Nineteen included studies (18 behavior-based interventions and one pharmacotherapy with counseling) reported on the acceptability of weight management interventions, which varied in intensity from a brief use of a computerized clinical decision support system using motivational interviewing for weight management¹⁶⁴ to multiple group sessions addressing healthy lifestyle behaviors with the parents and child meeting separately.¹³³ Participants—both parents and children—rated their satisfaction with the weight management interventions highly on various satisfaction questionnaires. In most trials, 80 percent or more of participants had high satisfaction or acceptability ratings, and continuous satisfaction scores typically were above 4 on a 5-point scale (Table 1).^{118, 129, 130, 136, 147, 160, 163, 164} In a good-quality trial that involved a computerized clinical decision support system with point of care prompts at well-child visits, motivational interviewing with their primary care provider, and four health coaching phone sessions with an optional text messaging component, ninety-one percent of parents would recommend the intervention to family and friends.¹⁶³ In another fair-quality trial in younger children (age 6 to 9 years) involving an estimated 24 hours of contact via group and phone sessions, the majority of parents reported that they would undergo the intervention again.¹³⁰ Many of the participants also found the behavior-based interventions to be helpful or useful in weight loss (Table 1).^{118, 126, 129, 130, 138, 140, 147, 166} The interventions were also rated high in quality and value; for example, all the parents of one fair-quality study rated the Positive Parenting Program (Triple P) as good to excellent.¹³⁰ Primary care providers also found the interventions to be valuable^{143, 166} and helpful¹⁶⁹ and intended to deliver the intervention again.¹⁴³ The participants of four included studies reported that the intervention met their particular weight loss needs.^{126, 130, 147, 166}

Appendix E Table 1

Acceptability of Behavior-Based Interventions in Included Studies, Participant Report.

A few themes emerged when asking families for feedback on their experiences, both in the included trials and other studies, including a qualitative study of 14 parents who had dropped out of a weight management program.³¹⁸ Themes included a desire for more frequent and direct contacts or visits with the interventionist, appreciation for a component or option directed in the home, and increased parental involvement and family education, rather than only targeting the child. In one good-quality trial evaluating monthly individual family sessions with health advisors, the parents liked involving both themselves and their child during the sessions as well as the broad selection of lifestyle behaviors for modification from which to choose.¹⁴⁷ About half wanted to target more than one behavior change a month, attend more frequent visits, and receive more frequent followup telephone calls between sessions. A few parents would have also preferred home visits or for the intervention to take place at an alternative site for convenience or due to transportation issues. The parents of one-fair quality trial found the home component of the intervention essential to following the treatment recommendations (e.g., clean out pantry of junk food).¹⁵⁹ In another fair-quality study of an intervention aimed at parenting skills with an estimated 38 hours of contact, the parents indicated that they would have liked a booster session to refresh their knowledge and skills since the intervention only lasted 14 weeks and followup assessment occurred at 12 months.¹²⁹ Other studies have reported that parents of children in weight management programs strongly support interventions that include behavioral modification through collaborative goals and family support,^{319, 320} which the majority of interventions in included studies provided. At least one included fair-quality study reported modifying the SHAPEDOWN intervention to include more extensive parental involvement and supportive family education materials based on feedback from group leaders.¹⁴³ Similarly, the survey of families dropping out of a weight management program indicated a preference for greater family involvement rather than the child being the primary target.³¹⁸

When designing weight management interventions, consideration of the preferences of the participating children and adolescents, such as focusing on healthy eating and physical activity and not restricting activities that they enjoy (e.g., playing computer games), is also important. A survey of middle school students reported that the most important components were those that focused on adopting healthy eating and physical activity behaviors as opposed to drinking less soda pop, playing less video/computer games, and watching less television.³²¹ The survey among middle school students also reported that they preferred to increase physical activity, rather than reduce calories, for improved energy balance.³²¹ In contrast, the caretakers of children in one included fair-quality trial suggested reducing sugar-sweetened beverages was the easiest behavior to target in children compared to increasing intake of fruits and vegetables, increasing moderate-to-vigorous physical activity, or decreasing television time.¹³⁸

Weight management interventions should also be developed to be relevant, applicable, and feasible to a primary care setting by considering the perspective of the primary care provider. Four included trials that involved primary care providers assessed the acceptability of the interventions from their perspective (Table 2). One good-quality trial evaluated the effect of four consultations with a general practitioner on weight management.¹⁴² At each consultation, the family could choose an appropriate healthy lifestyle behavior change from a set of evidence-based materials (e.g., drink more water), and the general practitioner provided solution-based support to families during the consultations. Eighty-five percent of the general practitioners found the intervention materials had good or very good relevance to primary care. In another good-quality trial, intervention participants visited their general practitioners every 4 to 8 weeks after an initial hour-long family session with an obesity specialist team.¹⁶⁹ The general practitioner reviewed BMI and lifestyle change progress, identified and solved problems, and set new goals using a brief solution-focused technique. Data from all sessions was shared between the obesity specialist team and the general practitioner using the HopSCOTCH web-based shared care software, which provided a structured intervention for each session. The majority of general practitioners thought that the overall shared care approach was helpful (77%), the specialists management plan was helpful (88%), and being able to contact the specialist team was helpful (67%). Half of general practitioners, however, did not find the HopSCOTCH software easy to use. In a fair-quality trial that evaluated the use of an overweight prevention protocol during a well-child visit, 65 percent of the professionals (72% of which were pediatricians) at the Youth Health Center graded the intervention as a seven or higher on a 10-point scale (directionality not reported).¹⁶⁶ The professionals indicated that motivating the parents to attend additional sessions and changing the family health-related lifestyle were the most often experienced difficulties while using the overweight prevention protocol (specific details not reported). And finally, the majority of pediatric primary care physicians who provided a brief session to participants in one fair-quality trial reported the training (88%) and materials (68 to 71%) were helpful and useful.¹⁵⁷ Although children in these interventions were not more likely to reduce excess weight than the usual care groups, the generally positive attitude of the participating providers suggests that these interventions may be useful and feasible components of a more intensive intervention.

Appendix E Table 2

Acceptability of Behavior-Based Weight Management Interventions in Included Studies, Provider Report.

Study investigators also need to consider reasons participants choose to discontinue a weight management intervention. High attrition rates and poor adherence are important limitations of weight management studies. Although the followup rates of included studies in this review were adequate (ranging from 63.4 percent¹¹⁷ to 100 percent¹⁵⁰), some interventions were modified to improve adherence and compliance. One trial, for example, changed calorie goals to goals on food types and portion size, and removed goals for daily weighing due to considerable resistance from families and health professionals during the pilot study (specific details not reported).¹²⁴ It is possible that adhering to such frequent self-monitoring is difficult whereas monthly monitoring of weight and height was rated as very or extremely easy to do in another fair-quality study.¹³⁸ A survey of 14 parents who did not return to the Canadian Nutrition Services Pediatric Weight Management Program reported physical barriers (e.g., logistics), organizational barriers (e.g., clinic environment), motivation (i.e., the family’s readiness to change), and components of the interventions as common reasons for attrition.³¹⁸ The qualitative responses indicated that information-only interventions were vulnerable to dropouts because many participants were already knowledgeable about the information (e.g., what is a food pyramid).³¹⁸ The survey also indicated that parents wanted the intervention to be targeted more toward the family and not the child only.³¹⁸ Tailoring the counseling technique in weight management interventions based on sex or race/ethnicity and other sociodemographic characteristics (e.g., immigration status) may also improve attendance and satisfaction.²¹⁷ The survey also reported that parents would prefer having the interventionist gain an understanding of what the family knows and how to address diet and lifestyle areas with which the family struggles (and thus, tailoring the intervention).³¹⁸ Overall, addressing preferences and barriers may improve adherence and compliance in weight management interventions.

Although we identified no studies on screening for childhood overweight or obesity, we did find studies reporting that parents believe primary care physicians play an integral role in identifying and treating childhood weight issues^{322, 323} and find screening to be acceptable³²⁴ in a health care setting. Primary care physicians who provide parents with weight-related feedback improve the parent’s recognition and awareness of child overweight and increase the likelihood of participating in weight loss and healthy lifestyle programs.^325–327