Context Matters in Pediatric Obesity: Commentary on InnovativeTreatment and Prevention Programs for Pediatric Overweightand Obesity

Barbara H. Fiese,1,2 PHD, and The STRONG Kids Team1Family Resiliency Center and 2Department of Human and Community Development, University of Illinois

at Urbana-Champaign

All correspondence concerning this article should be addressed to Barbara H. Fiese, PHD, University of

Illinois at Urbana-Champaign, 904 West Nevada, Doris Kelley Christopher Hall, MC-081, Urbana, IL

61801, USA. E-mail: bhfiese@illinois.edu

Received July 16, 2013; revisions received July 27, 2013; accepted August 8, 2013

This commentary reviews the 9 articles in the Special Issue on Innovative Treatment and Prevention

Programs for Pediatric Overweight and Obesity. Taking a socio-ecological perspective, contextual factors such

as characteristics of the child, family, community, and culture are offered as ways to improve treatment and

prevention programs. Using a more tailored approach that takes into account individual differences in family

communication patterns and problem solving is warranted. Pediatric psychologists are urged to consider the

role of prevention and targeted efforts during early childhood to reduce the prevalence of childhood obesity.

Key words family function obesity; prevention/control; weight management.

The Journal of Pediatric Psychology has long been a leader in

publishing innovative approaches to treating and under-

standing complex health conditions in childhood and ad-

olescence. There is perhaps a no more complicated and

daunting condition than childhood obesity in its resistance

to amelioration. Without exception, each article begins

with dire statistics drawn from nationally representative

datasets indicating that in 2009–2010, 16.9% of children

and adolescents between 2 and 19 years of age were con-

sidered obese (Ogden, Carroll, Kit, & Flegal, 2012). The

editors of this special issue are to be commended for col-

lecting an excellent set of articles that represent the state of

the science in treating overweight and obesity in childhood

and adolescence. For some readers of this issue, there may

be disappointing news in that many of the innovative and

intensive treatments described had little appreciative effect

above and beyond less intensive and standard forms of

intervention. For example, Berkowitz and colleagues

(2013) compared the relative effectiveness of an in-

person 17 session family-based group life style manage-

ment program with a self-directed family-based life style

management program and found that both were (modestly)

effective in weight loss for adolescents. Similarly, Davis and

colleagues report that an intensive family-based telemedi-

cine intervention was equally effective in reducing BMI as a

pediatrician-delivered program (Davis, Sampilo, Gallagher,

Landrum, & Malaone, 2013). Motivational Interviewing

(MI) techniques were also compared using enhanced

approaches supporting more autonomy within the family

(Saelens, Lozano, & Scholz, 2013) and self-efficacy in

youth (Walpole, Dettmer, Morrongiello, McCrindle, &

Hamilton, 2013). Both of these studies found little differ-

ences in BMI change between the enhanced approach or in

comparison to a control group. A skeptic may conclude

that family-based interventions add little value to obesity

treatment for children and youth. This conclusion would

be in contrast to the large literature base suggesting that

family-based interventions are effective in weight manage-

ment for children (Whitlock, O’Connor, Williams, Beil, &

Lutz, 2010). What appears to be missing from the discus-

sion in the carefully controlled randomized controlled trials

(RCTs) is the context in which the family-based interven-

tions are delivered and the daily experiences of the families

receiving treatment.

Journal of Pediatric Psychology 38(9) pp. 1037–1043, 2013

doi:10.1093/jpepsy/jst069

Advance Access publication September 6, 2013

Journal of Pediatric Psychology vol. 38 no. 9 � The Author 2013. Published by Oxford University Press on behalf of the Society of Pediatric Psychology.All rights reserved. For permissions, please e-mail: journals.permissions@oup.com

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The authors of these articles are not discouraged by

their findings but rather offer discussions about universal

elements of interventions as well as new directions in the

treatment of pediatric obesity. The program described by

Berkowitz and colleagues (2013) illustrates the important

role that primary care providers can play in supporting

weight loss with their patients. Similarly, Davis and col-

leagues (2013) found that treatment by physicians was

just as effective as a more comprehensive telemedicine

approach. Both the Berkowitz and Davis studies illustrate

the role that unobserved factors such as the relationship

between provider and patient may play in effecting change.

For adolescents who may have established a relationship

with their primary care provider over many years, imple-

menting a lifestyle change may be as effective as imple-

menting change when establishing new relationships—

albeit with added support. Walpole and colleagues

(2013) directly address how the client/therapist relation-

ship may be more similar than different across treatment

conditions.

In addition to characteristics of therapist and/or pro-

vider that may account similarities across treatment and

comparison groups, it is also important to consider char-

acteristics of the family. Saelens and colleagues (2013)

incorporated a self-directed approach as did Berkowitz

and colleagues (2013). The effectiveness of self-directed

approaches may be better understood by readiness to

change and a better understanding of family characteristics

that make it more or less likely that the family will be

receptive to the intervention. The remaining articles

address some of these issues. First, it is important to

consider what is meant by family context.

Family Context of Pediatric Obesity

In a previous special issue of the Journal of Pediatric

Psychology dedicated to overweight in childhood, Black

and Young-Hyman (2007) conclude ‘‘the articles in this

Special Issue highlight the psychological, family, health,

and social challenges associated with weight-related

issues among children, illustrating the importance of incor-

porating contextual factors into an understanding of child

overweight.’’ (p. 2). Several socio-ecological models have

been put forth to elucidate the complexities in the causes

of childhood obesity (Birch & Anzman, 2010; Fiese &

Jones, 2012; Harrison et al., 2011). Harrison and col-

leagues (2011) describe the 6 Cs of the ecologies that con-

tribute to childhood overweight and obesity: Cell, Child,

Clan, Community, Country, and Culture. Fiese and Jones

(2012) adapted this model to consider the intersecting role

that the family plays in regulating eating behavior in chil-

dren (Figure 1).

Children differ in terms of their acceptance of new

foods and ability to self-regulate food intake. Differences

in sensory sensitivities and inhibitory control may be asso-

ciated with early patterns of food consumption (Smith,

Roux, Naidoo, & Venter, 2005). However, these choices

are likely moderated by parenting practices (Webber,

Cooke, Hill, & Wardle, 2010).

Providing food to children extends beyond the need to

give sustenance, but rather it is embedded in daily rou-

tines, emotional regulation, and rule-making activities of

family life. These activities extend across generations and

are embedded in cultural practices and beliefs. The dyadic

exchanges between parent and child may affect food con-

sumption through its effect on emotion regulation and

parental feeding practices. Pressure to eat and over-

controlling feeding practices have been associated with

increased risk for child overweight and eating disorders

(Ventura & Birch, 2008). Thus, a family atmosphere

whereby children are pressured to ‘‘clean their plate’’

may backfire against healthy nutrition practices, as children

are less likely to attend to satiety cues and rely more on

emotional or environmental cues to regulate food intake.

Even a relatively simple practice such as family meal-

times has been found to reduce the odds of being over-

weight and developing an eating disorder (Hammons &

Fiese, 2011). Families that engage in more regular meal-

times (three or more times per week) also engage in better

CultureTraditions

Beliefs

CommunityAcess to FoodSocial Norms

FamilyStructure

Feeding PracticesProcess-Communication

ChildSelf Regulation

Food Sensitivities

Figure 1. Socio-Ecological Model Food and Family Adapted from

Harrison et al. (2011) and Fiese and Jones (2012).

1038 Fiese and The STRONG Kids Team

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nutritional practices, serving more fruits and vegetables

than those who share meals less regularly (Hammons &

Fiese, 2011). However, it may not be sheer frequency of

shared meals that account for better health outcomes, as

the types of communication, including positive response to

affect and expressed genuine concern about the child’s

daily activities, are also associated with reduced risk for

overweight and obesity (Fiese, Hammons, & Grigsby-

Toussaint, 2012).

Societal factors also affect mealtime practices, such as

exposure to media. Several studies have documented the

effects of food advertising on the consumption of high fat

foods and sugar sweetened beverages (Harrison, Liechty, &

The STRONG Kids Program, 2012; Institute of Medicine,

2013). The ever presence of cell phones and other forms of

mobile media at the table also present challenges in terms

of distractions and preventing positive forms of communi-

cation known to promote healthy outcomes (Fiese, Winter,

& Botti, 2011).

Families differ in terms of access to healthy foods.

Low-income families and families living in rural communi-

ties have more difficulty accessing fresh fruits and vegeta-

bles and often have to rely on corner stores or convenience

stores to procure food (Larson, Story, & Nelson, 2009).

In addition to limited access to healthy foods, African

American and Hispanic families in low-income neighbor-

hoods often find it difficult to access culturally relevant

foods common to their traditional diets (Grigsby-

Toussaint, Zenk, Odoms-Young, Ruggiero, & Moise,

2010).

Relevant to this discussion and the studies reported in

this special issue, is whether these contextual variables

reported in descriptive studies have been taken into con-

sideration and if so, how can it inform future prevention

and treatment efforts?

Characteristics of the Child

Loss of Control (LOC) eating, body image, eating disor-

ders, and body dissatisfaction were considered in two of

the reports (Cassidy et al., 2013; Wilksch & Wade, 2013).

These are important characteristics to consider in an ado-

lescent age-group and as comorbidities of obesity. As

pointed out by Cassidy and colleagues, body image is

integrally embedded in cultural values. If interventions

address body image as part of weight reduction then cul-

tural considerations must surely be taken into account.

Surprisingly, outside of LOC little attention is paid to

other self-regulatory features such as inhibition and emo-

tional regulation more broadly speaking. Future research

may want to consider individual differences in self-

regulation that may influence responsiveness to treatment

and the likelihood that individuals will stay engaged in

treatment.

Family Structure and Process

Although the majority of the reports in this special issue

refer to family-based interventions, none of the studies

report on family structure. Given the rapid changes in

family demographics, it is important to know whether

the child or adolescent is being raised by a single parent,

may reside in multiple households in a given week, and

may be receiving different messages about eating and phys-

ical activity norms from multiple family members. Only the

Cassidy report identified parent as the mother, grand-

mother, or father. There is increasing evidence that marital

status is related to child health outcomes, with children

living in households with cohabitating adults faring less

well (Bzostek & Beck, 2011). The mechanism of this

effect may be due to economic resources as well as the

ability of adults to adequately monitor children’s health-

related behaviors including sleep, TV viewing, and eating.

Future obesity trials should include an assessment of

family structure as well as adults responsible for feeding

and arranging physical activity opportunities for the child

or adolescent.

A promising approach taken by St. George and col-

leagues (2013) incorporates both a focus on family process

variables and attention to variability within families. Project

SHINE implemented a family communication and moni-

toring intervention to reduce sedentary behavior in adoles-

cents. The family communication intervention was

successful in decreasing sedentary behavior and further,

those families that demonstrated the most positive com-

munication had adolescents that improved the most in

decreasing sedentary behavior. The results of this study

are important from a conceptual and analytical perspective.

Conceptually, the study incorporated a key feature of

family functioning, positive communication, known to be

associated with positive health outcomes (Alderfer et al.,

2008). Families can communicate in a variety of ways—

either directly—‘‘It is time for our family walk.’’ Or

indirectly—‘‘Get your lazy body off the couch.’’ Future

research may incorporate more nuanced and comprehen-

sive approaches to family functioning including the

McMaster model that assesses problem solving, communi-

cation, roles, affective responsiveness, affective involve-

ment, behavior control, and general functioning (Epstein,

Ryan, Bishop, Miller, & Keitner, 2003) and has been

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applied to the study of chronic health conditions in chil-

dren including obesity (Herzer et al., 2010). Theory-driven

approaches to family communication and functioning are

warranted for future research in this promising area.

The SHINE project also points toward innovative strat-

egies in analyzing family response to treatment. In consid-

ering the interaction between treatment condition and

communication scores, the authors were able to demon-

strate that those families with high scores on communica-

tion had the most significant decrease in sedentary

behavior. It is important to understand within-group dif-

ferences, particularly as it comes to families, in planning

for future intervention efforts. Tailored approaches that

target families most receptive to change and most likely

to benefit from interventions may explain some of the

modest effects seen in previous RCTs. Clearly not all fam-

ilies are created equal. More sophisticated understanding

of these differences in communication and problem solving

strategies may improve the effectiveness of future clinical

trials.

Community as a Resource

Ecological models require that the community be system-

atically integrated with family and institutional resources.

Programs such as 5-2-1-0 as described by Rogers and

colleagues (2013) have become increasingly popular

across the United States, yet are infrequently evaluated.

This innovative approach to evaluation is to be com-

mended for its comprehensiveness and involvement of

multiple stakeholders. There are several take home mes-

sages from this report for pediatric psychologists. First, it

is important to consider the value of simple messages that

can be repeated in multiple settings. Be assured, these are

not simplistic messages, but ones that take much care and

thought to develop as described by the authors. These

messages can be reinforced by health care providers and

practicing psychologists as lessons for healthy living not

only for those seeking treatment for obesity and over-

weight. Indeed, the interventions described by Berkowitz

and colleagues (2013) and Davis and colleagues (2013) are

examples where a community-based intervention could be

paired with primary care-based interventions for a more

comprehensive approach. Second, this is the only report

that addresses young children and child care settings.

Recent estimates suggest that 27% of 2- to 5-year-old chil-

dren are overweight and 12% are obese (Ogden et al.,

2012). Pediatric psychologists can play an important role

in preventing childhood obesity by working closely with

childcare providers and directors in offering educational

sessions on healthy eating and physical activity. Programs

such as the 5-2-1-0 provide clear and easy to follow steps

that can be implemented in early care and education

settings. Third, this community-based effort illustrates

how public campaigns can have an influence on policies

at child care centers, schools, and the workplace. Active

involvement by pediatric psychologists in these efforts

can only strengthen the research to practice to policy

connections.

Cultural Context

The Cassidy (Cassidy et al., 2013) and Olvera (Olvera,

Leung, Kellam, & Liu, 2013) reports directly address

cultural context of obesity interventions. Cassidy and col-

leagues highlight the need to consider how body image

ideals may differ across cultures. Starting at an early age,

parents tend to underestimate their child’s weight with

parents of overweight children more likely to consider

them to be of healthy weight (Hager et al., 2012). When

cultural norms are considered, values for robust and full-

figured physiques are often in contrast to media images of

the ‘‘thin ideal.’’ The Cassidy report points to an important

topic to discuss, particularly for adolescent girls who often

struggle with body image as part of a normative process.

The Olvera report on the BOUNCE program illustrates

the importance of considering the context of the daily lives

of African American and Hispanic youth. Summer time is a

vulnerable period for many low-income youth with few

available resources. Planning physical activity programs as

part of summer programs has the potential to affect a

significant number of youth. It is impressive that these

researchers were able to affect change in percent body fat

after only a 30-day intervention. Future efforts may pair

physical activity programs with the Summer Food Service

Program sponsored by the United States Department of

Agriculture (http://www.fns.usda.gov/summer-food-serv

ice-program-sfsp) to increase the likelihood that the pro-

gram is sustainable over time.

Conclusion

The articles in this special issue represent some of the best

science in the treatment of pediatric overweight and obe-

sity. Carefully constructed and implemented RCTs are the

gold standard for clinically based treatment programs. The

investigators of these programs are to be commended for

their innovation in adapting new paradigms and consider-

ing how treatment of childhood obesity can be improved.

However, these trials do not come without costs. Strict

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inclusionary and exclusionary criteria, time commitment

for lengthy sessions, travel time to facilities, and coordina-

tion of family schedules often make it difficult to reach

children and youth in need. Alternative approaches pre-

sented in this special issue such as telemedicine and self-

directed programs are promising but require further work.

To increase the effectiveness of existing programs

and inform new programs, greater attention to the socio-

ecological context of childhood obesity is warranted.

Variation in child self-regulation, family structure, family

routines, cultural traditions, and community resources

may influence the likelihood that any given treatment

will have an effect. As we move more toward models of

personalized medicine, pediatric psychology can take a

leadership role in recognizing the contextual factors that

are the causes and consequences of childhood obesity.

This will result in a sharper and more refined approach

to practice and policy.

A glaring omission, with the exception of the commu-

nity-based effort (Rogers et al., 2013), was attention to

early childhood and preventative efforts. The Institute of

Medicine (2011) has called for increased attention for the

prevention of childhood obesity starting at birth. There are

clear and actionable steps that pediatric psychologists can

take working with parents, pediatricians, health care pro-

viders, and hospitals to prevent childhood obesity. Simple

steps include the promotion of breast feeding, responsive

feeding practices during early childhood, reducing screen

time to <2 hr per day, practicing good sleep hygiene, and

being physically active as a family. It is incumbent on

pediatric psychologists to be strong advocates for families

to prevent childhood obesity and promote healthy habits

from an early age.

Childhood obesity is complex condition. The last

special issue dedicated to childhood overweight did not

yet recognize obesity as a classification in childhood

(Black & Young-Hyman, 2007). In many ways we have

come a long way in better understanding just how multi-

faceted this condition is. Although the simple story is more

calories in than expended, the persistent difficulty in turn-

ing the tide clearly suggests that context matters. The next

generation of researchers will be challenged to integrate

solid clinical science with an understanding of the intrica-

cies of contemporary family life. Hopefully this can be done

before the health of a significant number of children is

further compromised.

Acknowledgments

The STRONG Kids Team includes Kristen Harrison,

Kelly Bost, Brent McBride, Sharon Donovan, Diana

Grigsby-Toussaint, Juhee Kim, Janet Liechty, Angela

Wiley, Margarita Teran-Garcia, and Barbara Fiese.

Funding

Preparation of this manuscript was supported, in part, by

USDA National Institute of Food and Agriculture, Hatch

Project number 793 328, and the Christopher Family

Foundation Food and Family Program.

Conflict of interest: None declared.

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