were assigned to a BFI or an individual standard of care condition. Assessments
were completed at baseline, posttreatment, and 9-month follow up. There were no
differences in weight outcomes across treatment conditions. However, there were
trends to suggest differences in weight change by child race. Specifically, children
identified as African American benefited less from the BFI than Caucasian children.
Implications for practice and research are discussed.
Childhood obesity in the United States is a vital public health concern. Cur-rent estimates indicate that almost 35% of children aged 6 to 19 years in the
United States are overweight or obese (Ogden, Carroll, Curtin, Lamb, & Flegal,
2010). Obesity is a major risk factor in the development of type 2 diabetes and
Goran, Ball, & Cruz, 2003; Weiss et al., 2004). One of the most important
treatments to prevent diabetes and other obesity-related conditions in childrenand adolescents is improved weight status. Reduction in percentage overweight
has been related to a variety of positive health outcomes in obese children,
including improvements in insulin and fasting glucose and cardiovascular risk
factors (Figueroa-Colon, von Almen, Franklin, Schuftan, & Suskind, 1993;
Hoffman, Stumbo, Janz, & Nielson, 1995).The most effective interventions for childhood obesity address dietary intake
and physical activity through the use of behavioral modification strategies (Je-
lalian & Saelens, 1999). Behavioral family interventions (BFIs) have been the
most studied intervention for pediatric obesity, producing the best short-term and
long-term outcomes for pediatric weight loss (Epstein, Paluch, Roemmich, &Beecher, 2007; Jelalian & Saelens, 1999). These interventions combine nutrition
education and behavioral modification techniques to help children and parents
work together to gradually decrease caloric intake, maintain adequate nutrient
intake, and increase physical activity to encourage long-term maintenance of
weight reduction in children. BFIs are commonly delivered in a group format
comprised of 6 to 10 families. In a series of studies, Epstein et al. demonstratedthe short-term and long-term effectiveness of a BFI delivered in a group format,
with an average reduction of 20% in percentage overweight at 10-year follow up.
Although BFIs show documented long-term decreases in children’s percent-
age overweight (Epstein et al., 2007), the generalizability of these interven-
tions is less clear. Many of these programs have been developed and testedin well-controlled, clinic settings with middle-class families and delivered by
a multidisciplinary team of interventionists. There is little published research
evaluating these interventions in community-based settings or with families from
economically disadvantaged backgrounds.
Children from low-income backgrounds are at greater risk for obesity com-pared with children in higher socioeconomic status (SES) groups, independent
of race and ethnicity (Goodman, Slap, Huang, 2003; Janicke, Harman, Kelleher,
214 JANICKE ET AL.
& Zhang, 2009). In addition, children from low-income backgrounds also appear
more likely to experience obesity-related health problems, such as type 2 diabetes
(Kumanyika & Grief, 2006). The higher rates of obesity among ethnic minorityand low-income children, when combined with the adverse health effects of
childhood obesity, are likely to produce continued racial and economic differ-
ences in health outcomes (Kumanyika & Grief, 2006).
A wide variety of factors may contribute to these disparities. Most directly,
economic constraints may lead to the purchase of cheaper, energy-dense foods(Drewnowski, & Darmon, 2005). More indirectly, relative to higher SES commu-
nities, low-income communities have fewer supermarkets that stock fresh, good
quality, affordable foods such as whole grains or low-fat dairy products and
meats (Morland, Wing, Diez Roux, & Poole, 2002). With fewer supermarkets
available, low-income families may shop more often in corner convenience stores
with markedly less healthful foods. Youth from low-income backgrounds arealso disproportionately exposed to marketing activities that can impact food
consumption. Low-income children watch more television, and have higher
levels of media exposure, compared to children from higher-income families
(Roberts, Foehr, & Rideout, 2005). Other factors that may contribute to this
disparity include the built environment, less safe neighborhoods for physicalactivity, and parent knowledge and attitudes about obesity.
Although some factors impacting pediatric obesity in economically disadvan-
taged populations will require community and public policy interventions, there
are several aspects of the home environment (e.g., availability of healthy foods,
television viewing, and parenting behaviors) that may be amenable to changein low-income populations through targeted interventions (Kumanyika & Grief,
2006). With the focus on building a home environment to support healthy eating
and physical activity patterns for family members, BFIs may be well-suited
to help address healthy lifestyle habits within these families. Unfortunately,
few studies have examined these interventions with economically disadvantaged
families, as well as in community-based settings. Moreover, little research hasexamined potential moderators of treatment outcome (i.e., age, gender, and race)
to answer the question of what interventions work best for which children
(Robinson, 2008). Too little is known about how to improve the health of those
who are at greater health risks or bear the greatest burden of disease (Kerner,
Rimer, & Emmons, 2005). The lack of published intervention studies evaluatingBFIs to address obesity in economically disadvantaged families highlights a
pressing need for treatment research in this area. The purpose of this pilot study
is to evaluate the efficacy of a BFI delivered via group contacts on child body
mass index (BMI) z score compared to an individual standard of care (ISC)
treatment in an important and underserved population: overweight and obeseschool-age children and their parents enrolled in Medicaid. It is hypothesized
the children randomized to a behavioral group intervention will show greater
OBESE CHILDREN ENROLLED IN MEDICAID 215
decreases in BMI z score relative to children assigned to an individualized
standard care intervention. We also examine potential moderators of treatment
outcomes such as child age, gender, and race.
METHOD
Participants were 40 children enrolled in the Florida Medicaid program, ages
6 to 12 years, and their parent or legal guardian. Participants were recruited
from three midsized communities in north central Florida. All children had a
BMI above the 85th percentile based on age and gender norms published by
the Centers for Disease Control (CDC; Kuczmarksi et al., 2000). There was
no parental weight requirement. Families were excluded if the child or parenthad a medical condition that contraindicated mild energy restriction or moderate
physical activity, were using prescription weight-loss drugs, or were enrolled in
another weight-loss program. Families were also excluded if the child had a
significant developmental delay (e.g., autism or mental retardation).
Procedures
Families enrolled in Medicaid were recruited via solicitation during primary
care clinic visits, distribution of brochures through local schools, newspaper ar-
ticles, and community presentations. The intervention was promoted as a healthy
lifestyle program to help establish effective weight-management strategies forchildren and families. Interested parents were invited to call our office to learn
about the study, complete a telephone screening, and schedule an in-person
screening visit. At the in-person screening, children and their parents completed
consent forms and measures of their height and weight. Those dyads that met
eligibility criteria were scheduled for a baseline assessment.
Recruitment, assessment, and treatment occurred in three different commu-nities approximately 40 miles apart. Two treatment groups were conducted in
City A, and one treatment group was conducted in both Cities B and C.
Assessments. Baseline assessments were held 2 weeks before the start ofthe intervention. At the baseline assessment visit, children and parents completed
paper-and-pencil questionnaires, as well as measures of height and weight. At the
end of the baseline visit, each family was notified of their assignment to treatment
condition. All families completed posttreatment assessment (end of Month 3)
within 2 weeks after the last treatment session of their intervention program, andthen a follow-up assessment visit 6 months later (Month 9). The same assessment
measures completed at baseline were completed at posttreatment and 9-month
216 JANICKE ET AL.
follow-up assessments. Families received $50 as compensation for completing
the posttreatment and $50 for completing the follow-up assessment.
Participant assignment to treatment condition. Treatment occurred over
four cohorts across three different treatment sites; Cohorts 1 and 3 were held
at Site A, Cohort 2 was held at Site B, and Cohort 4 was held at Site C. Our
intention was to randomly assign child–parent dyads to one of two treatment
conditions: a BFI delivered via group meetings with other families or an ISC
condition for each cohort. Assignment of families to the two treatment conditionswas unbalanced to ensure that at least six child–parent dyads in each treatment
cohort were assigned to the BFI, as six or more child–parent dyads is considered
optimal to facilitate group functioning (Epstein et al., 2007). Although we were
able to randomly assign children to the treatment conditions in three of the four
cohorts, recruitment efforts in our second cohort resulted in only six eligibledyads enrolling in the study. As we required six families per group, we were
not able to randomize dyads to the ISC condition in Cohort 2.
Outcome Measures
Height and weight were assessed for the child and parent by a trained research
team member. Height without shoes was measured to the nearest 0.1 cm using aHarpendon stadiometer (Holtain Ltd., Crosswell, United Kingdom). Weight was
measured to the nearest 0.1 kg with one layer of clothing on and without shoes
using a calibrated balance beam scale. BMI z scores were calculated for each
child based on normative data from the CDC (Kuczmarksi et al., 2000). Parents
also completed a demographic questionnaire at baseline to gather data on the age
and gender of participants, parent marital status and education, and estimatedfamily income. Children and parents in the BFI also completed measures of
program satisfaction at posttreatment.
Interventions
Group-based behavioral family group intervention. Child–parent dyads
assigned to the group-based BFI participated in 12 weekly, 90-min sessions overthe course of 3 months. Each week a new knowledge and skills topic related to
lifestyle change was addressed. For all child and parent participants, the primary
treatment objectives were to decrease caloric intake in a nutritionally sound
manner and to increase moderate intensity exercise. Changes in dietary habits
were addressed via a modified version of the Stoplight System (Epstein et al.,2007). Child and parent participants were asked to monitor everything they ate
and drank using a daily food log. Abbreviated monitoring forms were available
OBESE CHILDREN ENROLLED IN MEDICAID 217
for families who struggled with completing the daily monitoring forms. Children
and parents were asked to gradually reduce the amount of high-fat/high-sugar
“red” foods to an ideal level of no more than 14 servings per week. However,goals were tailored to meet the needs of each family based on baseline dietary
intake and weekly progress in reaching goals.
Increased physical activity was promoted through a pedometer-based step
program. Children and parents were each provided with pedometers and were
encouraged to monitor their physical activity and gradually increase their dailysteps. Program goals were based on baseline level of steps and targeted an
increase of at least 3,000 steps per day by the end of the program for both
children and parents. Children were also asked to gradually decrease sedentary
activities so they spent no more than 2 hr per day watching television, playing
computer games, or playing video games.
During each group meeting, children and parents attended simultaneous, butseparate, parent and child groups. The parent group meetings were divided into
three segments. The first segment was used to review parent and child progress
in implementing the strategies discussed for changing their eating or exercise in
the previous session. Parents described the progress they and their child achieved
since the previous meeting and any problems they encountered. Difficultiesreported by parents were dealt with through group support, discussion, and
problem solving. The second segment focused on knowledge and skill training
related to the basics of energy balance and nutrition, appropriate methods for
increasing physical activity, and behavior management (e.g., goal-setting, self-
monitoring, and stimulus control). During the last segment of each session,children and parents were brought together to set specific goals for the week.
Goal-setting focused on developing specific plans for making healthy substi-
tutions and environmental changes. New goals were systematically introduced
throughout the program, with goals individualized to each family’s progress.
During child group meetings, children and interventionists briefly discussed
the progress achieved and challenges encountered since the previous meeting.Children then participated in a fun exercise or game. Children also helped pre-
pare and sample a healthy snack. During the food-sampling portion of each ses-
sion, fun and educational activities were used to teach children about nutrition,
strategies to increase physical activity, and strategies to cope with psychosocial
concerns. Finally, children engaged in another physical activity before meetingwith their parents for goal-setting. Each family was reimbursed $5 for each
treatment session attended as compensation for travel expenses.
ISC. Families randomized to the ISC treatment condition participated in
three 60-min intervention sessions over 12 weeks, each spaced 6 weeks apart.Families met individually with a treatment team member for these sessions.
During the first session, the child and parent were introduced to the Stoplight
218 JANICKE ET AL.
System, and the interventionist engaged the family in a discussion of environ-
mental modification. Guided by family-reported barriers to eating healthy foods,
the interventionist worked with the child and parent to set specific goals andplans to decrease “red” foods and increase consumption of fruits and vegetables.
During the second session, the interventionist reviewed the family’s progress in
making lifestyle changes and reaching their dietary goals. Problem solving was
used to help the family resolve any difficulties and establish updated dietary
change goals. The importance of physical activity, positive parent support, andmodeling were discussed. Finally, the child and parent were given pedometers,
and the interventionist helped them establish specific goals and plans to increase
physical activity. During the third session, the interventionist reviewed progress
since the last intervention contact, refined dietary intake and physical activity
goals and plans to reach these goals, and discussed strategies to maintain healthy
lifestyle changes. Each family was reimbursed $5 for each treatment sessionattended. The ISC intervention is consistent with recommendations by an expert
committee on pediatric obesity for a brief, clinic-based intervention (Spear et al.,
2007).
Interventionists
The interventions were delivered by masters-level graduate students and a post-
doctoral fellow in clinical psychology. There were different parent group leadersacross the three intervention sites. All interventionists received 8 hr of train-
ing before the intervention and had prior experience in behavioral approaches
to weight management. Interventionists across treatment sites participated in
weekly supervision meetings with David M. Janicke. David M. Janicke periodi-
cally reviewed audio tapes of group treatment session to assist with supervision
and help ensure treatment fidelity.
RESULTS
Summary of Participant Characteristics at Baseline
Baseline demographic and weight status data are displayed in Table 1. Themean age of participants was 9.12 years (SD D 1:90). Just over one half of the
sample was boys (52.5%), and there were roughly equal numbers of Caucasian
(47.5%) and African American (40%) child participants. Twenty-seven child–
parent dyads were assigned to the BFI, and 13 were assigned to the ISC.
There were no statistically significant differences between treatment conditionson variables listed in Table 1, with the exception of racial status. There were
significantly more children identified by their parent as African American in the
OBESE CHILDREN ENROLLED IN MEDICAID 219
TABLE 1
Baseline Demographic and Anthropometric Variables
Variable
All Participants
(N D 40)
BFI Only
(n D 27)
ISC Only
(n D 13)
Child age: M (SD) 9.12 (1.90) 9.30 (1.98) 8.77 (1.74)
Child gender
Male 52.5% 55.6% 46.2%
Female 47.5% 44.4% 53.8%
Child race
Caucasian 47.5% 40.7% 61.6%
African American 40.0% 51.9% 15.4%
Other 12.5% 7.4% 23.0%
Caregiver relationship
Mother 72.5% 70.4% 76.9%
Father 12.5% 14.8% 7.7%
Grandparent 10.0% 7.4% 15.4%
Other 5.0% 7.4% 0%
Caregiver age: M (SD) 40.10 (9.94) 40.08 (10.71) 40.15 (8.59)
Caregiver education
Did not finish high school 7.5% 11.1% 0.0%
High school degree 25.0% 37.0% 0.0%
Some college 45.0% 33.3% 69.2%
College degree 17.5% 11.1% 30.8%
Post-graduate school 5.0% 7.5% 0.0%
Annual family income
Below $9,999 12.5% 18.5% 0.0%
$10,000–$19,999 40.0% 44.5% 30.8%
$20,000–$29,999 22.5% 22.2% 23.1%
$30,000–$39,999 7.5% 3.7% 15.5%
$40,000 & Above 15.0% 11.1% 23.1%
Not reported 2.5% 0.0% 7.5%
Child BMI z score: M (SD) 2.21 (0.43) 2.17 (0.47) 2.33 (0.26)
Parent BMI: M (SD) 40.58 (9.71) 41.02 (10.04) 39.69 (9.44)
Note. BFI D behavioral family intervention; ISC D individual standard of care; BMI D body
mass index.
BFI (52%) relative to the ISC (15%) (df D 1, n D 40), �2D 5:29, p < :03.
Although each family was encouraged to have both parents attend treatment
sessions, only one parent from each family participated in treatment sessions;
almost all adult participants were women (90%).
Participant Screening and Randomization
Participant flow during the pilot study is presented in Figure 1. Overall, 73
child–parent dyads called our research office to inquire about participating in
220
FIG
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Par
tici
pan
tfl
ow
char
t.
221
222 JANICKE ET AL.
the project. Of these 73 dyads, 49 dyads completed phone screening and initial
in-person screening visits. Nine of the 49 dyads that completed the in-person
screening visit ultimately did not complete the baseline assessment visit andwere not randomly assigned to treatment. Five of these nine dyads no-showed for
their baseline assessment visit and did not return our phone calls, and four dyads
officially withdrew from the study before completing the baseline assessment.
Therefore, 40 child–parent dyads were assigned to treatment across all sites
(27 to the group treatment and 13 to the individual treatment). Unbalancedassignment to treatment condition in this pilot study was necessary to ensure an
adequate number of participants in the BFI groups to allow for effective group
treatment.
Thirty-three of the 40 child–parent dyads completed both posttreatment and
follow-up assessments. There were no significant differences between child–
parent dyads that did and did not complete all three assessment visits on childage, child gender, child race, parent age, child baseline BMI z score, and total
number of children living in the home. There were also no differences in weight
status change across treatment sites for children in the BFI from baseline to
posttreatment, F.3; 19/ D 0:85, p D :48; and baseline to follow up, F.3; 19/ D
0:75, p D :54.
Child Weight Status Change
Baseline to posttreatment. Child BMI z score values at all three assess-
ment points are displayed in Table 2. An analysis of covariance (ANCOVA)
comparing Child BMI z Score � Treatment Condition at posttreatment, whilecontrolling for baseline child BMI z score, was not significant, F.1; 32/ D 1:46,
p D :24. The effect size (ES) based on Cohen’s d was .27. For children in the
BFI only, correlation analyses were conducted to assess the relations between
child weight status change and key variables. A large and statistically significant
relation was found between change in child weight status and change in parent
weight from baseline to posttreatment (r D :56, p D :01) such that parents whogained less weight had children who exhibited better improvements in weight
status. The relations between child weight change at posttreatment and other key
variables exhibited small to medium correlations, but none reached statistical
significance. These included child age (r D �:26, p D :25), session attendance
(r D �:26, p D :25), child weight status at baseline (r D �:25, p D :26), andparent weight status at baseline (r D �:20, p D :42). An independent-sample
t test also found that there was no difference in weight status change by child
gender (t D �0:29, p D :77).
Baseline to 9-month follow up. An ANCOVA comparing Child BMI z
Score � Treatment Condition at follow up, while controlling for baseline child
BMI z score, was not significant, F.1; 32/ D 0:90, p D :77. The ES based
on Cohen’s d was .10. For children in the BFI only, a large and statisticallysignificant correlation was found between change in child weight status and
change in parent weight from baseline to follow up (r D :60, p D :01)
such that parents who gained less weight had children who exhibited better
improvements in weight status from baseline to follow up. The relations between
child weight change and session attendance exhibited a medium ES, but did not
reach statistical significance (r D �:33, p D :13).
Child Weight Status Change by Race
As there were significantly more African American children in the BFI com-
pared to the ISC condition, differences in Weight Status Change � Race were
examined (see Table 3). When examining only children assigned to the BFI,visual inspection of the data suggests that Caucasian children benefited from
this program, whereas African American children did not appear to benefit from
the program. Specifically, at posttreatment, children in the BFI identified as
African American exhibited an average increase in weight status of .05 BMI
z score units (SD D 0:13) relative to baseline, whereas Caucasian childrenexhibited a decrease of .03 z score units (SD D 0:07) during this time period.
At the 9-month follow up, African American children in the BFI exhibited a
Other (n D 2) 109.1 ˙ 15.0 111.6 ˙ 8.9 111.3 ˙ 5.4 �0.2 ˙ 4.0 0.60 ˙ 8.3
Note. BMI D body mass index; BFI D behavioral family intervention; ISC D individual standard of care.
continued worsening of weight status, with an increase of .09 BMI z score units
(SD D 0:24) relative to baseline. However, Caucasian children exhibited further
improvements over this timeframe, as they experienced a mean overall decreaseof .08 BMI z score units (SD D 0:24) from baseline to follow up. This is in
contrast to Caucasian children in the ISC, who exhibited very little change in
weight status from baseline to follow up (M D 0:017, SD D 0:060). Although
the small sample sizes within racial groups limited our ability to find statistically
significant group differences at posttreatment, F.1; 19/ D 3:06, p D :09 (ES D
.76) and follow up, F.1; 19/ D 2:43, p D :13 (ES D .74), the ESs (Cohen’s d )
were large.
Parent Weight
There were no significant differences in parent weight change from baselineto either posttreatment or follow-up assessment between treatment conditions
(see Table 2). Table 3 shows Parent Weight � Race at all three assessments.
When examining only parents in the BFI, there was a significant difference
in Weight Status Change � Race. Specifically, Caucasian parents exhibited
significantly more favorable weight outcomes from baseline to posttreatment(t D �2:34, p D :03) and baseline to follow up (t D �2:13, p D :05)
compared to African Americans. Three parents in the BFI group (1 African
OBESE CHILDREN ENROLLED IN MEDICAID 225
American and 2 Caucasians) declined to be weighed; thus, in Table 3, the
number of African American and Caucasian parent participants differed from
corresponding child totals.
Participant Satisfaction
An analysis of variance found no significant differences in parent-reported “over-
all program satisfaction” between the BFI (M D 3:84, SD D 0:37) and ISC
(M D 3:50, SD D 0:93) conditions, on a scale of 1 to 4. There were nostatistically significant differences in Program Satisfaction � Race. Overall pro-
gram satisfaction for children in the BFI was high: 90 on a scale of 0 to 100.
Program satisfaction data was not collected from children assigned to the ISC
condition.
DISCUSSION
There are few treatment options available for obese children and their parentsfrom economically disadvantaged backgrounds, except for overcrowded primary
care or specialty clinics that often provide only brief, infrequent appointments to
help address a complex, multidimensional problem. This is a substantial concern
as frequent, consistent, and extended intervention contacts are often necessary to
help children and families make changes to healthy lifestyle habits that endureand lead to improvements in long-term weight status (Wilfley et al., 2007).
This pilot study is one of the first to examine the efficacy of a group-based
BFI addressing pediatric obesity delivered solely to children from economically
disadvantaged backgrounds.
Our initial analysis showed there was no difference in weight status outcomes
from pretreatment to posttreatment and follow up for children assigned to theBFI relative to those in the ISC condition. The overall ES was small. This
was not entirely surprising given that the treatment was relatively short, at
only 12 weeks. We implemented a brief intervention due to concerns that
barriers to attending weekly meetings for low-income families would make it
difficult to attend a longer program. Despite our efforts to reduce these barriers,participant attendance at the BFI group meetings (55%) was lower than expected.
This likely had a negative impact on the adoption of healthy behaviors and,
ultimately, weight change. It is possible that poor attendance also hindered the
effectiveness of the program for those with more consistent session attendance,
as smaller groups reduce the potential positive effects of group interactions andmay dampen the enthusiasm of participating families. Also noteworthy is that
parent weight loss was positively associated with change in child weight status.
226 JANICKE ET AL.
This is consistent with previous research in this area (Epstein et al., 2007) and
highlights the importance of parents joining their children in making healthy
behavior changes.The lower than expected rates of participant attendance are consistent with
the pediatric weight-management literature, which shows poor attendance and
treatment completion for families of children enrolled in Medicaid (Zeller et al.,
2004). It is likely that a variety of life circumstances commonly experienced by
families from economically disadvantaged backgrounds made attending weeklytreatment sessions on a consistent basis difficult for participants. A number of
participating parents and guardians reported changing jobs, taking a second job,
or changing working schedules that required shift hours that greatly limited
session attendance. Some families reported transportation difficulties due to
automobile troubles and inadequate finances to pay for car repairs, or because
they were dependent on others for car rides to treatment meetings. A surprisingnumber of families missed meetings because of illness or poor health of family
members. These stressors also often lead to practical considerations for families.
Most notably, a number of single parents reported that because they worked two
jobs or were dealing with other family health issues or stress, they had limited
time to prepare healthier meals. Rather, they served or purchased meals basedon convenience.
These points highlight the necessity of developing interventions or delivery
mechanisms to improve the ability of families to more consistently participate in
regularly scheduled intervention contacts. Two alternative treatment models to
help facilitate more consistent participant contact with treatment professionalsare home-based contacts and phone-counseling contacts (Patrick et al., 2006;
Stark et al., 2010). Each of these models has demonstrated success in pediatric
weight-management intervention trials when used to augment behavioral clinic-
based interventions, and may eliminate some of the barriers to attending clinic-
based treatment. In addition, conducting treatment meetings at more convenient
neighborhood locations or within existing and respected community networks(i.e., neighborhood community centers, boys and girls clubs, and churches) may
also serve to improve treatment attendance and could potentially enhance cultural
relevance and acceptance (Tucker, 2002).
Although BFIs have been deemed efficacious in well-controlled research
settings, the methods of these studies may not reflect what is do-able for familiesfrom economically disadvantaged populations in real-life settings. One barrier to
full participation seems particularly relevant. BFIs addressing weight manage-
ment, as commonly implemented in efficacy studies (Esptein et al., 2007; Jelalian
& Saelens, 1999), require families to monitor and record daily dietary intake
and physical activity throughout the intervention. This is a critical mediator oftreatment outcomes in behavioral weight-management programs (Mockus, Ep-
stein, & Wilfley, 2005). This is challenging even for families with good financial
OBESE CHILDREN ENROLLED IN MEDICAID 227
and support resources. However, for families burdened with financial hardship
and other associated pressures, monitoring and recording their family’s dietary
intake and physical activity is not a priority and is challenging at best. Familiesconsistently expressed frustration and difficulty with completing monitoring
forms; and on those occasions when they did record food intake and activity, the
forms were often incomplete and inaccurate. Continually encouraging families
to engage in this activity can be embarrassing and threatening to families, even
if group leaders strive to be flexible and accepting. Ultimately, it can havethe undesirable outcome of pushing families away from participation, as the
perceived burden is too much for them. Finding strategies to reduce this burden
on families, but that can still lead to successful health behavior changes, is a
critical question for future research.
Beyond individual and family factors, there were community-level factors
associated with living in economically disadvantaged areas that appeared toimpact participants’ abilities to fully participate in the intervention. Along with
the higher perceived cost of healthy foods by many participants, a number of
families complained that many grocery stores in their neighborhoods had limited
high-quality fruits and vegetables or other healthy food options. In addition, for
a number of other families, limited access to safe and high-quality playgroundequipment further limited their opportunities to engage in physical activity, as
they could not afford to sign their children up for organized team sports.
As behavioral health interventions are often delivered to children and families
from diverse backgrounds, it is vital to assess potential moderators of treatment
outcome. Although differences in child weight status did not reach statisticalsignificance, this study provides data suggestive of differential outcomes by race.
Caucasian children appeared to benefit more from the BFI program compared
to African American children, as the ES at the 9-month follow up was large.
Previous research has shown that African American families have higher rates of
attrition from pediatric weight-management programs compared to Caucasians
(Epstein et al., 2007). However, there were no differences in Attrition � Race inthis study. Moreover, although differences by race in many treatment outcome
studies are often confounded by income, this study included only those enrolled
in Medicaid.
Although additional research with larger samples is needed before definitive
conclusions can be drawn, our experience highlights the importance of develop-ing interventions that are culturally relevant to appropriately address the needs
of African American families (Kumanyika & Grief, 2006; Wilson, 2009). There
is often a cultural mismatch existing between weight-management programs and
the needs and cultural perspectives of African American families (Kumanyika
& Morssink, 1997). Several strategies may help address this mismatch. Duringour group meetings, we noted a high frequency of African American parents
asking to bring extended family members to group sessions, as well as the
228 JANICKE ET AL.
importance that these extended family members held in raising children. As
such, a strategy to improve treatment participation and facilitate support for
making healthy lifestyle changes is to allow participants to bring friends orextended family members to the meetings. Family and friend participation may
provide culturally salient support to help participants adopt healthier lifestyle
behaviors and make group settings more enjoyable (Ard, Rosati, & Oddone,
2000; Kumanyika et al., 2009).
In addition, research suggests that African Americans have difficulty com-plying with dietary recommendations when the changes in diet are alien to their
lifestyle and contain unfamiliar foods (Ard et al., 2000). For our intervention, we
took a dietary program created with primarily Caucasian families and attempted
to generalize it to African American families. Although we asked families to
discuss their personal food choices, we likely did not cover enough of the
foods African American families commonly consume. Including more ethnicfoods choices during weekly snacks and discussing and reviewing alternative
foods choices that are more commonly consumed in African American homes
would have likely made the treatments more culturally relevant (Ard et al., 2000;
Kumanyika et al., 2009). Incorporating cooking demonstrations with foods that
are commonly consumed in African American homes or demonstrating howfamily recipes can be modified consistent with their cultures and traditions
would also help in this regard (Kumanyika et al., 2005). In addition, participants
and group leaders could take “field trips” to grocery stores and restaurants in
traditional African American neighborhoods to give families applied experience
and assistance in making healthy choices that are more relevant to their lives(Kumanyika et al., 2005). This may also increase interventionist appreciation
of the difficulties families face when attempting to make healthy food choices
within the constraints of food offerings in their community. Ideally, children
and parents will be able to more easily follow dietary guidelines by focusing on
foods that are familiar to families.
A few other suggestions are noteworthy. It has been suggested that AfricanAmerican adults and children may be less motivated to lose weight for aesthetic
purposes due to greater cultural acceptance of higher weight (Ard et al., 2000).
Thus, education about risk-factor modification and management of diseases
associated with obesity through dietary changes may be a better motivational
technique for group leaders. Moreover, because families from disadvantagedneighborhoods may have less playground equipment and safe neighborhoods
to support outdoor play for children, it may be helpful to provide information
on free or low-cost opportunities for physical activity within each participant’s
neighborhood and community (Kumanyika et al., 2005). It would also seem
important to identify and find ways to incorporate activities into group meetingsand daily life that youth can identify with as part of their cultural values (e.g.,
hip-hop dance to increase physical activity; Wilson, 2009).
OBESE CHILDREN ENROLLED IN MEDICAID 229
There are some limitations in this study that must be acknowledged. Child–
parent dyads were not randomly assigned to treatment condition during Cohort 2
due to the limited number of eligible dyads in that cohort. Thus, this study did notutilize a randomized controlled design. Although there were no differences be-
tween treatment sites in baseline demographic variables or weight status change,
it is possible that participants differed in some other critical, but unmeasured,
variable. Second, there was an uneven assignment of African American children
across the two treatment conditions, with over 50% of the children in the BFIidentified as African American, compared to only 15% in the ISC. Although
the outcome analysis controlled for race, the small number of African American
children in the ISC condition (n D 2) provided a less than optimal estimate
of how African American children may respond to the standard care control
condition. Finally, due to the small sample size and pilot nature of this study,
we did not use intent-to-treat analyses. Thus, our analyses did not account forfamilies who did not complete the posttreatment and follow-up assessments.
Implications for Practice
Given higher rates of obesity, as well as the lack of resources and effec-
tive treatment options available for children and families from economicallydisadvantaged backgrounds, such BFI programs could increase the services
available to families. Moreover, the group delivery format potentially allows
for a more effective child:interventionist ratio than individual treatment sessions
with families, placing less of a burden on health care professionals, as well as
potentially decreasing the cost of providing treatment. Despite the limitationsnoted earlier, these findings have potential implications for policy, research, and
practice. Although future outcome research is necessary to enhance and evaluate
the pilot treatment program described here, this study suggests that greater efforts
need to be made to increase the ecological validity of behavioral family-based
weight-management interventions for children by reducing the potential barriers
to participation and increasing the cultural relevance of these interventions forfamilies from diverse backgrounds. A number of recommendations were pro-
vided in the preceding paragraphs to help researchers and clinicians move toward
this goal. However, it will be important to make these improvements while
still maintaining cultural relevance and effectiveness for non-African American
children.
ACKNOWLEDGMENT
The study was funded by a grant from the Florida Agency for Health Care
Administration via the Florida Center for Medicaid and the Uninsured.
230 JANICKE ET AL.
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