RESEARCH
Research and Professional Briefs
An Adolescent Weight-Loss Program Integrating
Family Variables Reduces Energy Intake
HEATHER KITZMAN-ULRICH, PhD; ROBERT HAMPSON, PhD; DAWN K. WILSON, PhD; KATHERINE PRESNELL, PhD; ALAN BROWN, PhD;
MARY O’BOYLE, PhD
ABSTRACT
Family variables such as cohesion and nurturance have
been associated with adolescent weight-related health
behaviors. Integrating family variables that improve
family functioning into traditional weight-loss programs
can provide health-related benefits. The current study
evaluated a family-based psychoeducational and behavioral skill-building weight-loss program for adolescent
girls that integrated Family Systems and Social Cognitive Theories. Forty-two overweight (ⱖ95th percentile)
female adolescent participants and parents participated
in a 16-week randomized controlled trial comparing three
groups: multifamily therapy plus psychoeducation
(n⫽15), psychoeducation-only (n⫽16), or wait list (control; n⫽11) group. Body mass index, energy intake, and
family measures were assessed at baseline and posttreatment. Adolescents in the psychoeducation-only group
demonstrated a greater decrease in energy intake compared to the multifamily therapy plus psychoeducation
and control groups (P⬍0.01). Positive changes in family
nurturance were associated with lower levels of adolescent energy intake (P⬍0.05). No significant effects were
found for body mass index. Results provide preliminary
support for a psychoeducational program that integrates
family variables to reduce energy intake in overweight
adolescent girls. Results indicate that nurturance can be
an important family variable to target in future adolescent weight-loss and dietary programs.
J Am Diet Assoc. 2009;109:491-496.
H. Kitzman-Ulrich is a research assistant professor and
D. K. Wilson is a professor, Department of Psychology,
University of South Carolina, Columbia. R. Hampson is
an associate professor, K. Presnell is assistant professor,
A. Brown is a professor, and M. O’Boyle is an instructor, Department of Psychology, Southern Methodist University, Dallas, TX.
Address correspondence to: Heather Kitzman-Ulrich, PhD, Department of Psychology, University of
South Carolina, 1233 Washington St, 9th floor, Columbia, SC 29201. E-mail: kitzman@mailbox.sc.edu
Manuscript accepted: July 3, 2008.
Copyright © 2009 by the American Dietetic
Association.
0002-8223/09/10903-0009$36.00/0
doi: 10.1016/j.jada.2008.11.029
© 2009 by the American Dietetic Association
O
besity has become an epidemic health problem in
the Unites States in recent decades (1), and recent
reports indicate 15% of adolescents are considered
overweight (2). Previous studies have found that family
variables, including cohesion and nurturance, have been
associated with childhood overweight (3-5), therefore, incorporating family variables into traditional weight-loss
programs could provide additional health-related benefits. Family variables, based on Family Systems Theory,
refer to aspects of family functioning, including cohesion,
nurturance, and conflict resolution (6).
Family variables, such as nurturance (eg, connectedness, warmth, and caring) (7), have been directly related
to the adolescent health behaviors of eating breakfast (3),
fruit and vegetable intake (3,8), self-esteem, and body
satisfaction (9), and inversely related to negative weightcontrol behaviors (9). In addition, a survey of girls found
lower levels of parental nurturance in overweight compared to normal-weight girls (5). Family cohesion, defined
as closeness and emotional bonding between family members (10), was found in a large survey to be lower in
overweight girls (4). Parents’ report of family satisfaction,
which is an indicator of global family competence and
incorporates nurturance, cohesion, conflict resolution,
and shared decision making (11), was a mediator of adolescent weight loss (12). Although these studies point to
the importance of family variables, few weight-loss programs have included family variables.
It is evident from the current literature that key family
variables (3-5,8,9) and parental involvement (13) in adolescent weight-loss programs need further exploration. In
the current study, a multifamily therapy group was utilized as a novel approach to parental involvement with
the potential for improving family variables. These
groups have been implemented in other adolescent health
behaviors, have demonstrated improvements in family
variables, and provide opportunities for families to learn
and gain support from each other (14-16).
This study expands on previous research by evaluating
a family-based psychoeducational weight-loss program
for adolescents that included components to improve family variables (family competence, nurturance, conflict resolution, and cohesion). This study also assessed the efficacy of a multifamily therapy group. In addition, this
study provides information on family variables and their
relationship with adolescent body mass index (BMI; calculated as kg/m2) and energy intake over time. The primary hypothesis tested was that the multifamily therapy
plus psychoeducation group and the psychoeducationonly group would demonstrate greater reductions in ad-
Journal of the AMERICAN DIETETIC ASSOCIATION
491
olescent BMI z score and energy intake as compared to
the control group, with strongest effects in the multifamily therapy plus psychoeducation group.
METHODS
Participants
Participants and family members were recruited through
pediatrician offices and promotional materials. Only female adolescents were recruited because of the preliminary nature of this study and possible developmental
differences in weight-related behaviors by sex. Adolescent eligibility criteria included BMI ⱖ95th percentile, 12
to 15 years of age, not participating in a weight-loss
program, ability to engage in physical activity, and at
least one adult family member willing to participate. Of
66 eligible families, 44 families volunteered for the study.
Two families withdrew prior to randomization, resulting
in 42 families.
Procedures
The study was a prospective, 16-week, randomized trial
with three groups: multifamily therapy plus psychoeducation, psychoeducation-only, and control (wait-list control group did not participate in any intervention during
the 4-month study period). The study was conducted in
two cohorts between December 2002 and June 2003 and
was approved by the Institutional Review Board of The
Cooper Institute and Southern Methodist University. Informed consent and assent were collected and participants were randomized through letters containing group
assignment.
Psychoeducational Curriculum. Participants and their parents in the multifamily therapy plus psychoeducation and
psychoeducation-only groups received the psychoeducational curriculum during 16 weeks that included behavioral skill-building and psychosocial components (see Figure) facilitated by master-level family therapists and
trained graduate students. The psychoeducational curriculum was previously used in studies to increase exercise
in sedentary adults (17) and was adapted for the present
study based on Social Cognitive (18) and Family Systems
(6) theories for adolescent weight-loss behaviors and parental involvement. The psychoeducational curriculum
did not include a specific caloric restriction because many
adolescents do not comply with self-monitoring of daily
food intake (19). For that reason, adolescents were encouraged to monitor food-group servings with a pictorial goal
sheet to achieve a healthful diet within their recommended
calorie range based on the Food Guide Pyramid (20).
Facilitator Training. All facilitators attended a 1-day training
workshop and were given facilitator guides for each session.
A senior marriage and family therapist and a coinvestigator
with previous experience conducting weight-loss programs
provided supervision.
Multifamily Therapy Group. In addition to the psychoeducational curriculum, the multifamily therapy plus psychoeducation group attended a multifamily therapy group
that lasted approximately 45 minutes. Facilitators were
given discussion points based on the psychoeducational
curriculum and followed principles of group therapy facilitation, such as positively reinforcing desired behavior
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March 2009 Volume 109 Number 3
and keeping families on task (21). Families were able to
discuss implementing the psychoeducational curriculum
in their home environment and to share successes, frustrations, and coping strategies in the multifamily therapy
plus psychoeducation group. Participants in the psychoeducation-only group did not participate in a multifamily
therapy group. To be consistent with intervention attention, participants in the psychoeducation-only group
played interactive games related to health behaviors during this time.
Fidelity. Participants completed satisfaction surveys at
the end of each session. Average attendance was 42.6%
for the multifamily therapy plus psychoeducation group
and 45.6% for the psychoeducation-only group during the
16-week program.
Measures. All measures were collected by trained staff
prior to randomization at baseline and at 16 weeks
postintervention.
BMI. Weight and height was collected on a balance
beam scale with stadiometer (seca700, SECA, Hamburg, Germany) and were used to calculate BMI. BMI z
score was calculated with EpiInfo (version 3.4.3., 2007,
Centers for Disease Control and Prevention, Atlanta,
GA) based on the Centers for Disease Control sexspecific 2000 reference curves.
Diet Measure. Dietary intake in adolescent participants
was measured with the 24-hour diet recall administered
by a registered and licensed dietitian and two trained
dietetics graduate students. The registered dietitian provided supervision and conducted observations of graduate student recalls. The 24-hour diet recall is a structured
interview that assesses food intake from the previous day
and has high correlations to validation standards (eg,
chemical analysis) (22), and has demonstrated ability to
detect dietary change between groups (23). It has also
been shown to be advantageous to other self-report measures of dietary intake, such as food records (24). Three
24-hour multiple-pass recalls (2 weekdays and 1 weekend) were collected using established procedures (25) at
baseline and postintervention. The initial recall was collected in person and remaining recalls were collected on
random days by telephone. Food models and illustrations
were provided to aid in reporting of food intake over the
telephone. Diet recall data was entered into the Food
Intake Analysis System (version 3.99, 2000, University of
Texas-Houston School of Public Health, Houston).
Family Measures. The Self-Report Family Inventory (SFI),
a 36-item self-report questionnaire, was used to measure
family variables (11). The SFI has acceptable rates of
reliability and validity and corresponds well with other
self-report questionnaires measuring family variables
(11). Items are rated on a 5-point scale, with higher scores
indicating greater family dysfunction. In the current
study, Cronbach’s ␣ for the SFI subscales was .91 for
Health/Competence, .71 for Cohesion, and .81 for Conflict. The Health/Competence subscale contains 19 items
and is a global measure of family health or satisfaction
(11). The current study also included the conflict resolution subscale because adolescence is often a difficult developmental period (7). The conflict resolution subscale,
containing 12 items, measures the family’s ability to effectively resolve conflict. The cohesion subscale has five
Title
Session 1
Getting started
Session 2
Substituting healthful
alternatives
Session 3
Benefits and barriers
Session 4
Goal setting and rewarding
yourself
Session 5
Communication skills
Session 6
Social support
March 2009 ● Journal of the AMERICAN DIETETIC ASSOCIATION
Session 7
Energy balance
Session 8
Body image
Session 9
Media literacy
Session 10
High-risk situations
Session 11
Stress and time management,
celebration and wrap-up
Social Cognitive and Family System
Theories variables
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Nurturance
Cohesion
Self-monitoring
Increasing knowledge
Increasing healthful opportunities
Increasing knowledge
Substituting healthful alternatives
Self-monitoring
Comprehend benefits
Increasing healthful opportunities
Self-monitoring
Increasing knowledge
Comprehend benefits
Caring about consequences to others
Comprehend benefits
Goal-setting
Shared decision making
Competence
Conflict resolution
Cohesion
Nurturance
Self-monitoring
Goal-setting
Increasing healthful opportunities
Caring about consequences to others
Self-monitoring
Increasing healthful opportunities
Increasing knowledge
Enlisting social support
Increasing self-esteem
Increasing knowledge
Goal-setting
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Self-monitoring
Goal-setting
Increasing healthful opportunities
Caring about consequences to others
Increasing self-esteem
Nurturance
Competence
Shared decision making
Nurturance
Comprehend benefits
Increasing knowledge
Substituting alternatives
Increasing healthful opportunities
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Warning of risks
Increasing knowledge
Substituting alternatives
Reminding yourself
Increasing healthful opportunities
Content
Application
Activities
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Environmental contributors to obesity
Discuss typical day
Creating a supportive environment (parents only)
Motivations for weight loss (girls only)
Complete supportive environment handout
(break-out session parents)
Complete you and your weight handout
(breakout session girls)
Introduction Icebreaker—
Getting to know you
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Moderate-intensity physical activity
Basics of healthful eating
Cues for activity and inactivity
Cues for making healthful food choices
Lifestyle log
Moderate-intensity walk
● Barriers and benefits
● Problem-solving barriers
● Healthful choices, portion sizes—food groups
● How to set effective goals
● Rewarding yourself
Assessing barriers and benefits handout
Think about physical activity this coming
week
Set goals for physical activity, media, and
nutrition
Set rewards for self and reciprocal rewards
● Fruit group
● Fitting fruit into your diet, benefits of fruit
● Effective communication skills (reflective listening, “I”
statements, honoring different perspectives)
How I see my family activity (evaluate
family communication and compare
answers in family dyads, group
discussion on family activity)
Easy fruit drinks
Plan one family meal during
next week
● Vegetable group
● Social support
● How to deal with bullies and saboteurs
Recruiting my support troops handout
(determine type of support needed, who
can provide, and how to ask for it)
Role-play how to deal with
saboteurs/bullies
● Milk group
● Strategies for getting recommended number of servings per
day, healthful choices
● Energy expenditure
● Moderate intensity physical activities
● Meat group
● Healthful choices and serving sizes
● Building self-esteem
● Deconstructing the ideal body—girls
● Possible contributors to weight gain—parents
● Healthful eating vs dieting
● The tip of the Food Guide Pyramid (moderation, serving sizes)
● All foods can fit
● Media Literacy—girls (group discussion on advertisements)
● Media Literacy—parents (setting boundaries, monitoring)
Recall of a typical day’s food intake,
calculate calories for the whole day
Recall of a typical day’s activity, calculate
calories expended
Taste test
Burning calories equation
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Relapse prevention
High-risk situations
Fast food and eating out
Stress management
Time management
Quick and easy meal ideas
Celebration
Assess long-term goals
Building self-esteem worksheet (breakout
session girls)
The Ideal Body Matrix
Possible contributors to weight gain
worksheet (breakout session parents)
Persuasion strategies
Group discussion on all foods can fit
Breakout session girls
Breakout session parents
Show commercial videos and
discuss as a group
Assessing high-risk situations handout
Pick healthful meals from
menus
Are you stressed worksheet
Physical activity and nutrition
jeopardy
Figure. Psychoeducational curriculum: Theoretical constructs and intervention content used in a study evaluating a family-based psychoeducational and behavioral skill-building weight-loss
program for adolescent girls.
493
Table. Mean (standard deviation) change in energy intake and body mass index (BMI) z score
from baseline to post-intervention by group among adolescent girls in a study evaluating a
family-based psychoeducational and behavioral skill-building weight-loss program
Variable
BMI z score
Energy intakea
Baseline
BMI z score
Energy intake
Postintervention
BMI z score
Energy intake
Change score
BMI z score
Energy intake
a
Multifamily therapy
ⴙpsychoeducation
Psychoeducation only
Control
4™™™™™™™™™™™™™™™™™™™™™™™™ n ™™™™™™™™™™™™™™™™™™™™™™™™3
14
13
8
8
9
7
4™™™™™™™™™™™™™™™™ mean (standard deviation) ™™™™™™™™™™™™™™3
2.2 (0.4)
2.3 (0.3)
2.3 (0.3)
1,512.6 (622.3)
1,555.5 (493.8)
1,095.1 (372.1)
2.2 (0.4)
1,574.0 (515.1)
0.0 (0.1)
61.44 (423.9)b
2.2 (0.3)
1,190.4 (296.3)
⫺0.1 (0.1)
⫺365.1 (456.7)b
2.3 (0.3)
1,422.5 (430.5)
0.0 (0.1)
327.4 (402.0)b
Participants with fewer than two recalls at baseline were not included.
P⬍0.01.
b
items and measures feelings of closeness and emotional
bonding between family members. Family nurturance
comprises feelings of warmth and caring and has been
found to be related to health behaviors in adolescents
(3,8). Therefore, a new 7-item subscale of the SFI was
developed for this study to specifically assess nurturance
(Cronbach’s ␣⫽.82).
Statistical Analyses
All data was entered by trained study staff using double
data entry to reduce errors. Analysis of covariance controlling for race was used to test for differences between
groups for BMI z score, energy intake, and family variable change scores (SAS, version 9.1, 2002-2003, SAS
Institute, Inc, Cary, NC). Change scores for BMI z score
and energy intake were calculated by subtracting baseline from postintervention with a negative score indicating a reduction in energy intake or BMI z score. Family
variable change scores were calculated by subtracting
postintervention from baseline with a positive score indicating an improvement in family variables. Based on a
large effect size and an ␣ level of .05, 66 subjects were
needed for adequate power (0.80) to detect differences
between three groups and 42 subjects were needed to
detect differences between two groups.
RESULTS AND DISCUSSION
Baseline data were collected on 42 adolescent females
(mean age⫽13.3 years; mean BMI⫽33.6; 55% white), 42
mothers (mean age⫽42.9 years; mean BMI⫽33.0; mean
educational level⫽14.6 years), and 26 fathers (mean
age⫽45 years; mean BMI⫽34.9). Analysis of variance
indicated that the psychoeducation-only group had considerably higher SFI Nurturance scores (mean⫽2.5, standard deviation [SD]⫽0.7) compared to the control group
(mean⫽1.6, SD⫽0.8) at baseline, indicating lower levels
of nurturance in the psychoeducation-only as compared to
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March 2009 Volume 109 Number 3
the control group. There were no other significant differences in baseline values between groups.
Eighty-three percent of families completed baseline
and 16-week measures (n⫽35), however, diet recall data
was limited to adolescents who completed at least two
recalls at baseline (n⫽24, of which 96% completed three
recalls at baseline and 80% completed three recalls at
post). At postintervention, three of the 24 participants
with baseline recall data completed only one recall. Findings did not change when these participants were removed. Seven families did not complete postintervention
measures (three families dropped out at baseline and four
families were lost to follow-up). Analyses comparing completers vs noncompleters revealed that noncompleters
were significantly older (mean⫽14.0, SD⫽1.2) than completers (mean⫽13.1, SD⫽1.0) (P⬍0.05).
Adolescent baseline, postintervention, and change
scores are shown in the Table for BMI z score and energy
intake. Analysis of covariance found a significant difference in energy intake (F⫽6.68, P⬍0.01), indicating a
significant reduction in energy intake from baseline to
postintervention in the psychoeducation-only group (leastsquares mean⫽⫺381.1, standard error [SE]⫽136.8), compared to the multifamily therapy plus psychoeducation
(least-squares mean⫽66.8, SE⫽128.9) and control (leastsquares mean⫽338.8, SE⫽146.2) groups. This finding is
consistent with previous studies that incorporated lifestyle
approaches to improve health behaviors (26,27) and provides preliminary support for incorporating lifestyle approaches in adolescent weight-loss and dietary programs.
No significant effects were found for BMI z score. This could
be due to the short duration of the study, as previous successful weight-loss studies were longer (28-30). In addition,
because this study focused on a healthful diet instead of a
specific calorie restriction, a longer duration may be
needed to demonstrate changes in BMI.
A partial correlation controlling for baseline energy
intake and race indicated that positive changes in nur-
turance were associated with lower levels of energy intake at postintervention (r⫽⫺0.60; P⬍0.05). This is consistent with previous studies that have found nurturance
to be related to adolescent weight-related behaviors (3,8).
Yet, improvements in overall family variables were not
demonstrated in this study, which could be attributed to
families improving in some but not all family variables.
More intensive treatment may be necessary to improve
overall family functioning and demonstrate changes in
family variables.
Interestingly, analysis of covariance found a significant worsening of conflict in the multifamily therapy
plus psychoeducation group (least-squares mean⫽⫺0.43,
SE⫽0.15) compared to the psychoeducation-only (leastsquares mean⫽0.22, SE⫽0.15) and control (least-squares
mean⫽0.20, SE⫽0.19) groups (F⫽5.76; P⬍0.01). In addition, the multifamily therapy plus psychoeducation group
did not lead to greater improvements as hypothesized
and did not demonstrate reductions in energy intake.
Increases in conflict within the family could have attenuated any affect of the psychoeducational curriculum on
energy intake. Furthermore, conflict issues may have
arisen without sufficient time to resolve them during the
multifamily therapy group. These findings are inconsistent with previous adolescent health studies, such as
eating disorders, that have reported multifamily therapy
groups as a positive experience (14,15). Larger studies
are needed to determine whether multifamily therapy
groups could be beneficial in weight-loss programs.
There are several limitations of the present study that
need to be addressed. Although our study is consistent
with other weight-loss studies that have demonstrated
modest levels of attendance (31), modest attendance rates
were an issue that could have reduced the impact of the
intervention. Further research is needed to determine
how to improve attendance rates in weight-loss studies.
Another limitation of the study was that although the
psychoeducation-only group produced a substantial reduction in energy intake, corresponding changes in BMI
were not seen. Most likely, the reduction in energy intake
demonstrated at postintervention was a cumulative effect
of the intervention and, therefore, a longer measurement
period would have been useful to further evaluate changes
in BMI. However, reducing dietary intake in overweight
youth is an important first step to weight loss and may
provide the confidence for continued behavior change.
Power to detect effects was limited due to the small sample size in the present study. A final limitation of the
present study concerns the accuracy of the 24-hour dietary recall methods. Although there was substantial
variability in this measure in the present study, the variability of the dietary recalls was consistent with other
published studies in youth (32,33). Future research is
needed to replicate the findings of this study in a larger
sample of youth.
CONCLUSIONS
This study evaluated a psychoeducational weight-loss
program for overweight female adolescents that integrated family variables and a multifamily therapy group
as a novel approach to parental involvement. The findings from this study provide preliminary support for a
family-based psychoeducational weight-loss program
that integrated family variables to reduce energy intake
in overweight (⬎95th percentile) adolescent girls. Reductions in energy intake are an important component of the
energy balance equation and weight loss. Another key
finding was that family nurturance was associated with
lower levels of energy intake and may be an important
family variable to consider in future family-based weightloss programs.
This study was funded by the Hogg Foundation for Mental Health.
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