Weighing Physical Activity: The Impact of a Family-Based Group

Lifestyle Intervention for Pediatric Obesity on Participants

Physical Activity
Jason Van Allen,1 PHD, Kelsey B. Borner,2 MA, Laurie A. Gayes,2 MA, and Ric G. Steele,2 PHD, ABPP
1

Clinical Psychology Program, Texas Tech University and 2Clinical Child Psychology Program,

University of Kansas

All correspondence concerning this article should be addressed to Jason Van Allen, PHD, Department of
Psychological Sciences, Texas Tech University, Box 42051, Lubbock, TX 79409, USA.
E-mail: jason.vanallen@ttu.edu
Received June 18, 2014; revisions received August 15, 2014; accepted August 16, 2014

Key words

obesity; physical activity; randomized controlled trial.

Current estimates indicate that approximately one-third of

youth in the United States are either obese (body mass
index, BMI  95th percentile) or overweight (BMI  85th
percentile; Ogden et al., 2012). Although these rates have
dramatically increased during the past 30 years, recent data
indicate that the prevalence of overweight and obesity is
beginning to stabilize (Ogden et al., 2008, 2010).
Nevertheless, this public health epidemic remains a priority
of national and international health organizations and is a
considerable financial burden through all levels of health
care, with projected estimated costs reaching nearly $860
billion by 2030 (Wang, Beydoun, Liang, Caballero, &
Kumanyika, 2008). Additionally, youth with obesity are
at risk for a multitude of negative physical and psychosocial consequences (Jensen & Steele, 2010; Schwimmer,
Burwinkle, & Varni, 2003; Shoup, Gattshall, Dandamudi,

& Estabrooks, 2008; Storch et al., 2007; Zeller &

Modi, 2008) and are less likely to engage in physical activity (PA; Ness et al., 2007).
In an effort to combat the alarming prevalence of obesity and its attendant physical and psychological health
risks, researchers are disseminating effective pediatric obesity interventions into the public sphere. Consistently
established as an efficacious form of treatment (Kitzmann
et al., 2010; Wilfley et al., 2007), family-based lifestyle
interventions are recommended as the first line of treatment for overweight and obese youth according to
Barlow and the Expert Committee for the Assessment,
Prevention, and Treatment of Pediatric Obesity (2007).
These interventions use behavioral strategies (e.g., goal setting, stimulus control, self-monitoring; Dalton &
Kitzmann, 2012) to promote nutrition change and

Journal of Pediatric Psychology 40(2) pp. 193202, 2015

doi:10.1093/jpepsy/jsu077
Advance Access publication September 19, 2014
Journal of Pediatric Psychology vol. 40 no. 2 The Author 2014. 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

Downloaded from http://jpepsy.oxfordjournals.org/ by guest on November 25, 2016

Objectives To examine differences in self-reported physical activity (PA) between participants enrolled in
the treatment versus active control condition of a pediatric obesity intervention, and to test associations between parent and child PA. Methods Participants (N 93) included children aged 717 years and their
parent. Analyses tested whether participants in the treatment condition reported greater PA at
postintervention and 12-month follow-up compared with the control condition. Further, researchers examined change in PA across time and whether change in parent PA was associated with change in child
PA. Results Children in the treatment condition reported greater PA at 12-month follow-up. Parents in
the treatment group reported a significant increase in PA between baseline and postintervention. Change in
parent PA was associated with changes in child PA across multiple periods. Conclusions Family-based
obesity interventions may promote long-term change in self-reported PA among youths, and change in parent
PA may be a contributing factor.

194

Van Allen, Borner, Gayes, and Steele

Prochaska, Rodgers, & Sallis, 2002), and it is hypothesized

that parental modeling, encouragement, and support are
key mechanisms of this relationship.
Nonetheless, despite the long-term health benefits of
PA and the important role of parents in influencing their
childs activity level, relatively few studies to date have examined changes in PA at long-term follow-up, changes in
parent PA, or associations between change in parent PA
and change in child PA within the context of a weightmanagement intervention (McGovern et al., 2008; Wilfley
et al., 2007). If interventions neglect to measure these
essential treatment components when evaluating the success or failure of a particular lifestyle intervention, the potential long-term success of the intervention may be
difficult to assess. Investigating such outcomes could
help identify the types of interventions that are more
likely to benefit the entire family and promote sustained
treatment benefits. For example, significant change associations between parent and child PA may provide additional
support for the use of cost-effective parent-only interventions in this context (Golan, 2006; Janicke, 2013).
The present study was designed to address these gaps
in the literature by assessing short- and long-term changes
in self-reported PA among youths and their caregiver enrolled in a randomized practical trial of two family-based
group interventions for pediatric obesity (Steele et al.,
2012), and to examine associations between change in
parent and child PA over study periods. More specifically,
these secondary data analyses examined the patterns of
change in PAat postintervention and 12-month followupfor participants in both the experimental treatment
(Positively Fit; PF) and active control (Brief Family
Intervention; BFI) conditions. Group comparisons were
tested with regard to self-reported PA at each time
point for both children and their caregiver. Finally, associations between change in parent PA and change in
youth PA were examined. It was hypothesized that
youths and their caregiver in the experimental treatment
condition (PF) would report significant changes in PA,
compared with baseline reports, immediately after the intervention (Time 2) and at 12-month follow-up (Time 3),
and that participants in the experimental treatment condition (PF) would report significantly higher levels of PA
compared with participants in the active control condition
at each time point. Because parents play a key role in the
modeling and promotion of family PA (Bauman et al.,
2012; Golan Weizman, Apter, & Fainaru, 1998), it was
hypothesized that change in parents PA would be significantly positively associated with change in youths PA
between baseline and Time 2, between Time 2 and
Time 3, and between baseline and Time 3.

Downloaded from http://jpepsy.oxfordjournals.org/ by guest on November 25, 2016

education, as well as PA (Staniford et al., 2011). PA components vary considerably across obesity interventions and
range from using structured, supervised exercise programs
to simply encouraging goal setting to increase PA (Staniford
et al., 2011).
Increasing PA is not only a core component of lifestyle
interventions for children who are obese or overweight, but
is also recommended for all youth by the Centers for
Disease Control and Prevention (2012). However, despite
known physical and psychological benefits, only 30% of
U.S. children meet the recommended guidelines of 60 min
of moderate/vigorous PA per day (Centers for Disease
Control and Prevention, 2012). Irrespective of weight
status, low levels of PA are associated with lower quality
of life (Shoup et al., 2008), depressive and anxious symptoms (Parfitt, Pavey, & Rowlands, 2009), and lower overall
self-concept and self-esteem (Ahn & Fedewa, 2011) among
youth. On the other hand, increased PA in children and
adults has been associated with improved cardiovascular
functioning; improved strength, self-esteem, and body
image; better general mood states; reduced risk of back
injuries; reductions in stress; enhanced immune system
functioning; a reduction in low-density lipoproteins; and
the prevention of various chronic diseases (e.g., obesity,
diabetes; Harsha, 1995; Penedo & Dahn, 2005; Sothern,
Loftin, Suskind, Udall, & Blecker, 1999).
To date, research evaluating PA outcomes of pediatric
obesity interventions is limited, as the outcome of interest
is typically (and often exclusively) BMI and body composition (Cliff, Okely, Morgan, Jones, & Steele, 2010).
However, PA may offer several advantages as an alternative
outcome of interest. For example, PA represents a proximal
treatment outcome that is more amenable to short-term
change than BMI and may support long-term weight loss
(Wing & Phelan, 2005). Furthermore, a recent meta-analysis suggested that increased PA, not weight loss, may be
responsible for improved cardio-metabolic outcomes such
as blood pressure, triglycerides, and cholesterol following
obesity interventions (Ho et al., 2012).
Like youth PA, parental PA change is a frequently overlooked outcome of family-based pediatric obesity interventions. It is well-established that parental outcomes are
critical to measure, as obese youths with high parental involvement (in treatment for obesity) generally have better
outcomes than children and adolescents with less involved
parents (Kitzmann et al., 2010). Such findings suggest that
positive child effects are likely because of lifestyle changes
made by parents and children alike, rather than among
individuals alone. Numerous studies have demonstrated
significant associations between parent PA and youth PA
(Davidson, Cutting, & Birch, 2003; Ferreira et al., 2006;

Weighing Physical Activity

Method
Participants

Procedures
Families were recruited for this study through physician
and school nurse referral and advertisements in the community. After completing an initial telephone screening,
parents attended a pretreatment orientation session.
Interested parents then provided consent and children provided assent, if they were interested in participating.
Families who provided consent/assent then completed
self-report and anthropometric data collection. If multiple
children from the same family were participating in the
intervention, the oldest child who was overweight or
obese was identified as the target child. Participants
were then block randomized into either the PF or BFI
treatment condition and began the intervention soon
after. Measures were again completed at the conclusion
of the intervention and a final time 1 year after the conclusion of the intervention. Families received $20 for

completing the pretreatment assessment and the postintervention assessment and $50 after completion of the
12-month follow-up assessment. All procedures were
approved by the Human Subjects Committee of the
second authors institutional review board.

Description of the Interventions

Positively Fit
This manualized intervention consists of weekly group
treatment sessions approximately 90 min in duration for
10 weeks (Steele et al., n.d.). Parents and children attended
separate sessions for the nutrition education, PA education, and behavioral intervention components, and
united for a final summary and goal-setting component.
Brief Family Intervention
Participants in this active control condition received the
Trim Kids manual (Sothern, von Almen, & Schumacher,
2002) at the start of treatment and were instructed to read
portions of the book throughout treatment. They also received three 60-min individual face-to-face sessions with
one of two registered dietitians participating in the study.

Measures
Demographic Information
At the pretreatment orientation session, demographic variables including child age, gender, ethnicity, family income,
parent education level, and parent marital status were collected from the parent or guardian. Detailed information
regarding baseline demographic informationas well as
means and standard deviations of the measures described
belowis presented in Table I.
Anthropometric Variables
Child and parent weight and height were collected at Time
1, Time 2, and Time 3 using a calibrated electric scale
(model number SECA 813, SECA Corp., Hanover, MD,
USA) and a portable stadiometer (model number SECA
214, SECA Corp.), with participants in light clothing and
no footwear. BMI z-scores (zBMI) were calculated using a
SAS application provided by the Centers for Disease
Control and Prevention (CDC, 2007).
Physical Activity
Participants completed a self-report measure of PA
(Physical Activity Questionnaire for Older Children
[PAQ-C]; Kowalski, Crocker, & Faulkner, 1997) at Time
1 (baseline), Time 2 (postintervention), and Time 3 (12month follow-up). The PAQ is a nine-item self-report 7-day
recall questionnaire that assesses general levels of PA.
Respondents indicate how often they have engaged in a

Downloaded from http://jpepsy.oxfordjournals.org/ by guest on November 25, 2016

Participants were recruited as part of a randomized clinical

trial of a family-based behavioral intervention for pediatric
obesity (PF) as compared with an active control group
(BFI). This study is a secondary data analysis of participants enrolled in the original PF intervention project,
and the data have not been previously reported in the literature. Eligibility criteria for participation in the study included: (a) the participating child or adolescent was
between 7 and 17 years of age; (b) the participants BMI
percentile was categorized as overweight (i.e., BMI  85th
percentile) or obese (i.e., BMI  95th percentile); (c) one
parent was willing to participate in the intervention; (d) the
participant did not have any serious mental illness or developmental delays; (e) the parent and child spoke English;
(f) the parent provided written informed consent; and (g)
the child verbally assented to participation.
A total of 147 families were screened for eligibility. Of
the eligible families, 4 did not meet inclusion criteria, 16
refused to participate, and 34 could not be contacted, resulting in 93 families enrolled in the study. Forty-seven
families were allocated to the PF intervention and 46 families were allocated to the BFI control condition. Of the 93
families enrolled in the study, 11 families did not complete
any treatment sessions, 66 families completed the postintervention assessment, and 58 families completed the 12month follow-up. All children and caregivers enrolled in
the study at baseline completed the PA measure. One caregiver did not complete the PA measure at Time 2, while
three children and one caregiver did not complete the measure at Time 3.

195

196

Van Allen, Borner, Gayes, and Steele

Table I. Baseline Demographic Characteristics of Participants
Mean  SD or n (%)

Variable

Age (years)
Female gender

Child
participants
(N 93)

11.57  2.64

Parent
participants
(N 93)

39.76  7.33

56 (58.9)

87 (93.5)

White, not Hispanic

66 (70.2)

72 (76.6)

Black, not Hispanic

13 (13.8)

11 (11.7)

Ethnicity

Hispanic
Other
Parent education

4 (5.3)

7 (8.5)

10 (10.6)

3 (3.2)

Some high school

2 (2.1)
10 (10.6)

Attended college

18 (19.1)

Junior college or

13 (13.8)

vocational school
College graduate

28 (30.9)

Postgraduate work
Graduate degree

8 (8.5)
14 (14.9)

Marital status
Married, living together

58 (61.7)

Divorced

24 (25.5)

Other

11 (12.8)

Family income

4,072.54  2,724.70

(gross monthly)
BMI z-score (child)
or BMI (parents)

2.22  0.35

33.62  9.25

list of 22 physical activities (e.g., skipping, bicycling, walking, aerobics, swimming, baseline, football, soccer, basketball, dance, ice skating, skateboarding), as well as their
activity level during multiple times of day (i.e., physical
education class, recess, lunch, after school, evenings, and
weekend) over the past week. Responses (scored on a scale
of 15) are tailored to each item to assess frequency and/or
intensity. A score of 1 indicates no activity or sedentary
behavior (i.e., sitting); 2 equals very low activity (i.e., standing around) or moderate-vigorous activity one time per
week; 3 indicates moderate activity (i.e., ran or played a
little bit) two or three times per week; 4 equals moderatevigorous activity (i.e., ran around a played quite a bit) several times per week, and 5 indicates very vigorous activity
almost every day per week. An average score between 1 and
5 is computed to provide an overall activity score. The PAQ
has demonstrated adequate testretest reliability (r .75
.82) and reasonable validity (r .45.53) when compared
with objective measures of PA (Kowalski et al., 1997). The
PAQ does not directly discriminate between specific activity intensities (i.e., light, moderate, vigorous), but rather

Statistical Analyses
Study analyses were conducted using SPSS statistical software, version 20. Multiple analyses of variance and linear
regressions were conducted to examine whether any demographic or anthropometric variables were associated with
self-reported PA, or change in PA, between any time points.
Age was significantly negatively associated with PA among
youth at each time point, and was thus included as a covariate in between-group comparisons. No other demographic variable, nor zBMI, was associated with child PA
at any time point. Ethnicity, gender, zBMI, and parent education were associated with parents PA at Time 3 (but at
no other time point); Caucasian participants, males, parents with lower zBMI, and participants with a college
degree reported higher PA at this time point. Thus, these
variables were tested as interaction variables in primary
study analyses in addition to controlling for these variables
in between-group analyses if no interaction was present.
There were no significant associations between demographic variables and change in PA, or between anthropometric variables and change in PA, among parents and
children regardless of the periods tested.
Primary analyses involved (a) statistical comparisons
of mean differences in PA between the PF and BFI
groups for both youths and caregivers, at baseline, Time
2 (postintervention), and Time 3 (12-month follow-up); (b)
comparisons of within-group change in PA among youths
and caregivers for PF and BFI groups; and (c) an examination of the associations between change in parent PA and
change in child PA for all study intervals, with participants
collapsed across groups.
Between-group comparisons of youth PA across study
conditions (PF vs. BFI) were examined using multiple oneway independent analyses of covariance with age included
as the covariate. Between-group comparisons of parent PA
at Time 3 were initially examined by testing interactions
between categorical covariates (i.e., gender, ethnicity, and
parent education) and study condition. When interactions
were not significant, the mean differences in PA between
study groups were examined while controlling for the influence of each covariate in this association. Because these
categorical covariates were not significantly associated with
parent PA at Time 1 or Time 2, independent-samples t tests
could be used to test for differences in PA between participants in the two study conditions. Further, paired-samples
t tests were conducted to evaluate within-group changes in
self-reported PA for youths and parents between baseline
and Time 2, Time 2 and Time 3, and baseline and Time 3.

Downloaded from http://jpepsy.oxfordjournals.org/ by guest on November 25, 2016

High school graduate

provides a summary score that can be compared between

groups or time points.

Weighing Physical Activity

197

Table II. Between-Group Comparisons of Physical Activity at Study Time Points for Youths and Caregivers
Time 1
N

Mean

SE

PF kids

47

2.72

0.12

BFI kids

46

2.44

0.12

PF parents
BFI parents

47
46

1.81
1.78

0.10
1.10

Time 2
F

p-value

3.25

.08a

0.07

.79

Mean

SE

35

2.65

0.11

31

2.72

0.11

34
31

2.17
1.96

0.10
0.13

Time 3
F

p-value

0.04

.85a

1.61

.21

Mean

SE

28

2.73

0.15

27

2.26

0.14

28
29

1.98
1.70

0.14
0.12

p-value

8.24

.006a,*

0.42

.52b

Note. aResults controlling for youths age as a covariate. Bold values represent statistically significant results (p < 0.05).
b
Results controlling for parents gender, ethnicity, education, and BMI at Time 3.

Table III. Within-Group Comparisons of Physical Activity Between Time Points for Youths and Caregivers
Times 12

Times 23

Mean T1

Mean T2

PF kids
BFI kids

35
31

2.62
2.48

2.65
2.71

0.237
1.68

PF parents

34

1.85

2.17

2.72

.01*

26

2.10

BFI parents

31

1.74

1.96

1.32

.20

28

1.94

p-value

.81
.10

Mean T2

Mean T3

p-value

Mean T1

Mean T3

p-value

26
27

2.66
2.74

2.62
2.26

0.12
4.08

.76
.000**

28
27

2.80
2.51

2.73
2.26

0.378
1.55

.71
.13

1.93

1.29

.21

28

1.75

1.98

1.79

.09

1.66

2.67

.01

29

1.69

1.70

0.09

.93

Note. Means and N values for within-group comparisons include only those participants who completed study measures at both time points. Bold values represent
statistically significant results (p < 0.05).
*p < .05, **p < .001.

Finally, hierarchical multiple regressions were conducted to test associations between change in parent PA
and change in youth PA from baseline to Time 2, Time 2 to
Time 3, and baseline to Time 3 for the entire sample collapsed across groups. For these analyses, change scores
were calculated by subtracting self-reported PA scores between time points and the resulting change scores were
entered into regression analyses. Group membership (PF
vs. BFI) was entered into the first block of each hierarchical
multiple regression to determine whether these associations were present regardless of treatment condition.
Change in parent PA was entered in the second block of
the regression, with change in child PA entered as the dependent variable.

Results
Results partially supported study hypotheses. As shown in
Table II, baseline data from youth participants indicated
that there were no significant differences in self-reported
PA between the PF (M 2.72, SE 0.12) and BFI
(M 2.44, SE 0.12) conditions while controlling for
age (F(1) 3.25, p > .05). Contrary to study hypotheses
with regard to postintervention (Time 2), results indicated
that there was not a significant difference in PA between
the PF (M 2.65, SE 0.11) and BFI (M 2.72,
SE 0.11) conditions while controlling for age
(F(1) 0.04, p > .05). However, consistent with study

hypotheses, participants in the PF condition reported

higher levels of PA at 12-month follow-up (Time 3;
M 2.73, SE 0.15) compared with participants in the
BFI condition (M 2.26, SE 0.14) while controlling for
age. This difference was statistically significant
(F(1) 8.24, p < .01), and resulted in a small-medium
effect size (!2 0.07; Vacha-Haase & Thompson, 2004).
Table III depicts within-group analyses, which revealed that
mean self-reported PA did not increase significantly for the
PF group between Time 1 and Time 2, Time 1 and Time 3,
or Time 2 and Time 3; however, there was a significant
decrease in self-reported PA between Time 2 and Time 3
for the BFI group (t(26) 4.08, p < .001, r .62).
As shown in Table II, baseline data from parent participants indicated that there were no significant differences in PA between the PF (M 1.81, SE 0.10) and
BFI (1.78, SE 0.10) conditions (t 0.26, p > .05).
Similar to youth participants, there were no group differences in PA between the PF and BFI conditions at Time 2.
Moreover, there were no significant differences in PA between groups at Time 3. Results depicted in Table III partially support study hypotheses, as parents in the PF group
(and not the BFI group) reported significant increases in
PA between baseline (M 1.81, SE 0.10) and Time 2
(M 2.17; SE 0.10; t(33) 2.72, p < .05, r .43); however, there was no significant difference between baseline
PA and Time 3 PA, or between Time 2 PA and Time 3 PA in
the PF group. With respect to the BFI group, study

Downloaded from http://jpepsy.oxfordjournals.org/ by guest on November 25, 2016

Times 13

198

Van Allen, Borner, Gayes, and Steele

analyses revealed that mean self-reported parent PA decreased significantly between Time 2 and Time 3
(t(27) 2.67, p < .05, r .46).
Consistent with study hypotheses, cross-sectional
analyses indicated that change in parent PA was significantly positively associated with change in youth PA between baseline and Time 2 (R2 .09, F(2,53) 4.27,
p < .05), and between baseline and Time 3 (R2 .194,
F(2,47) 5.91, p < .01). In addition, a prospective change
model indicated that change in parent PA from baseline to
Time 2 was significantly positively associated with change
in youth PA from baseline to Time 3 (R2 .13,
F(2,45) 3.32, p < .05). Change in parent PA between
Time 2 and Time 3 did not significantly predict change
in youth PA between Time 2 and Time 3.

This study examined the long-term effects of a family-based

pediatric weight-management intervention on youths and
parents changes in PA, which has rarely been assessed in
the field to date (Cliff et al., 2010; Janicke et al., 2014). An
examination of this kind is beneficial given the health benefits of PA in general (Harsha, 1995; Penedo & Dahn,
2005; Sothern et al., 1999) and the important roles of
PA and family involvement in weight management.
Results partially supported study hypotheses: Children in
the treatment condition (PF) reported higher PA compared
with participants in the active control condition (BFI) at
1-year follow-up (Time 3). Within-group analyses revealed
consistent changes between postintervention (Time 2) and
12-month follow-up (Time 3) for both the parent and child
BFI participants (PA decreased for each group). For the
child groups specifically, it appears that the PF groups
self-reported PA gains between Time 1 and Time 2 were
better maintained than those of the BFI group. This maintenance is especially notable because youth tend to decrease levels of PA each year during the transition from
childhood to adolescence (Nader, Bradley, Houts,
McRitchie, & OBrien, 2008).
Results also partially supported study hypotheses related to cross-sectional change associations, as change in
parent PA was significantly positively associated with
change in child PA between baseline and Time 2, and between baseline and Time 3. In addition, a prospective
change model indicated that increases in parent PA between baseline and Time 2 were associated with increases
in child PA between baseline and Time 3 for the entire
sample collapsed across groups. These findings suggest
that parent and youth PA may change in concert and

Downloaded from http://jpepsy.oxfordjournals.org/ by guest on November 25, 2016

Discussion

that changes in parent PA may play an important role in

long-term PA outcomes regardless of whether youths
received PA education as part of the active treatment condition. Because the present study included child participants with a wide range of ages (717 years old), future
studies may find that associations between changes in
parent and child PA may vary as children transition from
children to adolescence and become more independent in
their PA choices.
Although the measure of PA used in this investigation
(PAQ-C) does not directly translate to minutes of PA,
recent literature has determined a potential cutoff point
for assessing adequate levels of PA. According to Voss
and colleagues (2013), a cutoff of 2.9 (on a scale of 15)
may discriminate youth with insufficient levels of PA from
those engaging in sufficient levels. At 12-month follow-up,
youth in the PF group reported an average level of activity
at 2.73, which approaches the cutoff at 2.9, whereas youth
in the BFI group reported an average level of activity at
2.26, which falls well below the cutoff. These results suggest that youth and parents did not meet sufficient levels at
any time point, which may speak to insufficient levels of PA
among youth of any weight status, and the need for pediatric obesity interventions to devote resources toward
increasing PA levels of participants.
Study results are potentially important to researchers
and clinicians alike for a variety of reasons. First, because
weight loss is often a lengthy process for the majority of
overweight and obese individuals (Ho et al., 2012), an
examination of proximal outcomes (e.g., PA) is important
when evaluating an interventions real-world effectiveness
because the maintenance and/or improvement of these
proximal behaviors postintervention will be important for
long-term success. Reporting of youth PA change continues
to lag behind reporting of BMI (Cliff et al., 2010; Janicke
et al., 2014), though such data are emerging. The results of
this study support those of other pediatric obesity interventions reporting improvements in youth PA rates at
follow-up (Nemet et al., 2005; Sacher et al., 2010).
While such data are encouraging, other interventions
have not demonstrated significant improvements in participant PA (Bocca, Corpeleijn, Stolk, & Sauer, 2012; Davis
et al., 2013; DeBar et al., 2012; Shelton et al., 2007). This
discrepancy suggests that more information is needed to
better clarify the effective components of PA interventions.
Second, study results suggest that the specific exercise
education and motivational components of the PF intervention may be effective at promoting PA in the long term
compared with individuals who do not receive similar educational and motivational interventions. PF was designed
to promote PA maintenance and long-term health behavior

Weighing Physical Activity

Limitations and Future Directions

Although encouraging, study findings should be considered in light of important limitations. This investigation
used only self-report of PA obtained via questionnaires,
rather than using more objective measures of PA (e.g.,
actigraphy). A self-report measure does not gather detailed
information regarding the various levels of intensity of an
individuals PA, may be a poor estimate of activity duration, and is influenced by error typically associated with all
self-report measures (e.g., measurement error, reporting
bias, common method variance; Adamo et al., 2009).
Nonetheless the self-report measure used in the present
study has been validated against other methods of activity
assessment (Janz, Lutuchy, Wenthe, & Levy, 2008;

Kowalski et al., 1997) and provides a cost-effective assessment tool when conducting an expensive clinical
research trial.
Another limitation of the present study is that PA
levels were assessed at two time points: postintervention
and 12-month follow-up. More frequent assessments of PA
are needed to model patterns of change over the course of
an intervention and during the study follow-up phase
postintervention, and to test causal models of change. In
addition, the study design prevented researchers from testing which specific treatment components may have resulted in long-term changes in PA, and it is unclear why
participants in the treatment condition reported significantly more PA at 12-month follow-up but not immediately
postintervention. It may be the case that change in PA is a
long-term process (similar to change in BMI) and that small
changes in PA are more realistic in the short-term, but it
may also be the case that study participants made changes
in PA unrelated to treatment content during the postintervention time frame. Finally, study attrition may have also
limited the generalizability of findings. The number of potential participants who did not initiate treatment after
eligibility screening and randomization (N 65) appears
to be considerably larger compared with similar familybased behavioral interventions (Boudreau et al., 2013;
Janicke et al., 2008; Nemet et al., 2005), though it is important to note that the number of participants who initiated treatment and remained in the study at Time 3 (58 of
82; 70.7%) was similar to that of other studies (Boudreau
et al., 2013; Janicke et al., 2008; Nemet et al., 2005).
The present study provides a number of directions for
future research. Future studies should examine longitudinal models of PA change within the context of an intervention using more frequent and more objective estimates of
PA duration and intensity (e.g., via actigraphy). More sophisticated analyses of this kind would also allow researchers to test causal models of change, and could help
researchers identify critical moments of change in PA for
certain subsets of individuals (i.e., those at-risk for decreases in PA). As a result, at-risk individuals could receive
intervention booster sessions before negative patterns stabilize. Lifestyle interventions continue to adopt a blanket
approach to behavior change by delivering all treatment
components to all participants. Although the core components appear to be effective, existing research is limited in
its ability to identify which components are effective, and
for whom. Experimental designs should be conducted to
test the differential contributions of various treatment components to youths PA changes. In addition, a randomized
clinical trail comparing a parent-only PA intervention with
a combined parent and child education intervention could

Downloaded from http://jpepsy.oxfordjournals.org/ by guest on November 25, 2016

change. Throughout treatment, intervention therapists

stressed the importance of engaging in PA as a family,
and building habitual forms of leisure-time PA that are
feasible for all family members regardless of BMI or initial
exercise tolerance. Therapists also spent considerable time
helping families identify leisure-time activity options
during winter months, and planning activities that increase
in aerobic intensity in a graded fashion.
Third, examinations of caregivers changes in PA following a family-based treatment program are lacking; a
brief literature search conducted by the authors revealed
no studies reporting on caregiver PA changes. Such information may help researchers and clinicians understand
whether their interventions are having an impact on the
family more broadly. Results from this examination suggest
that the PF intervention did not impart the same long-term
changes in caregivers PA compared with child participants.
Nonetheless, the patterns of long-term between-group
change were similar for parents and children alike; the
mean level of self-reported PA increased between baseline
and Time 3 for parents and children in the PF group, but
decreased over the same period for parents and children in
the BFI group. Further, results from change analyses suggest that parents efforts to increase their PA may be vital in
promoting similar changes among youths. If similar results
can be replicated with causal designs, it would provide
support for the rationale of recent parent-only interventions in pediatric obesity, which suggest that parents are
the primary agents of change in youths health-promoting
behavior (Janicke, 2013; West et al., 2010). Parent-only
interventions have a number of potential advantages, including cost-effectiveness (Golan et al., 2006), reduced
likelihood of developing disordered eating attitude and behaviors (Braet, 2006), and convenience for therapists and
families (e.g., sessions do not have to be tailored to a
childs school schedule).

199

200

Van Allen, Borner, Gayes, and Steele

provide more definitive support for the efficacy of that

specific parent-only component. Future interventions also
should consider assessing a broad array of lifestyle behaviorsnot narrowly focusing on changes in weight and BMI
statusas changes in these behaviors may be associated
with physical health outcomes and may contribute to improvements in quality of life on their own.

Funding

Conflicts of interest: None declared.

References
Adamo, K. B., Prince, S. A., Tricco, A. C., ConnorGorber, S., & Tremblay, M. (2009). A comparison of
indirect versus direct measures for assessing physical
activity in the pediatric population: A systematic
review. International Journal of Pediatric Obesity, 4,
227.
Ahn, S., & Fedewa, A. L. (2011). A meta-analysis of the
relationship between childrens physical activity and
mental health. Journal of Pediatric Psychology, 36,
385397.
Barlow, S. E. (2007). The Expert CommitteeExpert committee recommendations regarding the prevention,
assessment, and treatment of child and adolescent
overweight and obesity: Summary report. Pediatrics,
120, S164S192.
Bauman, A. E., Reis, R. S., Sallis, J. F., Wells, J. C.,
Loos, R. J., & Martin, B. W. (2012). Correlates of
physical activity: Why are some people physically
active and others not? Lancet, 380, 258271.
Bocca, G., Corpeleijn, E., Stolk, R. P., & Sauer, P. J. J.
(2012). Results of a multidisciplinary treatment program in 3-year-old to 5-year-old overweight or obese
children. JAMA Pediatrics, 166, 11791181.
Boudreau, A. D. A., Kuroski, D. S., Gonzalez, W. I.,
Dimond, M. A., & Oreskovic, N. M. (2013). Latino
families, primary care, and childhood obesity.
American Journal of Preventive Medicine, 44,
S247S257.
Braet, C. (2006). Patient characteristics as predictors of
weight loss after an obesity treatment for children.
Obesity, 14, 148155.

Downloaded from http://jpepsy.oxfordjournals.org/ by guest on November 25, 2016

This study was supported by grant R40 MC 06631 from

the Maternal and Child Health Bureau (Title V, Social
Security Act), Health Resources and Services
Administration, U.S. Department of Health and Human
Services, awarded to R.G.S.

Centers for Disease Control. (2012). Physical

Activity Guidelines for Americans Midcourse
Report Subcommittee of the Presidents Council
on Fitness, Sports, & Nutrition. Washington, DC:
U.S. Department of Health and Human
Services.
Centers for Disease Control and Prevention (CDC).
(2007). Growth Chart Training: A SAS
Program for the CDC Growth Charts [Computer
software]. Available from http://www.cdc.gov/growth
charts/computer_programs.htm
Cliff, D. P., Okely, A. D., Morgan, P. J., Jones, R. A., &
Steele, J. R. (2010). The impact of child and adolescent obesity treatment interventions on physical
activity: A systematic review. Obesity Reviews, 11,
516530.
Dalton, W. T., & Kitzmann, K. M. (2012). A preliminary
investigation of stimulus control, self-monitoring,
and reinforcement in lifestyle interventions for pediatric overweight. American Journal of Lifestyle
Medicine, 6, 7589.
Davis, A. M., Gallagher, K., Taylor, M., Canter, K.,
Gillette, M. D., Wambach, K., & Nelson, E. (2013).
An in-home intervention to improve nutrition, physical activity, and knowledge among low-income teen
mothers and their children: Results from a pilot
study. Journal of Developmental & Behavioral
Pediatrics, 34, 609615.
Davison, K. K., Cutting, T. M., & Birch, L. L. (2003).
Parents activity-related parenting practices predict
girls physical activity. Medicine Science and Sports
and Exercise, 35, 15891595.
DeBar, L. L., Stevens, V. J., Perrin, N., Wu, P.,
Pearson, J., Yarborough, B. J., . . . Lynch, F. (2012).
A primary carebased, multicomponent lifestyle intervention for overweight adolescent females. Pediatrics,
129, e611e620.
Ferreira, I., van der Horst, K., Wendel-Vos, W.,
Kremers, S., van Lenthe, F. J., & Brug, J. (2006).
Environmental correlates of physical activity in
youthA review and update. Obesity Reviews, 8,
129154.
Golan, M., Kaufman, V., & Shahar, D. R. (2006).
Childhood obesity treatment: Targeting parents exclusively versus parents and children. British Journal
of Nutrition, 95, 10081015.
Golan, M., Weizman, A., Apter, A., & Fainaru, M.
(1998). Parents as the exclusive agents of
change in the treatment of childhood obesity.
American Journal of Clinical Nutrition, 67,
11301135.

Weighing Physical Activity

Journal of the American Medical Association, 300,

295305.
Nemet, D., Barkan, S., Epstein, Y., Friedland, O.,
Kowen, G., & Eliakim, A. (2005). Intense diet, behavior, and physical activity intervention effective for
obese children. Pediatrics, 115, 443449.
Ness, A. R., Leary, S. D., Mattocks, C., Blair, S. N.,
Reilly, J. J., Wells, J., . . . Riddoch, C. (2007).
Objectively measured physical activity and fat mass
in a large cohort of children. PLoS Medicine, 4,
476484.
Ogden, C. L., Carroll, M. D., Curtin, L. R., Lamb, M. M.,
& Flegal, K. M. (2010). Prevalence of high body
mass index in US children and adolescents,
2007-2008. JAMA, 303, 242249.
Ogden, C. L., Carroll, M. D., & Flegal, K. M. (2008).
High body mass index for age among US children
and adolescents, 20032006. JAMA, 299,
24012405.
Ogden, C. L., Carroll, M. D., Kit, B. K., & Flegal, K. M.
(2012). Prevalence of obesity and trends in body
mass index among US children and adolescents,
19992010. Journal of the American Medical
Association, 307, 483490.
Parfitt, G., Pavey, T., & Rowlands, A. V. (2009).
Childrens physical activity and psychological health:
The relevance of intensity. Acta Paediatrica, 98,
10371043.
Penedo, F. J., & Dahn, J. R. (2005). Exercise and wellbeing: A review of mental and physical health benefits associated with physical activity. Current Opinion
in Psychiatry, 18, 189193.
Prochaska, J. J., Rodgers, M. W., & Sallis, J. F. (2002).
Association of parent and peer support with adolescent physical activity. Research Quarterly for Exercise
and Sport, 73, 206210.
Sacher, P. M., Kolotourou, M., Chadwick, P. M.,
Cole, T. J., Lawson, M. S., Lucas, A., & Singhal, A.
(2010). Randomized controlled trial of the MEND
program: A vamily-based community intervention for
childhood obesity. Obesity, 18, S62S68.
Schwimmer, J. B., Burwinkle, T. M., & Varni, J. W.
(2003). Health-related quality of life of severely
obese children and adolescents. JAMA, 289,
18131819.
Shelton, D., Le Gros, K., Norton, L., StantonCook, S., Morgan, J., & Masterman, P. (2007).
Randomised controlled trial: A parent-based group
education programme for overweight children.
Journal of Paediatrics and Child Health, 43,
799805.

Downloaded from http://jpepsy.oxfordjournals.org/ by guest on November 25, 2016

Harsha, D. (1995). The benefits of physical activity in

childhood. American Journal of Medical Sciences, 310,
S109S113.
Ho, M., Barnett, S. P., Baur, L., Burrows, T., Stewart, L.,
Neve, M., & Collins, C. (2012). Effectiveness of
lifestyle interventions in child obesity: Systematic
review with meta-analysis. Pediatrics, 130,
e1647e1671.
Janicke, D. M. (2013). Treatment of pediatric obesity
using a parent-only approach: A case example.
Health Psychology, 32, 345350.
Janicke, D. M., Sallinen, B. J., Perri, M. G., Lutes, L. D.,
Huerta, M., Silverstein, J. H., & Brumback, B.
(2008). Comparison of parent-only vs family-based
interventions for overweight children in underserved
rural settings: Outcomes from Project STORY.
Archives of Pediatric and Adolescent Medicine, 162,
11191125.
Janicke, D. M., Steele, R. G., Gayes, L. A., Lim, C. S.,
Clifford, L. M., & Schnieder, E.M. (2014).
Systematic review of comprehensive behavioral
family lifestyle interventions addressing pediatric obesity. Journal of Pediatric Psychology, 39,
809825.
Janz, K. F., Lutuchy, E. M., Wenthe, P., & Levy, S. M.
(2008). Measuring activity in children and adolescents using self-report: PAQ-C and PAQ-A. Medicine
& Science in Sports & Exercise, 40, 767772.
Jensen, C. D., & Steele, R. G. (2010). Validation of the
perceptions of teasing scale (POTS) in a preadolescent sample: Associations with attitudes toward
physical activity. Childrens Health Care, 39,
249265.
Kitzmann, K. M., Dalton, W. T., Stanley, C. M.,
Beech, B. M., Reeves, T. P., Buscemi, J., . . .
Midgett, E. L. (2010). Lifestyle interventions for
youth who are overweight: A meta-analytic review.
Health Psychology, 29, 91101.
Kowalski, K., Crocker, P., & Faulkner, R. (1997).
Validation of the physical activity questionnaire
for older children. Pediatric Exercise Science, 9,
174186.
McGovern, L., Johnson, J. N., Paulo, R., Hettinger, A.,
Singhal, V., Kamath, C., . . . Montori, V. (2008).
Treatment of pediatric obesity: A systematic review
and meta-analysis of randomized trials. The Journal
of Clinical Endocrinology & Metabolism, 93,
46004605.
Nader, P. R., Bradley, R. H., Houts, R. M.,
McRitchie, S. L., & OBrien, M. (2008). Moderate-tovigorous physical activity from ages 9 to 15 years.

201

202

Van Allen, Borner, Gayes, and Steele

at-risk-for-overweight youth. Journal of Pediatric

Psychology, 32, 8089.
Vacha-Haase, T., & Thompson, B. (2004). How to
estimate and interpret various effect sizes. Journal of
Counseling Psychology, 51, 473481.
Voss, C., Ogunleye, A. A., & Sandercock, G. R. H.
(2013). Physical Activity Questionnaire for children
and adolescents: English norms and cut-off points.
Pediatrics International, 55, 498507.
Wang, Y., Beydoun, M. A., Liang, L., Caballero, B., &
Kumanyika, S. K. (2008). Will all Americans become
overweight or obese? Estimating the progression and
cost of the US obesity epidemic. Obesity, 16,
23232330.
West, F., Sanders, M. R., Cleghorn, G. J., &
Davies, P. S. W. (2010). Randomised clinical trial of
a family-based lifestyle intervention for childhood
obesity involving parents as the exclusive agents of
change. Behaviour Research and Therapy, 48,
11701179.
Wing, R. R., & Phelan, S. (2005). Long-term weight loss
maintenance. American Journal of Clinical Nutrition,
82, 22252255.
Wilfley, D. E., Tibbs, T. L., Van Buren, D. J.,
Reach, K. P., Walker, M. S., & Epstein, L. H.
(2007). Lifestyle interventions in the treatment of
childhood overweight: A meta-analytic review of
randomized controlled trials. Health Psychology, 26,
521532.
Zeller, M. H., & Modi, A. C. (2008). Psychosocial factors
related to obesity in children and adolescents.
In E. Jelalian, & R. G. Steele (Eds.), Handbook of
childhood and adolescent obesity (pp. 2542).
New York, NY: Springer.

Downloaded from http://jpepsy.oxfordjournals.org/ by guest on November 25, 2016

Shoup, J. A., Gattshall, M., Dandamudi, P., &

Estabrooks, P. (2008). Physical activity, quality of
life, and weight status in overweight children. Quality
of Life Research, 17, 407412.
Sothern, M. S., Loftin, M., Suskind, R. M., Udall, J. N.,
& Blecker, U. (1999). The health benefits of physical
activity in children and adolescents: Implications for
chronic disease prevention. European Journal of
Pediatrics, 158, 271274.
Sothern, M. S., von Almen, K., & Schumacher, H.
(2002). Trim Kids: The proven 12-week plan that has
helped thousands of children achieve a healthier weight.
New York, NY: HarperResource.
Staniford, L. J., Breckon, J. D., Copeland, R. J., &
Hutchison, A. (2011). Key stakeholders
perspectives towards childhood obesity treatment:
A qualitative study. Journal of Child Health Care, 15,
230244.
Steele, R. G., Aylward, B. S., Jensen, C. D.,
Cushing, C. C., Davis, A. M., & Bovaird, J. A.
(2012). Comparison of a family-based group intervention for youths with obesity to a brief individual
family intervention: A practical clinical trial of
Positively Fit. Journal of Pediatric Psychology, 37,
5363.
Steele, R. G.; The Pediatric Health Promotion and
Maintenance Lab (n.d.). Therapist manual for
Positively Fit: A family-based group intervention for
child and adolescent weight management.
Unpublished manuscript.
Storch, E. A., Milsom, V. A., DeBraganza, N.,
Lewin, A. B., Geffken, G. R., & Silverstein, J. H.
(2007). Peer victimization, psychosocial adjustment,
and physical activity in overweight and