NA

12w

eeks

Res

nico

wet

al.

2000

(17)

(not

spec

ified

)57

11–1

7-ye

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ldg

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(�35

%b

ody

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or�

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BM

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erce

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for

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gen

der

)

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mun

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ased

(fou

rp

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hous

ing

dev

elop

men

ts)

and

hom

eb

ased

Geo

rgia

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treat

men

tg

roup

,q

uasi

-exp

erim

enta

lS

ocia

lcog

nitiv

eth

eory

NA

6m

onth

s

*The

stud

ies

are

pre

sent

edac

cord

ing

toag

eof

par

ticip

ants

(�12

year

s,�

13ye

ars

and

acro

ssse

vera

lag

eg

roup

s).

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die

sw

ere

stra

tified

into

cate

gor

ies

bas

edon

the

age

ofth

em

ajor

ityof

the

par

ticip

ants

.† R

ace

ofp

artic

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tsis

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ican

Am

eric

an,

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ed.

‡ Stu

dy

setti

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wer

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bas

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hom

eb

ased

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bas

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dho

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bas

ed.

§ Par

ents

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rto

par

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iver

sor

gua

rdia

ns.

AA

,A

fric

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mer

ican

;B

MI,

bod

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ind

ex;

CB

PR

,co

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ory

rese

arch

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-up

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A,

not

app

licab

le;

RC

T,ra

ndom

ized

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rolle

dtr

ial;

YM

CA

,Yo

ung

Men

’sC

hris

tian

Ass

ocia

tion.



intervention strategies are presented according to age of themajority of participants: 12 years and younger (i.e. preado-lescence), 13 years and older (i.e. mid-to-late adolescence),and 8–18 years for studies that included youth across bothage groups.

About 15 of the 27 studies targeted only African–American girls (16–18,20–22,30–38), 6 targeted African–American girls and boys (39–44), 5 targeted multi-ethnicsamples of girls and boys (19,23,45–47), and 1 studyincluded a multi-ethnic sample of girls (48). Sample sizesranged from 15 (41) to 618 (23). The majority of studiestook place in a community setting (n = 15) (16,19,21,23,31,33,34,36,39,40,42,44–47), with the remainingtaking place in either the home (32,38) or a combination ofcommunity and home settings (9,17,18,20,22,30,35,37,41,43,48). The interventions ranged in duration from3 weeks (48) to 2 years (20,22,38), of which 15 werepilot studies (16,18,30,32,33,35,36,39–44,47,48), 1 was ashort-term study (12 weeks but not identified as a pilot)(34), and 12 were full-length, non-pilot studies (17,19–23,31,37,38,45,46). Seventeen of the studies were RCTs(16,18–23,30,31,33,35,37,38,42,46,47,49); eight wereuncontrolled (i.e. before and after) studies (17,32,36,39–41,43,48); two were non-RCTs (44,45); and one was arandomized trial of three active interventions (37). Nine ofthe studies were treatment studies that targeted overweightor obese participants (17,21,37,38,40,42,44,47,48). Theinterventions were implemented in 13 different states andincorporated a variety of theoretical frameworks, of whichsocial cognitive theory was most utilized. Methodologicalquality of the studies ranged from 1 (43) to 10 (18) with theRCTs consistently assessed as higher quality.

Intervention approaches

Behavioural change techniques and cultural adaptationTable 2 summarizes the specific behavioural change tech-niques and cultural adaptation strategies utilized. Withthe exception of five studies, both physical activity anddiet were the main focus of the behavioural change strate-gies. Most studies made specific attempts to tailor theirintervention components; these attempts varied, althoughmost reported culturally tailoring the content of inter-vention materials and messages. Three studies did notreport any level of cultural adaptation, and four additionalstudies limited their cultural modifications to recruitingonly African–American participants. Theories specific toAfrican–American families were not generally mentionedor identified for the behavioural change techniques.Although a variety of strategies were reported, no clearpattern based on age of the child or family member involve-ment emerged. Further descriptions of the interventioncomponents are available in the Supporting Information(Appendix S1).

Level and type of family member involvementWith respect to family member involvement, among thetreatment studies, none included the whole family, fourincluded multiple family members, and five incorporatedparent–child dyads only. All three of the whole familyinterventions were prevention studies. Prevention studiesalso included three multiple family members and 12parent–child dyad interventions. Examining the character-istics of family member involvement (Table 3), although aclear pattern does not emerge within each cluster, somesimilarities in intervention approach can be reported.

The three whole family prevention interventions targetedyounger children and incorporated some form of face-to-face intervention delivery with the expectation for some ofthe sessions to be attended jointly by all family members.There was no clear pattern of the goals for the familymembers in these three studies.

Among the interventions with multiple family memberinvolvement, the prevention studies focused most efforts onthe child; family members were included only to providesupport and there was a greater expectation for the child toattend the intervention sessions than the family members.Clear patterns did not emerge for the treatment studies;half engaged family members to make substantial behav-ioural changes and the expected attendance varied from allsessions attended jointly to all sessions attended separately.

The majority of studies engaged parent–child dyads only(n = 17). The two treatment studies that targeted parentalbehaviour change required all participants to attend allsessions separately then jointly with a face-to-face interven-tion delivery mode. The difference between the two studieswas Janicke et al. (47) targeted younger adolescents andMacDonell et al. (42) targeted older adolescents. The otherthree treatment studies that included a parent–child dyaddid not share any similarities.

Four of the 12 parent–child dyad prevention studiesincluded change strategies to improve the parent’s behav-iour, targeted younger children, and required the familymember to attend all sessions while the child’s attendancevaried from all sessions either jointly or separately orattendance not required because of the non-face-to-face,distant delivery. Only one of the parent-child dyad preven-tion studies designated no specific expectation for familymember attendance, which resulted in the child attendingall of the sessions alone. The remaining prevention studiesengaged the family members with support-related goals tohelp change the child’s behaviours with almost equal dis-tribution of participants attending some of the sessionsjointly or child attending all sessions alone. One parent–child dyad prevention pilot study was designed to directlyassess parent-only vs. child-only approaches vs. a non-weight-related comparison conditions (16), but the sub-sequent full-length RCT combined the parent and childconditions (20).



Table 2 Intervention strategies and cultural adaptation

Author year Focus of behaviourchange techniques

Specific behaviour changetechniques

Cultural adaptation*

Age � 12 yearsFitzgibbon et al.2005 (19)

PA and diet • Healthy eating and PA sessions that utilized puppetsand active games

• Weekly newsletters and homework

• AA-only sample at certain schools• Culturally tailored content and messages

Fitzgibbon et al.2011 (23)

PA and diet • Healthy eating and PA sessions that utilized puppets,songs/raps and active games

• Weekly homework

• Culturally relevant foods and traditionalrecipes

• Newsletters created for the family• Culturally relevant music and dances• Acknowledgement of community

environmental barriers to regular PA, healthfuleating, social roles and social support

Greening et al.2011 (46)

PA and diet • Monthly family events• Nutrition and PAs/contests• Modifications in intervention school’s food service• Nutrition and PA education sessions

No cultural adaptation mentioned

Janicke et al.2011 (47)

PA and diet • Knowledge and skill-based education sessions• Food and pedometer logs• Group support meetings (separate parent/child

meetings for learning component and together forgoal setting

• Taste-testing and snack prep for children• Exercise or games for children to be active


Stolley andFitzgibbon1997 (34)

PA and diet • Nutrition education sessions• Cooking demonstration• Music and dance incorporated into nutrition and PAs

• AA-only sample• Culturally tailored content and programming

Baranowski et al.2003 (30)

PA and diet • Camp programme to increase behavioural andpsychosocial factors related to healthy foods (i.e. fruitand vegetable intake, water consumption) and PA

• Self-monitoring using pedometers• Goal setting web site

• AA-only sample• Formative focus group with AA sample

Beech et al.2003 (16)

PA and diet • PA (hip hop aerobics) sessions• Healthy eating session with taste-tests of healthy

foods and food preparation/games• Culturally relevant take-home materials

• AA-only sample• Cultural sensitivity programming• Culturally tailored take-home materials

Klesges et al.2010 (20)

PA and diet • Nutrition and PA sessions (goal setting, providedfeedback, encouragement to participants, skillbuilding, self-monitoring, problem solving and socialsupport)

• Parents/guardians were encouraged to make changesin the home food environment

• Field trips

• AA-only sample• AA-only interventionists• Cultural sensitive programming and tailored

take-home materials

Robinson et al.2003 (18)

PA • After-school dance classes with healthy snack,homework period, and discussion of increased PA(dance) and reduced TV screen time (TV watching,videotape use and video game use)

• Family intervention that included role modelling forgirls by AA interventionist and behaviour changediscussions about reducing screen time

• Newsletters

• AA-only sample• AA-only interventionists and data collectors• Music and dance selection by AA participants• Attempted to account for a number of unique

elements associated with AA culture(collectivism, importance of family, presentorientation, importance of religiosity, sense ofhistorical racism and prejudice, and use ofsocial support as a coping strategy)



Table 2 Continued


Specific behaviour change techniques Cultural adaptation*

Robinson et al.2010 (22)

PA • After-school programme with dance, healthy snackand homework

• Public performances• START (Sisters Taking Action to Reduce Television)

home-based screen time reduction programme(self-monitoring, a 2-week TV turn-off, budgetingviewing hours, ‘intelligent’ viewing)

• Newsletters

• AA-only sample• AA culture infused through matched models,

music, intervention activities, language, values,social and historical influences

• AA-only dance instructors (college students orrecent graduates)

• Awards based on Kwanzaa principles• Utilized AA screen time intervention

Story et al.2003 (35)

PA and diet • PA and healthy eating programme based on youthdevelopment and resiliency approach to build onfamily and personal strengths

• Family night events with interactive games and goalsetting that they would continue throughout theprogramme

• Phone calls by staff to check in on goals and providesupport

• AA-only sample• AA-only instructors• Culturally tailored activities and programming

Barbeau et al.2007 (31)

PA • After-school programme that includedhomework/healthy snack time and PA (25-min PA skillinstruction; 35-min aerobic PA such as basketball, tag,softball, relay races; and 20-minstrengthening/stretching)

• Incentives for attendance

• AA-only sample

Fitzgibbon et al.1995 (33)

PA and diet • Nutrition education (taste-testing, menu planning,interactive lessons)

• Skills training (problem solving, decision-making, goalsetting)

• AA-only sample• 25% of interventionists were AA• Utilized ‘Rap Against Fat’ activity• Tailored health info for AA women

Raman et al.2010 (44)

PA and diet • Summer day camp with community-based exercise,nutrition and behavioural modification

• Monthly nutrition educational sessions• ‘Personal best’ approach to PA programme to create

an environment where overweight children developpositive self-esteem and respect

• Follow-up: weekly intervention sessions including PAand modelling, hands-on nutrition education and skillbuilding, and self-esteem modelling

• Outside-of-programme PA

• AA-only sample• Culturally tailored programming and content

Burnet et al.2011 (40)

PA and diet • PA and nutrition discussion topics• Behavioural goal setting• Skill building and group problem solving• Engaging in family activities (shopping, cooking,

exercise)• Self-monitoring practice• Group outings

• AA-only sample• Surface and deeper cultural tailoring• All female AA lay community leaders• Formative focus groups with AA families

Cullen andThompson 2008(32)

Diet • Interactive, computer-based nutrition education (goalsetting, problem solving)

• AA-only sample• Culturally tailored web site content and images

Newton et al.2010 (43)

PA and diet • Classroom-based PA opportunities/resources• Altered classroom and cafeteria environments and

provided teachers with materials and equipment• Newsletters and messages via programme’s web site

• AA-only sample



Table 2 Continued



Olvera et al.2010 (48)

PA and diet • Exercise class• PA education• Nutrition education (healthy meals modelling.

hands-on activities, games, handouts, homechallenge and cooking lessons)

• Behaviour counselling (art projects, poetry, journaling,behavioural contracts and home challenges)

• Parent programming (taught how to adapt to familymeals, completed activities to support daughter’shealthy food choices, and enhance their PA andself-esteem)

• Incorporated AA cultural values (collectivism,importance of respect and maternal roles, anduse of social support) in programme

• Culturally tailored activities (i.e. common AAfoods, dance)

Jackson et al.2010 (41)

PA and diet • Exercise class• Child take-home activities• Recipe/healthy snack preparation• Theatre games/dramatic writing• Nutrition education• PA education• Parent programming (1-h health info and recipe

making session, parent take-home activities)• End of the programme theatre performance/dinner for

family

• Formative focus groups with AA• AA-only sample• AA-only interventionists• Culturally tailored activities (i.e. hip hop

dance)

Age � 13 yearsWilliamson et al.2006 (38)

PA and diet • Internet-based, interactive nutrition education andcounselling via intervention web site/email

• Face-to-face counselling session• Behavioural self-monitoring online log

• AA-only sample• Culturally tailored activities (i.e. common AA

recipe, links to AA health web sites)• Counsellors educated on culturally specific

health info and dietary/PA-related issues

Frenn et al. 2003(45)

PA and diet • Internet and video intervention with healthy snack andgym labs (when available)

• PA and nutrition education sessions (topics includedasking and discussing with parents healthy foodoptions for the home; interactive, teen-specificbuilding awareness of fat in popular food, self-efficacyin selecting healthier options, peer model of preparinghealthy snacks and exercising; learning aboutrecommendations for PA)


Resnicow et al.2005 (21)

PA and diet • 30 min of PA• Taste-test and preparation of healthy foods• Dependent on treatment group, motivational

interviewing counselling calls• Retreat at national park• Two-way pagers for targeted messages

• AA-only sample• Formative assessment focus groups with AA

families

Wadden et al.1990 (37)

PA and diet • Incentive structure based on weight loss andattendance

• Take-home assignments• Various levels of parental involvement based on

treatment condition (parents received homeworkassignments, participated in programme with girl, ortalking with daughter or attended separate similarsession)

• AA-only sample• AA-adapted curriculum content

Thompson 2010(36)

PA • PA log• Aerobic dance class• PA education (knowledge about PA, goal setting,

benefits and barriers, body image, role models, socialsupport, hair maintenance, health statistics, solicitfeedback from girls about changing environments)

• AA-only sample• Incorporated AA cultural values (spirituality,

expressive communication, andinterconnectedness or commonality)

• AA-only interventionists



Behavioural and weight outcomes

In order to examine which family components were mosteffective, Table 3 also includes behavioural and weightchange results. As described in the Methods section,weight-related outcomes were not considered for short-term or pilot prevention studies or any before and after(uncontrolled) studies.

Among the nine treatment studies, three of the fivestudies that assessed physical activity positively impactedthis behaviour. However, no clear pattern related to familymember involvement, goal of the family member, format ofthe intervention delivery and age of child emerged. Treat-ment studies that reported an increase in physical activityexpected for all face-to-face sessions to be attended, butwho attended (child vs. family member vs. both) or howthe sessions were attended (separately vs. jointly) did notseem to influence physical activity changes. Three of thefour studies that assessed dietary intake reported null oropposite to expected results. Similarly, null or opposite toexpected findings were reported for the three full-lengthtreatment RCTs. The Wadden et al.’s study (37) of obesitytreatment in black adolescent girls is the only full-lengthstudy identified which designed to isolate effects of differ-ent types of parent–child involvement (child or parentalone or together). No statistically significant differenceswere found between either groups that involved parents

compared to the child alone. However, weight losses wereleast in the child-alone group (1.6, 3.7 and 3.1 kg for childalone, mother–child together, or mother–child separately,respectively).

In general, both physical activity and dietary intake werepositively affected in the prevention studies, regardless ofstudy design. All 14 of the 18 prevention studies thatassessed some form of physical activity behaviour and all 15of the prevention studies that assessed some form of dietaryintake were able to positively influence the behaviours. Mostof the studies assessed physical activity and dietary intakeusing several measures; four and eight of the preventionstudies also reported null or opposite to expected results forphysical activity and dietary intake, respectively. Seven full-length RCTs were prevention studies. Of those, six assesseda weight-related outcome with four reporting positiveeffects on weight. The two RCTs reporting negative or nulleffects on weight had the highest methodological qualityranking of the prevention studies.

The seven studies that mentioned limited or no interven-tion cultural adaptation reported generally favourable out-comes, although they also ranked low on methodologicalquality (scores = 1, 2, 3, 5, 5, 6, 6). All but Janicke et al.(47) and Cotton et al. (39), both which did not assessphysical activity or dietary behaviour, reported a statisti-cally significant increase in physical activity. Newton et al.(43), Barbeau et al. (31) and MacDonell et al. (42), who

Table 2 Continued



MacDonell et al.2011 (42)

PA and diet • Goal setting and barrier/problem solving sessionsbased on motivational interviewing approaches

• AA-only sample

Across both age groups (i.e. 8–18 years)Cotton et al.2006 (39)

PA and diet • Nutrition sessions (topics focused on reducingsweetened beverages, drinking low-fat milk,increasing fibre intake and fruits and vegetables)

• PA sessions (topics included cardio, strength andflexibility training; utilized PA gaming video software)

• AA-only sample

Resnicow et al.2000 (17)

PA and diet • Educational/behavioural activity (30–60 min of PA andpreparation/taste-testing of low-fat meals)

• Communication skills training to enhance the ability torequest healthy food from parent

• Nutrition education (topics included substitution,moderation and abstinence with respect to eating;understanding fat and calorie content of food;distinguishing emotional side of eating, reading foodlabels)

• Field trips to farmers’ markets or grocery store• Incentives based on active participation and

attendance

• AA-only sample• AA-tailored PA programming

*Cultural adaptation categorized as (i) none mentioned; (ii) targeted adaptation limited to recruitment of African–American participants or conductionof the intervention in a culturally familiar setting; or (iii) specific attempts to tailor intervention content. Adapted from Whitt-Glover and Kumanyika (25).AA, African American; PA, physical activity.



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Year

1:B

MI:

-W

aist

circ

:-

Year

2:B

MI:

+W

aist

circ

:+

Year

s1

and

2:%

BF:

+W

eig

ht:

-

Bar

anow

ski

etal

.20

03(3

0)P

aren

t–ch

ildon

lyS

upp

ort

rela

ted

Som

ese

ssio

nsjo

intly

Face

-to-

face

with

som

ety

pe

ofd

ista

ntfo

rmat

�12

Pilo

tR

CT

6∧M

VPA

:-

~PA

:+

kcal

:+

%fa

t:+

FJV:

+S

SB

:+

Wat

er:

+

Not

app

licab

le12

Fitz

gib

bon

etal

.20

05(1

9)P

aren

t–ch

ildon

lyS

upp

ort

rela

ted

All

sess

ions

child

only

Face

-to-

face

with

som

ety

pe

ofd

ista

ntfo

rmat

�12

RC

T7

Pos

t-in

terv

entio

nan

dye

ar2:

~Exe

rcis

efre

q:

+ Year

2:~E

xerc

ise

freq

:-

Pos

t-in

terv

entio

nan

dye

ar1: Fa

t:+

Sat

fat:

+Ye

ar2:

Fat:

-S

atfa

t:-

Pos

t-in

terv

entio

n:B

MI:

+B

MI-

z:+

Year

s1

and

2:B

MI:

+*B

MI-

z:+*

Fitz

gib

bon

etal

.20

11(2

3)P

aren

t–ch

ildon

lyS

upp

ort

rela

ted

All

sess

ions

child

only

Face

-to-

face

with

som

ety

pe

ofd

ista

ntfo

rmat

�12

RC

T8

∧MV

PA:

+*To

talk

cal:

-%

fat:

-Fr

uit:

+Ve

gg

ies:

+

BM

I:+

BM

I-z:

+



Tab

le3

Con

tinue

d

Aut

hor

year

Des

crip

tion

offa

mily

com

pon

ent

Out

com

ere

sults

2

Fam

ilym

emb

erin

volv

emen

t3G

oalo

ffa

mily

mem

ber

4E

xpec

ted

join

tat

tend

ance

5Fo

rmat

6A

ge

ofch

ild(y

ear)

Stu

dy

des

ign7

MQ

8P

hysi

cala

ctiv

ity9

Die

tary

beh

avio

ur10

Wei

ght

rela

ted

11

Fren

net

al.

2003

(45)

Par

ent–

child

only

Sup

por

tre

late

dA

llse

ssio

nsch

ildon

lyFa

ce-t

o-fa

cew

ithso

me

typ

eof

dis

tant

form

at

�13

NR

CT

2~M

VPA

:+*

%fa

t:+

Not

rep

orte

d

Bar

bea

uet

al.

2007

(31)

Par

ent–

child

only

No

spec

ific

goa

lA

llse

ssio

nsch

ildon

lyFa

ce-t

o-fa

cew

ithso

me

typ

eof

dis

tant

form

at

�12

RC

T6

~MPA

:+*

~VPA

:+

~MV

PA:

+*∧F

itnes

s:+*

Not

rep

orte

dB

MI:

+*W

aist

circ

:+

%B

F:+*

1 Ass

essm

ent

offa

mily

invo

lvem

ent

isad

apte

dfro

mM

cLea

net

al.

2003

(24)

taxo

nom

yfo

rin

terv

entio

nch

arac

teris

tics.

The

ind

exm

emb

er(o

rta

rget

edp

artic

ipan

tfo

rb

ehav

iour

alch

ang

e)fo

rea

chst

udy

was

the

child

.2 I

nter

pre

tatio

nof

outc

ome

resu

lts:

For

rand

omiz

edco

ntro

lled

tria

lsan

dno

n-ra

ndom

ized

cont

rolle

dtr

ials

,ou

tcom

esre

por

ted

are

for

bet

wee

n-g

roup

diff

eren

ces

unle

ssd

enot

ed;

ap

lus

sig

n(+

)in

dic

ates

atre

atm

ent

min

usco

ntro

ld

iffer

ence

inth

ed

esire

dd

irect

ion,

and

am

inus

sig

n(-

)in

dic

ates

ad

iffer

ence

opp

osite

toth

ed

esire

dd

irect

ion.

For

unco

ntro

lled

tria

ls,

outc

omes

rep

orte

dar

efo

rw

ithin

-gro

upd

iffer

ence

sun

less

den

oted

;a

plu

ssi

gn

(+)

ind

icat

esa

pos

t-in

terv

entio

nm

inus

bas

elin

ed

iffer

ence

inth

ed

esire

dd

irect

ion,

am

inus

sig

n(-

)in

dic

ates

ad

iffer

ence

opp

osite

toth

ed

esire

dd

irect

ion,

and

aze

ro(0

)in

dic

ates

noch

ang

e.*i

ndic

ates

ast

atis

tical

lysi

gni

fican

td

iffer

ence

ata

leve

lof

P<

0.05

.∧i

ndic

ates

anob

ject

ive

mea

sure

ofPA

(e.g

.ac

cele

rom

eter

,p

edom

eter

).~i

ndic

ates

asu

bje

ctiv

em

easu

reof

PA(e

.g.

self-

rep

ort

que

stio

nnai

re).

3 Fam

ilym

emb

erin

volv

emen

tca

teg

oriz

edas

(i)p

aren

t–ch

ildon

ly;

(ii)

mul

tiple

fam

ilym

emb

ers

that

incl

uded

par

ent–

child

pai

ran

dad

diti

onal

fam

ilym

emb

er(s

);or

(iii)

who

lefa

mily

(defi

ned

asen

tire

hous

ehol

dw

here

child

lives

mos

tof

the

time)

.4 G

oalo

ffa

mily

mem

ber

cate

gor

ized

as(i)

nosp

ecifi

cg

oal;

(ii)

sup

por

t-re

late

dg

oal(

min

imiz

ing

neg

ativ

esu

pp

ort,

pro

vid

ing

pas

sive

sup

por

t,p

rovi

din

gac

tive

sup

por

t);

or(ii

i)ch

ang

ein

own

targ

etb

ehav

iour

(foo

din

take

/phy

sica

lact

ivity

)fo

rw

eig

htco

ntro

l,w

eig

htm

aint

enan

ceor

wei

ght

loss

.5 E

xpec

ted

join

tat

tend

ance

atse

ssio

nsb

yin

dex

(tar

get

edp

artic

ipan

t)an

dfa

mily

mem

ber

cate

gor

ized

as(1

)si

ngle

sess

ion

join

tly;

(ii)

par

tial(

som

ese

ssio

ns)

join

tly;

(iii)

full

(all

sess

ions

join

tly);

(iv)

ind

exm

emb

eron

ly(f

amily

mem

ber

not

exp

ecte

dto

atte

nd);

(v)

fam

ilym

emb

eron

ly(in

dex

mem

ber

not

exp

ecte

dto

atte

nd);

or(v

i)al

lses

sion

sse

par

atel

y.6 F

orm

atof

inte

rven

tion

del

iver

yca

teg

oriz

edas

(i)d

ista

nt(le

tter,

pam

phl

et,

new

slet

ter,

onlin

e,te

lep

hone

)on

ly;

(ii)

face

-to-

face

only

;or

(iii)

face

-to-

face

with

som

ety

pe

ofd

ista

ntfo

rmat

.7 A

bb

revi

atio

nsfo

rd

iffer

ent

typ

esof

stud

yd

esig

ns:

NR

CT,

non-

rand

omiz

edco

ntro

lled

tria

l;R

CT,

rand

omiz

edco

ntro

lled

tria

l;U

CT,

unco

ntro

lled

tria

l.8 M

Q=

met

hod

olog

ical

qua

lity

whi

chis

bas

edon

the

sum

ofin

tern

alan

dex

tern

alva

lidity

crite

riam

et;

the

hig

hest

pos

sib

lesc

ore

is11

.In

tern

alva

lidity

was

eval

uate

dus

ing

the

six

crite

riaad

apte

dfro

mth

eD

elp

hilis

t(2

6).

Ext

erna

lval

idity

for

the

cont

rolle

dst

udie

sw

asas

sess

edus

ing

the

crite

riaou

tline

db

yG

reen

and

Gla

sgow

.9 A

bb

revi

atio

nsfo

rp

hysi

cala

ctiv

ity(P

A)

outc

ome

resu

lts:

ME

T,m

etab

olic

equi

vale

nt;

MPA

,m

oder

ate

phy

sica

lact

ivity

;M

VPA

,m

oder

ate

tovi

gor

ous

phy

sica

lact

ivity

;PA

pre

fere

nce,

pre

fere

nce

for

PAov

erse

den

tary

beh

avio

ur;

PAre

com

,kn

owle

dg

eof

PAre

com

men

dat

ions

;V

PA,

vig

orou

sp

hysi

cala

ctiv

ity.

10A

bb

revi

atio

nsfo

rd

ieta

ryb

ehav

iour

outc

ome

resu

lts:

FVJ

=fr

uit/v

eget

able

s/ju

ice;

SS

B:

sug

ar-s

wee

tene

db

ever

ages

;kc

al=

tota

lcal

orie

s;%

fat:

per

cent

ofca

lorie

sfro

mfa

t;ea

ting

hab

it=

over

alle

atin

gha

bit

mea

sure

db

yco

mp

osite

eatin

gsc

ore;

die

tary

reco

m=

know

led

ge

ofd

ieta

ryd

aily

reco

mm

end

atio

ns;

die

tary

pre

fere

nce

=d

ieta

ryp

refe

renc

eof

frui

tsan

dve

get

able

sov

ersw

eets

;he

alth

yw

ays

=d

ieta

ryw

ays

toea

the

alth

y;FV

=fr

uits

and

veg

etab

les;

%sa

tfat=

%of

calo

ries

from

satu

rate

dfa

ts;

%ca

rb=

%of

calo

ries

from

carb

ohyd

rate

s;%

pro

tein

=%

ofca

lorie

sfro

mp

rote

ins;

food

avai

l:fo

odav

aila

bili

ty;

par

ent

mod

ellin

g:

child

rep

ort

onp

aren

talm

odel

ling

ofhe

alth

yea

ting

;p

aren

ten

cour

:ch

ildre

por

tof

par

enta

lenc

oura

gem

ent

toea

the

alth

yfo

ods;

sat

fat=

gra

ms

ofsa

tura

ted

fat;

chol

=ch

oles

tero

l;fa

tg

ram

s=

tota

lgra

ms

offa

t.11

Ab

bre

viat

ions

for

wei

ght

-rel

ated

outc

ome

resu

lts:

BM

I,b

ody

mas

sin

dex

;ci

rc,

circ

umfe

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%b

ody

fat.

12D

ueto

the

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icul

tyin

inte

rpre

ting

wei

ght

-rel

ated

outc

omes

for

unco

ntro

lled

stud

ies

and

shor

t-te

rmor

pilo

tra

ndom

ized

cont

rolle

dtr

ials

,w

eig

ht-r

elat

edou

tcom

esar

ep

rese

nted

for

full-

leng

thR

CTs

only

.P

leas

ese

ete

xtfo

rfu

rthe

rex

pla

natio

n.13

For

Res

nico

w20

05st

udy,

det

ails

abou

td

iffer

ence

sb

etw

een

inte

rven

tion

and

cont

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roup

sar

eno

tp

rovi

ded

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ithin

-inte

rven

tion

gro

up(h

igh

atte

nder

svs

.lo

wat

tend

ers

and

mod

erat

ein

tens

ityvs

.hi

gh

inte

nsity

)d

iffer

ence

s.14

For

Wad

den

1990

stud

y,ex

pec

ted

join

tat

tend

ance

,g

oalo

ffa

mily

mem

ber

,an

dta

rget

ofb

ehav

iour

chan

ge

tech

niq

uew

ere

dep

end

ent

onto

whi

chtre

atm

ent

gro

upp

artic

ipan

tsw

ere

rand

omiz

ed.

15Fo

rR

esni

cow

2000

stud

y,d

etai

lsab

out

diff

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ces

bet

wee

nin

terv

entio

nan

dco

ntro

lgro

ups

are

not

pro

vid

ed.

Res

ults

focu

son

with

in-in

terv

entio

ng

roup

(hig

hat

tend

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vs.

low

atte

nder

s)d

iffer

ence

s.



recruited African American-only samples, also reportedstatistically significant, positive influences on some of theother outcomes they assessed: dietary and weight related,respectively. Greening et al. (46), who did not culturallyadapt any of their intervention, reported positive results forall outcomes. No studies were designed to isolate effects ofculturally vs. not culturally adapted interventions.

Discussion/conclusion

The purpose of this review was to examine interventionstrategies and assess intervention effectiveness in African–American girls based on level of family involvement andcultural adaptation. This systematic literature search iden-tified 27 family-based interventions that included physicalactivity, eating/nutrition, or weight change components, ofwhich many were pilot studies not linked to subsequentfull-length trials. Assessments of patterns related to inter-vention approaches and effectiveness were limited toqualitative assessments of similarities or patterns based onvarious groupings of studies. Studies reported diversepatterns of family involvement and cultural adaptationwith no use of theoretical perspectives specific to African–American family dynamics incorporated. Only one pilotand one full-length study permitted a direct comparison ofmore than one type of family involvement and no studiespermitted direct comparison of culturally adapted vs. non-adapted approaches. Effects on behavioural outcomes and,in some cases, on weight outcomes were in the expecteddirection, but statistically significant results were limited.The studies included in this review differed widely by inter-vention components, study design, and implementation,and also in quality. Null results were observed in two of thehighest quality studies, of which both were culturallyadapted. Overall, we were unable to draw clear inferenceswith respect to the most promising or effective ways ofinvolving family members in weight interventions withAfrican–American girls.

It has been well established throughout the adolescentobesity literature that intervening on family systemspresents a dynamic and multidimensional approach toinfluencing and engaging health behaviour change for bothchild and adult (8). In the studies examined in this review,the extent to which family members were required to beinvolved and the type of strategies directed towardsthem varied with respect to their role as behaviour changeagents in the context of the child. A majority of the inter-ventions included in this review incorporated parent–childinvolvement, although some studies reported multiplefamily members or whole family participation. Sessionattendance ranged from child only to all or some of thesessions attended by both family member(s) and child.Most family members served to support the behaviourchange goals of the child. However, several studies encour-

aged family members, as mostly secondary audiences, tomake individual behavioural changes that would perhapsinfluence the child’s behaviour.

Some patterns that surfaced are worthy of furthercomment. Of the nine treatment studies targeting over-weight participants, five of them engaged the familymembers to change their own behaviour and not justsupport the targeted child. Wrotniak et al. (50) found thata change in parental behaviour resulting in weight loss waspredictive of their overweight child’s weight loss in threefamily-based RCT studies. Although some of the findingsfor the five studies were non-significant (possibly due to thepilot nature of most of the studies), the outcomes tended tobe more positive for weight-related behaviours and out-comes than the treatment studies that did not try to changethe family member’s behaviour. This suggests that encour-aging participating family members to change their ownbehaviour and lose weight may be an effective strategy foroverweight children to either successfully lose excessweight or prevent additional weight gain.

All but 2 of the 10 studies included in this review thatengaged family members to change their own behaviourexpected the child and participating family member(s) toattend at least some, if not all, of the sessions together. Theoutcomes of the studies do not definitively ascertain thatthis is an effective strategy to change African–Americangirls’ behaviour, but there is a promise in exploring theeffect of face-to-face interaction with children and theirfamilial support network. This face-to-face contact mayprovide opportunity to discuss and complete activities,share knowledge, or set supportive goals that may be thekey for successful change. Conducting rigorous interven-tions to test the effect of family member attendance is alogical next step in this area of research.

Three of the studies required only the child to attend theintervention sessions. As with examining the effectivenessof other levels of family involvement, the findings are weakin supporting the effectiveness of this strategy, suggestingthat more research needs to be conducted regarding thisaspect of family interventions. However, it inherentlyseems that not engaging the family member(s) in someform of face-to-face contact, which has proven to be aneffective strategy, for a family-based study, is an under-utilization of family involvement. The Wadden et al.’s (37)study finding that children engaged in a family-based inter-vention who attended intervention sessions alone did notlose as much weight as the participants whose familymembers were involved in some type of face-to-facecontact (with or without their children) lends possiblesupport to this conclusion.

Similar to family-focused interventions, behaviouralprogrammes that are culturally relevant are consideredimportant when working with ethnic minority popula-tions, and appear to be well received (51–54). The studies



reviewed here reflect the variety of approaches that can beused for cultural adaptation, including recruitment of onlyAfrican–American samples and instructors, emphasizingcultural norms and traditions, preparing foods and plan-ning activities with which African Americans may befamiliar, placing African–American images on materials,incorporating focus group feedback of African Americans,and utilizing locations for intervention activities in prima-rily African–American communities. Most of the studiesincluded in this review addressed African–Americanculture through direct targeting, cultural tailoring or acombination of these approaches. The cultural tailoringmay confer familiarity and greater acceptance of the inter-vention but may not directly impact effectiveness. For thisreason, studies that compare culturally tailored with non-tailored interventions may be difficult to implement.

While the overall quality of the available evidence waslow from a study design perspective, several studiesincluded in this review developed and implemented inno-vative intervention strategies (i.e. computer technology(32,38), Internet delivery (30,45), theatre-based educationprogramme (41) and active video games) (39). The use ofcomputer technology and Internet intervention deliveryattempts to lessen the burden for families to meet outsidethe home. Utilizing digital media to increase physical activ-ity capitalizes on the higher than average digital media usein African–American youth (55). Theatre-based educationprogrammes have been used in overweight and obesityprevention in many studies (56), but this review highlightstheir use with African–American children and families.

Strengths

This is not the first review to examine obesity-related inter-ventions that included a family component; however, ourreview is unique and contributes significantly to theliterature, as we focused solely on African–Americangirls, a vulnerable population with obesity rates that areamong the highest observed among youth. Additionally,the other reviews (11–14), which made important contri-butions to the literature, had exclusions that our study didnot. Golley et al. (11) included studies that only targetedparents with children optionally involved while our studyincluded interventions that targeted and involved parents,children or both. Kitzman-Ulrich et al. (12) only includedinterventions that targeted family system components suchas parenting styles, parenting skills or family functioning,and excluded studies that minimally involved the familythrough take-home materials or contact at study-relatedevents. Because it is unknown what degree of familialinvolvement affects behavioural change, we included allstudies with any degree of family involvement. Knowldenand Sharma (13) included studies that only targeted youngchildren ages 2–7 years while our review included a wide

range of children and adolescents ages 5–18 years. Lastly,Swanson et al. (14) reviewed literature published onlyfrom 1998 to 2008, while we wanted to access all litera-ture that met our study criteria and did not restrict thetime period when the study was conducted or published.

Limitations

This review encountered several limitations in its synthesisof findings. Across the studies, comparing results was com-plicated by various methodological differences, such asintervention design, measures and reported outcomes.Many studies relied heavily on the use of subjective, self-reported measures, which are inherently biased. A majority(n = 15) of the studies were pilots with small numbers ofparticipants and short duration; few were associated withfull, longer-term studies. Also, our review focused on chil-dren aged 5 years and older. A review of studies in youngerchildren would also be of interest given that birth to pre-school age is a critical period for obesity risk development,as well as a period highly influenced by parents.

Future research

Although the studies identified in this review included avariety of approaches to family involvement, the optimalapproach or approaches with African–American girls arestill unclear. Whether these approaches differ for preventionand treatment or by age is a topic for further study. Also,the basis for choosing type and level of family involvementseems unclear or unsystematic, making it difficult tomake definitive conclusions. This is an area that needsmore attention in research design. Future studies shouldbe designed to test directly what factors related to familyinvolvement (i.e. family member designation, level ofinteraction between child and family member, and attend-ance of child and family member) are most effective inpositively influencing physical activity and dietary behav-iours. Without a clear, generalizable understanding or theo-retical framework of the function of family involvement onobesity-related behaviour change among African–Americanchildren, researchers will continue to struggle with develop-ing best practices for this area of public health. Technologi-cal approaches, including the use of social networking andmobile devices, are also worthy of further study. Finally,although this review was undertaken at a time when obesityrates were substantially higher in African–American girlsthan boys, rates in African–American boys have increased tolevels similar to those in girls. Thus, future research shouldexamine obesity interventions in both genders.

Implications for practice

To our knowledge, this review is the first to focus onempirical evidence of obesity interventions with a family



component that involved African–American girls. Thereview brings to light the need for rigorously tested obesityinterventions for African–American girls that allow directinferences about whether and how to involve familymembers and that, if possible, clarify the benefits ofvarious approaches to cultural adaptation. Recognizing theurgency in addressing disparities in obesity prevalence, thisreview has sought to present more detailed explanation ofthe what and how of intervention research, rather thanfocus on only comparing outcomes of a body of inconclu-sive and often methodologically flawed evidence from theperspective of assessing effectiveness. Although no defini-tive conclusions can be made about the most promisingstrategies, the findings provide substantial guidance for andwill motivate the design and implementation of futurestudies on this important topic. The health implications ofobesity begin in childhood and are even more prevalent inadults. The prevalence of obesity among African–Americanwomen is now 59%, compared to 33% in Caucasianwomen. Progress in the prevention and treatment of obesityin African–American girls will also help to prevent themfrom being obese as adults.

Conflict of interest statement

No author has any conflicts of interest to declare.

Acknowledgements

This research was supported by the Building Interdiscipli-nary Research Careers in Women’s Health Grant (No.K12HD055887) from the Eunice Kennedy ShriverNational Institutes of Child Health and Human Develop-ment (NICHD), the Office of Research on Women’sHealth, and the National Institute on Aging, NIH, admin-istered by the University of Minnesota Deborah E. PowellCenter for Women’s Health. The content is solely theresponsibility of the authors and does not necessarily rep-resent the office views of the NICHD or NIH. Additionalfunding was provided from the General Mills Foundationand through a Robert Wood Johnson Foundation grantto the African American Collaborative Obesity ResearchNetwork (AACORN), which supported the participationof Drs. Kumanyika and DiSantis. The authors would alsolike to thank Vanessa Madieros for assistance with litera-ture searches and data extraction.

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Supporting Information

Additional Supporting Information may be found in theonline version of this article:

Appendix S1. Detailed description of interventions.



obr1043 - perda de peso - atvfisica x dieta

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