ORIGINAL RESEARCH

An Intensive Family Intervention Clinic for

Reducing Childhood Obesity
Ronit Endevelt, RD, MSc, PhD, Orit Elkayam, MD, Rinat Cohen, MD,
Ronit Peled, MPH, PhD, Limor Tal-Pony, BSc, RD,
Ruth Michaelis Grunwald, MHA, BSc, RD, Liora Valinsky, RN, BSc, MPH,
Avi Porath, MD, and Anthony David Heymann, MBBS

Background: Childhood and adolescent obesity constitute a significant public health concern. Family
health care settings with multidisciplinary teams provide an opportunity for weight loss treatment. The
objective of this study was to examine the effect of intensive treatment designed to reduce weight using
a parent-child lifestyle modification intervention in a family health care clinic for obese and overweight
children who had failed previous treatment attempts.
Methods: This was a practice-based 6-month intervention at Maccabi Health Care Services, an Israeli
health maintenance organization, consisting of parental education, individual child consultation, and
physical activity classes. We included in the intervention 100 obese or overweight children aged 5 to 14
years and their parents and 943 comparison children and their parents. Changes in body mass index
z-scores, adjusted for socioeconomic status, were analyzed, with a follow-up at 14 months and a de-
layed follow-up at an average of 46.7 months.
Results: The mean z-score after the intervention was lower in the intervention group compared to
the comparison group (1.74 and 1.95, respectively; P ⴝ .019). The intervention group sustained the
reduction in z-score after an average of 46.7 months (P < .001). Of the overweight or obese children,
13% became normal weight after the intervention, compared with 4% of the comparison children.
Conclusion: This multidisciplinary team treatment of children and their parents in family health care
clinics positively affected measures of childhood obesity. Additional randomized trials are required to
verify these findings. (J Am Board Fam Med 2014;27:321–328.)

Keywords: Childhood Obesity, Early Medical Intervention, Health Education

Childhood and adolescent obesity constitutes a sig- and lifestyle in an obesogenic environment,2,3 have
nificant public health concern.1 Both overweight been shown to be risk factors for chronic morbidity
and obesity, which are mainly caused by poor diet in childhood and adulthood.4
The American Expert Committee recommenda-
tions regarding the prevention, assessment, and
This article was externally peer reviewed. treatment of child and adolescent overweight, pub-
Submitted 27 August 2013; revised 22 December 2013;
accepted 6 January 2014. lished in 2007,5 endorsed several primary care prac-
From Nutritional Services (RE, LT-P, RMG), Pediatric tices, including (1) documenting body mass index
Gastroenterology and Nutrition Services, Maccabi Obesity
Clinic (PE), the Pediatric Department (RC), Health Promo-
(BMI) by the physician, with the opportunity to
tion and Preventive Medicine (LV), the Medical Division guide the family toward healthier behaviors; (2)
(AP), and Central Medical Management (ADH), Maccabi establishing procedures to deliver obesity preven-
Healthcare Services, Tel Aviv, Israel; School of Public
Health, University of Haifa, Haifa, Israel (RE); the Depart- tion messages to all children; and (3) involvement
ment of Health System Management, Faculty of Health in and training of interdisciplinary teams, including
Sciences, Ben Gurion University of the Negev, Beer Sheva,
Israel (RP); and Sackler School of Medicine, University of nurses, physicians, and staff members.
Tel Aviv, Tel Aviv, Israel (ADH). Recent assessments point to the importance of
Funding: none.
Conflict of interest: none declared. improving children’s environment and the time
Corresponding author: Ronit Endevelt, RD, MSc, PhD, they spend engaged in physical activity.6 The pri-
Nutrition and Nutritional Services, Maccabi Health Care
Services, Hamered 27, Tel Aviv, Israel (E-mail: rendevelt@ mary care setting provides the opportunity for in-
univ.haifa.ac.il). terventions to reduce childhood obesity, such as

doi: 10.3122/jabfm.2014.03.130243 Family Intervention Clinic for Reducing Childhood Obesity 321
those successfully reported in the United Kingdom, ated separately from the routine care normally pro-
the United States, and Singapore.7–10 There is vided, with a special space to conduct meetings and
moderate- to high-strength evidence that diet physical activities.
and/or physical activity interventions implemented
in school settings help prevent weight gain or re- Study Design
duce the prevalence of overweight and obesity, as This study was conducted as a practice-based com-
noted in a 2013 report from the American Agency munity intervention. Children were recruited for
for Health Research and Quality.11 The generaliz- the intervention between January 2006 and De-
ability of evidence of the effectiveness of interven- cember 2007. The intervention program was oper-
tions primarily implemented in other settings is ated in 6-month cycles.
largely unknown.11
The role of parents in establishing a healthy
home environment and supervising children’s eat- Inclusion Criteria
ing habits and lifestyle is crucial. Research shows a From selected MHS regions we included children
strong correlation between parental and child obe- aged 5 to 14 years who were defined as overweight
sity, particularly among mothers and their chil- (according to Centers for Disease Control and Pre-
dren.12–14 Moreover, there is evidence of strong vention BMI curves for the 85th to 94th percen-
associations between parenting practices and tiles) or as obese (according to Centers for Disease
children’s eating habits, physical activity, and Control and Prevention BMI curves for the 95th
weight status, suggesting that the promotion of percentile and above)18 and who previously failed at
effective parenting is critical for the prevention least 2 other weight loss attempts (such as private
of obesity.15–17 consultation or self-effort to change lifestyle). In-
Maccabi Health Care Services (MHS) is the sec- clusion in the study required family physician re-
ond largest health maintenance organization in Is- ferral and the willingness and commitment of the
rael, providing primary care services to 2 million children and their parents to long-term participa-
beneficiaries throughout the country. A recent tion in the intervention program. Both participants
MHS internal analysis revealed that 11.4% of boys and their parents signed an informed consent and
and 12.2% of girls between the ages of 2 to 18 years an agreement to take part in the program; the study
treated by MHS were overweight, and 8.7% of the was approved by the local ethics committee. The
boys and 7.4% of the girls were obese according to children were divided into 2 intervention groups:
BMI percentiles. These findings were the impetus those 5 to 8 years old and those 9 to 14 years old.
for the development of an intensive parent-child The comparison group consisted of children
intervention program. aged 5 to 14 years, from the same MHS regions,
Our hypothesis was that a parent-child treat- who according to their computerized records were
ment program in the family health care setting overweight or obese during the same time period
would result in significant child weight loss relative and were matched (using a frequency matching
to usual childhood weight gain and that this relative method) to the intervention group by baseline BMI
loss can be sustained for a more than 2 years. This z scores. Data for these children were gathered
article presents the key elements of an intensive electronically.
parent-child family care treatment program and
examines the impact of this program on the relative BMI Measurements
weight loss of obese and overweight children. The intervention lasted for 6 months and went in
rounds. The children in the intervention group had
their height and weight measured at 3 time points:
Methods (1) at enrollment in the program (baseline measure-
Setting ment); (2) after the intervention following a mean
Four MHS primary care clinics (combined family of 14.3 months (range, 12–18 months) from the
and pediatric care) were chosen to host a multidis- baseline measurement (postintervention measure-
ciplinary team, which included a pediatrician, a ment); and (3) an additional measurement after a
dietician, a physical activity expert, and a social mean of 46.7 months (range, 36 – 67 months) from
worker. These designated family clinics were oper- the baseline measurement (final measurement). For

322 JABFM May–June 2014 Vol. 27 No. 3 http://www.jabfm.org

Table 1. Participants of Meetings Led by Dieticians and Social Workers
Meeting Subject Participants

1 The meaning of a healthy lifestyle and the changes required in the environment Parents
and behavior patterns, including shopping, exposure, choices, cooking, and
eating habits
2 Promoting the motivation for a change Parents
3 The meaning of an active lifestyle: changing the family’s physical activity Parents
patterns
4 The parent as a role model Parents and children
role playing
5 Parenting style and general parenthood skills Parents
6 Responsibility and boundaries in eating habits Parents
7 Strategies for dealing with conflicts and objections Parents
8 Family communication and adequate childhood body image Parents and children
role playing
9 Self-esteem promotion skills Parents
Self- and body confidence Children
10 Food variety and introduction to nutrients; choosing appropriate high-value Parents
foods
Healthy nutrition habits Children
11 How to spend leisure time; introduction to food labeling Parents
12 Behavior skills at parties and social events Parents
Dealing with tempting environment and developing resilience Parents and children

the comparison group, the final measurement after among others (for more specific details of the
the baseline (mean, 14.7 months) was used. program agenda see Table 1).
2. Children’s individual therapy consisted of 6 indi-
Data Source vidual meetings with a family physician, a physical
Data were extracted for both study groups from the therapist specializing in children’s physical activity,
MHS central computer system, in which all the and a dietician. This part of the intervention aimed
medical information, including BMI, is stored. at modifying nutrition and lifestyle; the physical
therapist helped children incorporate physical ac-
The Intervention tivity into their routine. Sessions were provided
An intensive multidisciplinary parent-child inter- separately for children aged 5 to 8 and 9 to 14
vention program was developed according to the years; they had the same agenda but used an age-
theories of Golan and Crow.19,20The program con- adjusted approach.
sisted of 3 elements. 3. Physical activity groups for the children, with in-
dividual physical fitness monitoring, were con-
1. Parents’ education groups for nutrition and ducted twice a week for 6 months. This program
healthy behavior were held with a dietician and a included setting individualized and tailored fitness
social worker every 2 weeks for 6 months, for a goals, aerobic activities, and joint fun and leisure
total of 12 meetings. This part of the intervention time physical activities for both children and par-
aimed at providing parents with effective tools for ents.
modification of lifestyle and the family environ-
ment. Some of these group sessions were held Families paid NIS 1500 (approximately US$450)
jointly with the children to enhance family com- per child for the 6-month program. MHS provided
munication. The issues discussed during these subsidies for children from low-income families.
group sessions included food-buying behavior,
cooking habits and style, food choices, eating hab- The Role of Each Profession in the Intervention
its, physical and emotional morbidity related to The family physician evaluated each child’s capa-
overweight, parenting style and skills, family strat- bility for physical activity, diagnosed obesity-re-
egies for conflict resolution, and body image, lated disease, and ordered blood tests as needed to

doi: 10.3122/jabfm.2014.03.130243 Family Intervention Clinic for Reducing Childhood Obesity 323
detect other pathologies. The physician also pro- differences in BMI z scores from baseline to the last
vided the children and the parents with an expla- measurement.
nation of the risks related to excessive weight. The The SER ranks as recorded on the MHS data-
dietician interviewed the parents and the children base were used for each child in accordance with
at enrollment, assessed the family’s eating patterns, Israeli Census data,22 which provide 20 categories
and helped each family to build a program for a ranging from 1 (very low) to 20 (very high). The 20
healthier home environment tailored to their indi- categories were collapsed into 4 ranks (1–5, 6 –10,
vidual needs. In addition, the dietician monitored 11–15, and 16 –20). For the multivariate analysis,
each child’s BMI. The physical therapist diagnosed linear regression models were estimated for the
the children’s musculoskeletal abnormalities re- change in BMI z score (postintervention minus
lated to obesity and helped each family plan how to baseline), which was the dependent variable. The
increase the amount of physical activity in their independent variables entered into the final model
weekly routine. The physical activity coach orga- were group (intervention ⫽ 1; comparison ⫽ 0) and
nized and facilitated the physical activity groups, SER.
often including activities tailored to specific chil-
dren. The social worker, trained in psychosocial
counseling, interviewed the parents to diagnose Results
their parenting style and helped the parents in their We recruited 116 children for the intervention; 16
efforts to promote a healthier family structure and children and their families who did not complete
increase parental authority when needed. the full term of the intervention were excluded
from the analysis. Thus, the intervention group
consisted of 100 children, including 63 girls and 37
Follow-up
boys, and their parents. The comparison group
After the intervention, the children continued rou-
comprised 943 children, with 43.7% girls and
tine follow-up with their family physician. Routine
56.3% boys (P ⬍ .001) (Figure 1). A significant
follow-ups involved measuring and recording BMI.
difference was found in the SER between the 2
Children in the comparison group had routine fol-
groups (Table 2).
low-ups with their family physician and/or local
The average time between the baseline and
dietician. They may have participated in privately
postintervention measurements was 14.3 (standard
run weight control programs that were open to the
deviation [SD], ⫾1.5) and 14.7 (SD, ⫾1.7) months
public during the same period of time, but their
for the intervention and comparison groups, re-
participation was not tracked.
spectively (P ⫽ .038). The average time from the
baseline to the last measurement (intervention
Statistical Analysis group only) was 46.7 months (SD, ⫾12.4 months).
Only children (and their families) from the inter- The mean z scores at baseline were not signifi-
vention group who had participated in at least 85% cantly different between the 2 groups (P ⬍ .099)
of the meetings, including the physical activity (Table 3). The mean z score for the postinterven-
classes, were included in the analysis. A z score tion measurement was lower in the intervention
(population norms) by age and sex was calculated group than in the comparison group (P ⫽ .019)
for each BMI measurement21 using SPSS 19 soft- (Table 3).
ware (SPSS, Inc., Chicago, IL). At recruitment, the rates of overweight and obe-
Univariate analysis techniques were used to eval- sity were almost the same. However, the rate of
uate the differences between the groups for base- obesity decreased by 55% in the intervention group
line and postintervention BMI z scores, age, sex, compared with 11% in the comparison group (Ta-
socioeconomic rank (SER), and weight category. ble 3). Multivariate analysis revealed that after con-
According to the nature of the variables either t test trolling for SER, the intervention was found to
or ␹2 analyses were used. As previously mentioned, have a positive effect on the change between the
an additional measurement was performed for the baseline and the postintervention BMI z scores,
intervention group after an average of 46.7 months with a more significant effect for obese children
from the baseline (final measurement). For this than for children who were overweight at baseline
group only, paired t tests were used to analyze the (Table 4).

324 JABFM May–June 2014 Vol. 27 No. 3 http://www.jabfm.org

Figure 1. Flow chart of the study population.

Discussion The decision to initiate the intensive care clinics,

The study results suggest that an intensive parent- designated solely for nutrition behavior and life-
child treatment program, conducted in designated style modification, was based on the urgent need to
family health care clinics by a multidisciplinary address the prevention, identification, and treat-
team, was associated with lower increase in chil- ment of childhood obesity and overweight prob-
dren’s weight compared with comparison children lems25,26 and on the success of such clinics in other
and that this difference was sustained over more countries. The program combined most of the el-
than 2 years. Moreover, the association between ements that have been suggested as key to the
the intervention and the reduction in weight was
more robust for children who were obese than
Table 3. Z-scores and Weight Categories by Study
those who were overweight at baseline. These find-
Groups
ings are possible because the parents of obese chil-
dren are likely more aware of their child’s condition Intervention Comparison P
Variable Group Group Value
and that underestimation of the overweight chil-
dren’s condition might impair parents’ motivation Mean z-score ⫾ SD
to adopt weight control measures.23,24 At baseline 2.07 ⫾ 0.35 2.12 ⫾ 0.3 .099
measurement
After the intervention 1.74 ⫾ 0.8 1.95 ⫾ 0.4 .019
At last measurement 1.75 ⫾ 0.6 — ⬍.000*
Table 2. Descriptive Characteristics of Study Groups
Weight categories at
Intervention Comparison baseline (%)
Group Group P Overweight 25.0 29.6 .337
Variable (n ⫽ 100) (n ⫽ 943) Value Obesity 75.0 70.4
Weight categories after
Mean age ⫾ SD at 9.03 ⫾ 1.6 9.0 ⫾ 2.7 .912
intervention† (%)
recruitment, years
Normal 13.0 4.8 ⬍.001
Girls (%) 63.0 43.7 ⬍.001
Overweight 53.0 32.9
Socioeconomic rank (%)
Obesity 34.0 62.4
1–5 3.4 9.3 ⬍.001
6–10 12.4 28.3
*Paired t test, baseline measurement vs. last measurement (av-
11–15 42.7 38.7 erage of 46.7 months from baseline).
†
16–20 41.6 33.7 Next measurement after the intervention ended; z-score con-
trols for age and sex.
SD, standard deviation. SD, standard deviation.

doi: 10.3122/jabfm.2014.03.130243 Family Intervention Clinic for Reducing Childhood Obesity 325
Table 4. Linear Regression Analysis Results for the ment. Therefore, from the very beginning it was
Dependent Variable ⌬ Z Score (After understood that the intervention must incorporate
Intervention ⴚ Baseline Measurements) strategies for healthier home environments that
Standard P
promote autonomy and self-regulation. These
Model B* Error Value strategies are critical for building a family’s confi-
dence in their ability to sustain their newly acquired
Model 1: all children
health behaviors independent of health profession-
Intervention ⫺0.118 0.049 .016
als’ support. In addition, we decided to conduct the
SER 0.046 0.016 .004
Model 2: obese children
intervention activities for 6 months, a period that
Intervention ⫺0.112 0.056 .047 was considered to be sufficient for ensuring sus-
SER ⫺0.059 0.019 .02 tained behavioral change. The results confirm this
Model 3: overweight children preliminary assumption and show that the inter-
Intervention ⫺0.128 0.099 .195 vention effect was sustained for almost 4 years.
SER ⫺0.014 0.029 .621 Researchers from Germany recently found that
a certain set of family characteristics might predict
*Model coefficient.
SER, socioeconomic rank. the success of a long-term weight reduction pro-
gram, with the need for tailored interventions.41
Likewise, our participants were recruited selective-
success of an intervention with overweight chil- ly; the strategy was to recruit families who were
dren, including parental involvement in treat- able to commit to a 6-month program on a bi-
ment,19,20,27 behavioral modification, and the in- weekly basis and to the follow-up provided by rou-
tensity of physical activity and the intervention.28 tine pediatric care after the program ended. It is
As such, the children participated in twice weekly believed that this element further contributed to
physical activity sessions, classes about eating and the success of the intervention program.
lifestyle habits, and cooking workshops, while the The comparison group also demonstrated a de-
parents participated in workshops guided by a di- crease in BMI (z score), albeit less so than the
etician and a social worker to help modify their intervention group. This may be explained by other
parenting style. The participation and involvement external factors, such as increasing public aware-
of parents in any childhood obesity treatment is ness about the risks of childhood obesity, consul-
crucial.19,29 –31 Both mothers and fathers32 influ- tation received from primary care physicians, and
ence their children’s eating habits through the con- participation in other private programs with no
trol of food socialization practices and through documentation.
their food-related parenting style. The home envi-
ronment is thus a critical sociocultural component Study Limitations
in the development of eating disorders.24 There- One limitation of this study was its lack of random-
fore, successful treatment should be family-based and ization, which prohibits a presentation of causal
should incorporate physical, nutritional, and psycho- inferences. The children and their families were
logical components.31,32–35 This family-based inter- recruited for the intervention based on their failure
vention approach can be implemented through des- in routine and other treatments, their commitment
ignated clinics or other community centers in to long-term participation, and their willingness to
developed as well as developing countries suffering pay for the services rendered. The comparison
from the growing epidemic of childhood obesity. group was gathered from the same clinics. Our
One of our important results was the sustainabil- method resulted in more girls and higher socioeco-
ity of the intervention’s impact. Only a few stud- nomic status in the treatment group despite pro-
ies36 – 40 have reported follow-up measures after an viding subsidies. Yet for these types of interven-
intervention (from 5 to 12 months) with positive tions, randomized recruitment is often difficult, as
outcomes in either behavioral or anthropometric previously described.42,43 Furthermore, although
measures. there was potential selection bias, our results high-
As was recently published,33 both parents and light the potential advantages of this kind of inten-
children reported the need for ongoing support to sive treatment for reducing children’s relative
sustain the behavioral changes made during treat- weight and fighting obesity.

326 JABFM May–June 2014 Vol. 27 No. 3 http://www.jabfm.org

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