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Obesity Prevention/Treatment
Family-focused physical activity, diet and obesityinterventions in African–American girls:a systematic review
D. J. Barr-Anderson1, A. W. Adams-Wynn2, K. I. DiSantis3 and S. Kumanyika4
SummaryObesity interventions that involve family members may be effective with racial/ethnic minority youth. This review assessed the nature and effectiveness of familyinvolvement in obesity interventions among African–American girls aged 5–18years, a population group with high rates of obesity. Twenty-six databases weresearched between January 2011 and March 2012, yielding 27 obesity pilot orfull-length prevention or treatment studies with some degree of family involve-ment and data specific to African–American girls. Interventions varied in type andlevel of family involvement, cultural adaptation, delivery format and behaviourchange intervention strategies; most targeted parent–child dyads. Some similari-ties in approach based on family involvement were identified. The use of theo-retical perspectives specific to African–American family dynamics was absent.Across all studies, effects on weight-related behaviours were generally promisingbut often non-significant. Similar conclusions were drawn for weight-relatedoutcomes among the full-length randomized controlled trials. Many strategiesappeared promising on face value, but available data did not permit inferencesabout whether or how best to involve family members in obesity prevention andtreatment interventions with African–American girls. Study designs that directlycompare different types and levels of family involvement and incorporate relevanttheoretical elements may be an important next step.
In the United States, disparities in obesity are evidencedby elevated obesity rates within racial/ethnic minoritiesrelative to those seen in Caucasians (non-Hispanic white)(1). This disparity affects African–American (non-Hispanicblack) girls aged 6–19 years, whose prevalence of obesity(�95th percentile) in 2007–2008 was 26%, compared to16% in their Caucasian counterparts (2), and remainedsteady in 2009–2010 (3). A striking disparity was also seenin an analysis of severe obesity (�120% of 95th percentile):
African–American girls had doubled the prevalence com-pared to Caucasian girls (18% vs. 9%, respectively) (4). Aneed for specially designed interventions to address obesityin African–American females is suggested by the disparityin prevalence and also by evidence of lesser effectiveness ofweight loss interventions in black compared to Caucasianpopulations. African Americans tend to lose less weightthan Caucasians when offered the same intervention (5–7),and this difference is particularly pronounced in females(5,7). These dissimilarities have been attributed to bothcultural and contextual issues, i.e. possible variations in
factors that influence the motivation or ability of partici-pants to adhere to behavioural change advice.
Family-based behavioural interventions are among themost successful for addressing childhood obesity (8), andmay have particular relevance to racial/ethnic minorityyouth (9). When targeting youth using behavioural changestrategies, it makes practical sense to engage the familyand not just the child. The child is not in sole control ofdecision-making related to healthy lifestyle choices.Rather, family dynamics (i.e. family rules, emotionalsupport, encouragement, positive reinforcement andfamily involvement) work as a unit, with parents influenc-ing their children and vice versa (8). Sociological researchsuggests that African–American households exhibit aninherent strength in their supportive, interpersonal parent–child and extended family bonds, in response to historicaldiscrimination (10). Thus, in addition to the generalfinding that a focus on family and home environmentsis important in child-focused obesity interventions,the inclusion of family members and using familiar sur-roundings such as neighbourhood community centresor homes as the setting for the interventions may alsobe forms of cultural adaptation for African–Americanchildren (10).
Although several reviews have focused on effects offamily involvement on outcomes (11–14), findings of thesereviews have pointed out the need for more evidence aboutthe effectiveness of such approaches on racial/ethnicminorities (12,14), and it is still unclear what level offamily involvement yields the largest impact on youthbehaviours and weight outcomes. Therefore, this reviewwas undertaken to examine evidence available for inter-vention studies with a family component for African–American girls. Based on an Institute of Medicine reportthat encouraged an inclusive approach to locating andassessing evidence about obesity prevention (15), all poten-tially relevant evidence was considered in order to obtaininsights about strategies used, how comprehensive theywere, and how they were conducted as well as impact onoutcomes. The overall objective was to gather a compre-hensive picture of the evidence available for this particulartype of intervention for a vulnerable population, African–American girls. Specific aims of the review were to (i)examine intervention strategies related to level of familyinvolvement and cultural adaptation and (ii) assess theeffectiveness of studies with different types and levels offamily involvement.
Methods
Data sources
In January and February 2011, relevant peer-reviewedjournal articles and abstracts from databases (AGRICOLA,
AMED, Biological Abstracts, BIOSIS Previews, CDSR[Cochrane], CENTRAL/CCTR, CINAHL, CochraneLibrary, DARE, ERIC, EMBASE, Health Source: Nursing/Academic Edition, PsycARTICLES, PsycINFO, PubMed orMEDLINE, Population Index, Proquest Digital Disserta-tion Abstracts Int’l, Proquest Digital Dissertations andTheses, Science Citation Index [Web of Science], Science-Direct, SCOPUS, Social Science Citation Index [Web ofScience], SPORTDiscus, TRIS, TRIP, Web of Science) wereretrieved during a systematic search of interventions forAfrican–American girls that included a family componentand incorporated weight change, physical activity and/ornutrition components. The following strategy and searchterms were applied: (adolescent OR girl OR teen OR childOR youth) AND (African-American OR black) AND(obesity OR weight OR overweight) AND intervention.Bibliographies from pertinent articles were also reviewedfor additional applicable interventions. In November 2011and March 2012, the electronic search was updated. Therewas no limit on publication year, except for the restrictionsof the databases. The earliest searchable year was 1887(PsycINFO).
Study inclusion and exclusion criteria
The inclusion criteria used for all articles and abstractswere (i) samples that included any African–American girlsaged 5–18 years; (ii) some degree of family involvement;(iii) intervention studies only; (iv) intervention strategiestargeting physical activity, eating/nutrition or weight; (v)any study design (e.g. randomized controlled trial [RCT],quasi-experimental or other); (vi) primary outcome relatedto physical activity, healthy eating (i.e. fruit, vegetable,water, sweetened beverage) or weight; (vii) availability ofdescription of intervention; (viii) studies conducted in theUnited States only; and (ix) intervention took place ineither a home or community setting (i.e. school, localtheatre, clinic, park or recreational centre, etc.).
There were no restrictions on the length of the interven-tion, year in which the intervention took place, or theweight of participants at study entry. Included articles werenot restricted to studies with African American-only orgirl-only samples. However, results for African Americansand girls had to be reported or considered separately (i.e.stratification or assessment of interaction) from other racialgroups and from boys. From the electronic searches, 8,709citations matched the initial search criteria. Each articletitle and abstract were reviewed independently by tworesearchers for duplicates and relevancy. Excluded werenon-English publications, news reports, review articles andsecondary data analyses. The remaining articles (n = 67)were then obtained for independent review by the sameauthors.
30 Family interventions in African–American girls D. J. Barr-Anderson et al. obesity reviews
Of the 67 articles thoroughly reviewed (Fig. 1), many wereexcluded because their results did not stratify for ethnicityand/or gender (n = 31), precluding assessment of interven-tion effects for African–American girls. No attempt wasmade to contact the authors of these studies to providesubgroup analysis for African–American girls. Otherreasons for exclusion were: the intervention did notinclude a family component (n = 5); baseline data but notpost-intervention data were reported (n = 4); the article
was a review or secondary data analysis (n = 4); and thetargeted child was less than 5 years of age (n = 1), result-ing in 22 articles. In November 2011, the databases weresearched again and five articles were found that met theinclusion and exclusion criteria. No additional articleswere identified after a further update of the search inMarch 2012, resulting in a final number of 27 articlesincluded in this systematic review. Of the studies included,four were pilot studies (16–19) for RCTs of 2-yearinterventions (20–23) that are also represented in thisreview.
Potentially relevant citations identified through systematic
searches in SEARCH ENGINES* (n = 8709)
Excluded citations that were duplicates or unrelated
(n = 8644)
Publications included from first literature search February 2011 (n = 22)
Articles carefully examined for inclusion (n = 67)
Excluded citations that did
not stratify by race/ethnicity
and/or gender(n = 31)
Excluded citations that
did not include a family
component (n = 5)
Excluded citations that
did not report post-intervention data (n = 4)
Excluded citations that were a review or secondary data analysis
(n = 4)
Five additional publications included from November 2011 literature search (n = 27)
Excluded citation that targeted a child less than 5(n = 1)
Figure 1 Flow chart of systematic search findings.*Search engines: AGRICOLA, AMED, Biological Abstracts, BIOSIS Previews, CDSR (Cochrane), CENTRAL/CCTR, CINAHL, Cochrane Library, DARE,ERIC, EMBASE, Health Source: Nursing/Academic Edition, PsycARTICLES, PsycINFO, PubMed or MEDLINE, Population Index, Proquest DigitalDissertation Abstracts Int’l, Proquest Digital Dissertations and Theses, Science Citation Index (Web of Science), ScienceDirect, SCOPUS, SocialScience Citation Index (Web of Science), SPORTDiscus, TRIS, TRIP, Web of Science.
obesity reviews Family interventions in African–American girls D. J. Barr-Anderson et al. 31
Variables of interest included the intervention behaviouralchange strategies, level of family involvement, culturaladaptations, and the effectiveness of the studies on diet,physical activity, and weight change. Data extracted fromeach article include data collection year, study populationdescription, study setting, study design, theoretical frame-work, key intervention components, intervention durationand follow-up periods, assessment measures for treatmenteffects, key intervention findings related to outcome vari-ables, strengths and limitations of the study, recommenda-tions for future research, and criteria related to internal andexternal validity.
Assessment of intervention components
Assessment of family participation or involvement wasadapted from previous work that evaluated the nature andeffectiveness of family involvement in weight control,weight maintenance and weight loss interventions (24).Family involvement was described according to (i) familymember involvement (i.e. parent–child only, multiplefamily members that included parent–child pair plus addi-tional family member[s], or whole family involvementdefined as entire household where child lives most of thetime); (ii) index member (i.e. targeted participant) of theintervention; (iii) format of intervention delivery (i.e.distant, face-to-face and/or other delivery); (iv) expectedjoint attendance by index and family member (i.e. single/partial/all sessions attended jointly/separately); (v) goal forthe family member (i.e. no specific goal, support-relatedgoal or change in own behaviour goal); and (vi) behaviourtargeted for change (i.e. physical activity and/or diet).
Cultural adaptation was described as (i) no culturaladaptation mentioned; (ii) adaptation limited to targetedrecruitment of African–American participants or conductof intervention in culturally familiar setting; or (iii) specificattempts to tailor intervention components (25).
Assessment of methodological quality
Internal validity was evaluated using six criteria adaptedfrom the Delphi list (26): (i) randomization performed; (ii)treatment allocation concealed for baseline data collection;(iii) groups similar at baseline; (iv) eligibility criteria speci-fied; (v) point estimates presented; and (vi) intention-to-treat analysis included. Criteria related to blinding werenot assessed because the nature of behavioural changeinterventions prevents research staff and participants frombeing blinded to treatment assignment. External validitywas assessed using seven criteria outlined by Green andGlasgow most applicable to behaviour change intervention
research (27): staff expertise, programme adaptation,long-term effects, institutionalization, attrition, consistentimplementation, and quality of implementation of differentprogramme components and mechanisms. A total meth-odological quality score was created by summing thenumber of internal and external validity criteria met (seeSupporting Information Appendix S1 for methodologicalquality assessment table).
Behavioural and weight change outcomes
Studies identified included some that recruited only over-weight or obese participants and were treatment orientedas well as those that focused on or included girls in thehealthy weight range and were prevention oriented. Westratified studies into treatment and prevention subsetswhen considering outcomes given the differences in studyparticipants, goals and participant motivations related totreatment vs. prevention. In particular, prevention studiestend to focus more on shaping lifelong habits than onweight loss strategies, and participant motivations foradherence may be much more heterogeneous than in treat-ment study populations. Both types of studies would beexpected to result in similar behaviour changes, but effectson weight are often smaller in prevention studies and maynot be detectable in the short term. We were also cognizantof the complexities of evaluating weight change outcomesin growing children and adolescents among whom weight,height and body mass index (BMI) increase with age andare evaluated on growth charts (28,29). Improvements inweight of active intervention vs. control groups may bereflected in various scenarios (weight loss, no change inweight or less weight gain; or reduced, stable, or less ofan increase in age and gender-specific BMI z-scores) inthe active intervention relative to control group. Takentogether, these issues led us to consider the direction of netweight change outcomes only in controlled trials (RCTs) oftreatment (any duration) and only in full-length RCTsof prevention. We considered the direction and significanceof behavioural change outcomes for all studies.
Results
Description of studies
Table 1 provides a general description of the study popu-lation, study setting and state location, study design andtheoretical framework, nature of comparison group (ifapplicable), and duration of intervention and post-intervention follow-up, grouped by age of participants (i.e.�12 years, �13 years or across both age groups). Studiesare grouped by participant age because studies that targetdifferent developmental stages likely require differentapproaches. Therefore, some of the results discussing the
32 Family interventions in African–American girls D. J. Barr-Anderson et al. obesity reviews
intervention strategies are presented according to age of themajority of participants: 12 years and younger (i.e. preado-lescence), 13 years and older (i.e. mid-to-late adolescence),and 8–18 years for studies that included youth across bothage groups.
About 15 of the 27 studies targeted only African–American girls (16–18,20–22,30–38), 6 targeted African–American girls and boys (39–44), 5 targeted multi-ethnicsamples of girls and boys (19,23,45–47), and 1 studyincluded a multi-ethnic sample of girls (48). Sample sizesranged from 15 (41) to 618 (23). The majority of studiestook place in a community setting (n = 15) (16,19,21,23,31,33,34,36,39,40,42,44–47), with the remainingtaking place in either the home (32,38) or a combination ofcommunity and home settings (9,17,18,20,22,30,35,37,41,43,48). The interventions ranged in duration from3 weeks (48) to 2 years (20,22,38), of which 15 werepilot studies (16,18,30,32,33,35,36,39–44,47,48), 1 was ashort-term study (12 weeks but not identified as a pilot)(34), and 12 were full-length, non-pilot studies (17,19–23,31,37,38,45,46). Seventeen of the studies were RCTs(16,18–23,30,31,33,35,37,38,42,46,47,49); eight wereuncontrolled (i.e. before and after) studies (17,32,36,39–41,43,48); two were non-RCTs (44,45); and one was arandomized trial of three active interventions (37). Nine ofthe studies were treatment studies that targeted overweightor obese participants (17,21,37,38,40,42,44,47,48). Theinterventions were implemented in 13 different states andincorporated a variety of theoretical frameworks, of whichsocial cognitive theory was most utilized. Methodologicalquality of the studies ranged from 1 (43) to 10 (18) with theRCTs consistently assessed as higher quality.
Intervention approaches
Behavioural change techniques and cultural adaptationTable 2 summarizes the specific behavioural change tech-niques and cultural adaptation strategies utilized. Withthe exception of five studies, both physical activity anddiet were the main focus of the behavioural change strate-gies. Most studies made specific attempts to tailor theirintervention components; these attempts varied, althoughmost reported culturally tailoring the content of inter-vention materials and messages. Three studies did notreport any level of cultural adaptation, and four additionalstudies limited their cultural modifications to recruitingonly African–American participants. Theories specific toAfrican–American families were not generally mentionedor identified for the behavioural change techniques.Although a variety of strategies were reported, no clearpattern based on age of the child or family member involve-ment emerged. Further descriptions of the interventioncomponents are available in the Supporting Information(Appendix S1).
Level and type of family member involvementWith respect to family member involvement, among thetreatment studies, none included the whole family, fourincluded multiple family members, and five incorporatedparent–child dyads only. All three of the whole familyinterventions were prevention studies. Prevention studiesalso included three multiple family members and 12parent–child dyad interventions. Examining the character-istics of family member involvement (Table 3), although aclear pattern does not emerge within each cluster, somesimilarities in intervention approach can be reported.
The three whole family prevention interventions targetedyounger children and incorporated some form of face-to-face intervention delivery with the expectation for some ofthe sessions to be attended jointly by all family members.There was no clear pattern of the goals for the familymembers in these three studies.
Among the interventions with multiple family memberinvolvement, the prevention studies focused most efforts onthe child; family members were included only to providesupport and there was a greater expectation for the child toattend the intervention sessions than the family members.Clear patterns did not emerge for the treatment studies;half engaged family members to make substantial behav-ioural changes and the expected attendance varied from allsessions attended jointly to all sessions attended separately.
The majority of studies engaged parent–child dyads only(n = 17). The two treatment studies that targeted parentalbehaviour change required all participants to attend allsessions separately then jointly with a face-to-face interven-tion delivery mode. The difference between the two studieswas Janicke et al. (47) targeted younger adolescents andMacDonell et al. (42) targeted older adolescents. The otherthree treatment studies that included a parent–child dyaddid not share any similarities.
Four of the 12 parent–child dyad prevention studiesincluded change strategies to improve the parent’s behav-iour, targeted younger children, and required the familymember to attend all sessions while the child’s attendancevaried from all sessions either jointly or separately orattendance not required because of the non-face-to-face,distant delivery. Only one of the parent-child dyad preven-tion studies designated no specific expectation for familymember attendance, which resulted in the child attendingall of the sessions alone. The remaining prevention studiesengaged the family members with support-related goals tohelp change the child’s behaviours with almost equal dis-tribution of participants attending some of the sessionsjointly or child attending all sessions alone. One parent–child dyad prevention pilot study was designed to directlyassess parent-only vs. child-only approaches vs. a non-weight-related comparison conditions (16), but the sub-sequent full-length RCT combined the parent and childconditions (20).
38 Family interventions in African–American girls D. J. Barr-Anderson et al. obesity reviews
Table 2 Intervention strategies and cultural adaptation
Author year Focus of behaviourchange techniques
Specific behaviour changetechniques
Cultural adaptation*
Age � 12 yearsFitzgibbon et al.2005 (19)
PA and diet • Healthy eating and PA sessions that utilized puppetsand active games
• Weekly newsletters and homework
• AA-only sample at certain schools• Culturally tailored content and messages
Fitzgibbon et al.2011 (23)
PA and diet • Healthy eating and PA sessions that utilized puppets,songs/raps and active games
• Weekly homework
• Culturally relevant foods and traditionalrecipes
• Newsletters created for the family• Culturally relevant music and dances• Acknowledgement of community
environmental barriers to regular PA, healthfuleating, social roles and social support
Greening et al.2011 (46)
PA and diet • Monthly family events• Nutrition and PAs/contests• Modifications in intervention school’s food service• Nutrition and PA education sessions
No cultural adaptation mentioned
Janicke et al.2011 (47)
PA and diet • Knowledge and skill-based education sessions• Food and pedometer logs• Group support meetings (separate parent/child
meetings for learning component and together forgoal setting
• Taste-testing and snack prep for children• Exercise or games for children to be active
No cultural adaptation mentioned
Stolley andFitzgibbon1997 (34)
PA and diet • Nutrition education sessions• Cooking demonstration• Music and dance incorporated into nutrition and PAs
• AA-only sample• Culturally tailored content and programming
Baranowski et al.2003 (30)
PA and diet • Camp programme to increase behavioural andpsychosocial factors related to healthy foods (i.e. fruitand vegetable intake, water consumption) and PA
• Self-monitoring using pedometers• Goal setting web site
• AA-only sample• Formative focus group with AA sample
Beech et al.2003 (16)
PA and diet • PA (hip hop aerobics) sessions• Healthy eating session with taste-tests of healthy
foods and food preparation/games• Culturally relevant take-home materials
• AA-only sample• Cultural sensitivity programming• Culturally tailored take-home materials
Klesges et al.2010 (20)
PA and diet • Nutrition and PA sessions (goal setting, providedfeedback, encouragement to participants, skillbuilding, self-monitoring, problem solving and socialsupport)
• Parents/guardians were encouraged to make changesin the home food environment
• Field trips
• AA-only sample• AA-only interventionists• Cultural sensitive programming and tailored
take-home materials
Robinson et al.2003 (18)
PA • After-school dance classes with healthy snack,homework period, and discussion of increased PA(dance) and reduced TV screen time (TV watching,videotape use and video game use)
• Family intervention that included role modelling forgirls by AA interventionist and behaviour changediscussions about reducing screen time
• Newsletters
• AA-only sample• AA-only interventionists and data collectors• Music and dance selection by AA participants• Attempted to account for a number of unique
elements associated with AA culture(collectivism, importance of family, presentorientation, importance of religiosity, sense ofhistorical racism and prejudice, and use ofsocial support as a coping strategy)
obesity reviews Family interventions in African–American girls D. J. Barr-Anderson et al. 39
Specific behaviour change techniques Cultural adaptation*
Robinson et al.2010 (22)
PA • After-school programme with dance, healthy snackand homework
• Public performances• START (Sisters Taking Action to Reduce Television)
home-based screen time reduction programme(self-monitoring, a 2-week TV turn-off, budgetingviewing hours, ‘intelligent’ viewing)
• Newsletters
• AA-only sample• AA culture infused through matched models,
music, intervention activities, language, values,social and historical influences
• AA-only dance instructors (college students orrecent graduates)
• Awards based on Kwanzaa principles• Utilized AA screen time intervention
Story et al.2003 (35)
PA and diet • PA and healthy eating programme based on youthdevelopment and resiliency approach to build onfamily and personal strengths
• Family night events with interactive games and goalsetting that they would continue throughout theprogramme
• Phone calls by staff to check in on goals and providesupport
• AA-only sample• AA-only instructors• Culturally tailored activities and programming
Barbeau et al.2007 (31)
PA • After-school programme that includedhomework/healthy snack time and PA (25-min PA skillinstruction; 35-min aerobic PA such as basketball, tag,softball, relay races; and 20-minstrengthening/stretching)
• Incentives for attendance
• AA-only sample
Fitzgibbon et al.1995 (33)
PA and diet • Nutrition education (taste-testing, menu planning,interactive lessons)
• Skills training (problem solving, decision-making, goalsetting)
• AA-only sample• 25% of interventionists were AA• Utilized ‘Rap Against Fat’ activity• Tailored health info for AA women
Raman et al.2010 (44)
PA and diet • Summer day camp with community-based exercise,nutrition and behavioural modification
• Monthly nutrition educational sessions• ‘Personal best’ approach to PA programme to create
an environment where overweight children developpositive self-esteem and respect
• Follow-up: weekly intervention sessions including PAand modelling, hands-on nutrition education and skillbuilding, and self-esteem modelling
• Outside-of-programme PA
• AA-only sample• Culturally tailored programming and content
Burnet et al.2011 (40)
PA and diet • PA and nutrition discussion topics• Behavioural goal setting• Skill building and group problem solving• Engaging in family activities (shopping, cooking,
exercise)• Self-monitoring practice• Group outings
• AA-only sample• Surface and deeper cultural tailoring• All female AA lay community leaders• Formative focus groups with AA families
Cullen andThompson 2008(32)
Diet • Interactive, computer-based nutrition education (goalsetting, problem solving)
• AA-only sample• Culturally tailored web site content and images
Newton et al.2010 (43)
PA and diet • Classroom-based PA opportunities/resources• Altered classroom and cafeteria environments and
provided teachers with materials and equipment• Newsletters and messages via programme’s web site
• AA-only sample
40 Family interventions in African–American girls D. J. Barr-Anderson et al. obesity reviews
Specific behaviour change techniques Cultural adaptation*
Olvera et al.2010 (48)
PA and diet • Exercise class• PA education• Nutrition education (healthy meals modelling.
hands-on activities, games, handouts, homechallenge and cooking lessons)
• Behaviour counselling (art projects, poetry, journaling,behavioural contracts and home challenges)
• Parent programming (taught how to adapt to familymeals, completed activities to support daughter’shealthy food choices, and enhance their PA andself-esteem)
• Incorporated AA cultural values (collectivism,importance of respect and maternal roles, anduse of social support) in programme
• Culturally tailored activities (i.e. common AAfoods, dance)
Jackson et al.2010 (41)
PA and diet • Exercise class• Child take-home activities• Recipe/healthy snack preparation• Theatre games/dramatic writing• Nutrition education• PA education• Parent programming (1-h health info and recipe
making session, parent take-home activities)• End of the programme theatre performance/dinner for
family
• Formative focus groups with AA• AA-only sample• AA-only interventionists• Culturally tailored activities (i.e. hip hop
dance)
Age � 13 yearsWilliamson et al.2006 (38)
PA and diet • Internet-based, interactive nutrition education andcounselling via intervention web site/email
• AA-only sample• Culturally tailored activities (i.e. common AA
recipe, links to AA health web sites)• Counsellors educated on culturally specific
health info and dietary/PA-related issues
Frenn et al. 2003(45)
PA and diet • Internet and video intervention with healthy snack andgym labs (when available)
• PA and nutrition education sessions (topics includedasking and discussing with parents healthy foodoptions for the home; interactive, teen-specificbuilding awareness of fat in popular food, self-efficacyin selecting healthier options, peer model of preparinghealthy snacks and exercising; learning aboutrecommendations for PA)
No cultural adaptation mentioned
Resnicow et al.2005 (21)
PA and diet • 30 min of PA• Taste-test and preparation of healthy foods• Dependent on treatment group, motivational
interviewing counselling calls• Retreat at national park• Two-way pagers for targeted messages
• AA-only sample• Formative assessment focus groups with AA
families
Wadden et al.1990 (37)
PA and diet • Incentive structure based on weight loss andattendance
• Take-home assignments• Various levels of parental involvement based on
treatment condition (parents received homeworkassignments, participated in programme with girl, ortalking with daughter or attended separate similarsession)
• AA-only sample• AA-adapted curriculum content
Thompson 2010(36)
PA • PA log• Aerobic dance class• PA education (knowledge about PA, goal setting,
benefits and barriers, body image, role models, socialsupport, hair maintenance, health statistics, solicitfeedback from girls about changing environments)
• AA-only sample• Incorporated AA cultural values (spirituality,
expressive communication, andinterconnectedness or commonality)
• AA-only interventionists
obesity reviews Family interventions in African–American girls D. J. Barr-Anderson et al. 41
In order to examine which family components were mosteffective, Table 3 also includes behavioural and weightchange results. As described in the Methods section,weight-related outcomes were not considered for short-term or pilot prevention studies or any before and after(uncontrolled) studies.
Among the nine treatment studies, three of the fivestudies that assessed physical activity positively impactedthis behaviour. However, no clear pattern related to familymember involvement, goal of the family member, format ofthe intervention delivery and age of child emerged. Treat-ment studies that reported an increase in physical activityexpected for all face-to-face sessions to be attended, butwho attended (child vs. family member vs. both) or howthe sessions were attended (separately vs. jointly) did notseem to influence physical activity changes. Three of thefour studies that assessed dietary intake reported null oropposite to expected results. Similarly, null or opposite toexpected findings were reported for the three full-lengthtreatment RCTs. The Wadden et al.’s study (37) of obesitytreatment in black adolescent girls is the only full-lengthstudy identified which designed to isolate effects of differ-ent types of parent–child involvement (child or parentalone or together). No statistically significant differenceswere found between either groups that involved parents
compared to the child alone. However, weight losses wereleast in the child-alone group (1.6, 3.7 and 3.1 kg for childalone, mother–child together, or mother–child separately,respectively).
In general, both physical activity and dietary intake werepositively affected in the prevention studies, regardless ofstudy design. All 14 of the 18 prevention studies thatassessed some form of physical activity behaviour and all 15of the prevention studies that assessed some form of dietaryintake were able to positively influence the behaviours. Mostof the studies assessed physical activity and dietary intakeusing several measures; four and eight of the preventionstudies also reported null or opposite to expected results forphysical activity and dietary intake, respectively. Seven full-length RCTs were prevention studies. Of those, six assesseda weight-related outcome with four reporting positiveeffects on weight. The two RCTs reporting negative or nulleffects on weight had the highest methodological qualityranking of the prevention studies.
The seven studies that mentioned limited or no interven-tion cultural adaptation reported generally favourable out-comes, although they also ranked low on methodologicalquality (scores = 1, 2, 3, 5, 5, 6, 6). All but Janicke et al.(47) and Cotton et al. (39), both which did not assessphysical activity or dietary behaviour, reported a statisti-cally significant increase in physical activity. Newton et al.(43), Barbeau et al. (31) and MacDonell et al. (42), who
Table 2 Continued
Author year Focus of behaviourchange techniques
Specific behaviour change techniques Cultural adaptation*
MacDonell et al.2011 (42)
PA and diet • Goal setting and barrier/problem solving sessionsbased on motivational interviewing approaches
• AA-only sample
Across both age groups (i.e. 8–18 years)Cotton et al.2006 (39)
PA and diet • Nutrition sessions (topics focused on reducingsweetened beverages, drinking low-fat milk,increasing fibre intake and fruits and vegetables)
• PA sessions (topics included cardio, strength andflexibility training; utilized PA gaming video software)
• AA-only sample
Resnicow et al.2000 (17)
PA and diet • Educational/behavioural activity (30–60 min of PA andpreparation/taste-testing of low-fat meals)
• Communication skills training to enhance the ability torequest healthy food from parent
• Nutrition education (topics included substitution,moderation and abstinence with respect to eating;understanding fat and calorie content of food;distinguishing emotional side of eating, reading foodlabels)
• Field trips to farmers’ markets or grocery store• Incentives based on active participation and
attendance
• AA-only sample• AA-tailored PA programming
*Cultural adaptation categorized as (i) none mentioned; (ii) targeted adaptation limited to recruitment of African–American participants or conductionof the intervention in a culturally familiar setting; or (iii) specific attempts to tailor intervention content. Adapted from Whitt-Glover and Kumanyika (25).AA, African American; PA, physical activity.
42 Family interventions in African–American girls D. J. Barr-Anderson et al. obesity reviews
recruited African American-only samples, also reportedstatistically significant, positive influences on some of theother outcomes they assessed: dietary and weight related,respectively. Greening et al. (46), who did not culturallyadapt any of their intervention, reported positive results forall outcomes. No studies were designed to isolate effects ofculturally vs. not culturally adapted interventions.
Discussion/conclusion
The purpose of this review was to examine interventionstrategies and assess intervention effectiveness in African–American girls based on level of family involvement andcultural adaptation. This systematic literature search iden-tified 27 family-based interventions that included physicalactivity, eating/nutrition, or weight change components, ofwhich many were pilot studies not linked to subsequentfull-length trials. Assessments of patterns related to inter-vention approaches and effectiveness were limited toqualitative assessments of similarities or patterns based onvarious groupings of studies. Studies reported diversepatterns of family involvement and cultural adaptationwith no use of theoretical perspectives specific to African–American family dynamics incorporated. Only one pilotand one full-length study permitted a direct comparison ofmore than one type of family involvement and no studiespermitted direct comparison of culturally adapted vs. non-adapted approaches. Effects on behavioural outcomes and,in some cases, on weight outcomes were in the expecteddirection, but statistically significant results were limited.The studies included in this review differed widely by inter-vention components, study design, and implementation,and also in quality. Null results were observed in two of thehighest quality studies, of which both were culturallyadapted. Overall, we were unable to draw clear inferenceswith respect to the most promising or effective ways ofinvolving family members in weight interventions withAfrican–American girls.
It has been well established throughout the adolescentobesity literature that intervening on family systemspresents a dynamic and multidimensional approach toinfluencing and engaging health behaviour change for bothchild and adult (8). In the studies examined in this review,the extent to which family members were required to beinvolved and the type of strategies directed towardsthem varied with respect to their role as behaviour changeagents in the context of the child. A majority of the inter-ventions included in this review incorporated parent–childinvolvement, although some studies reported multiplefamily members or whole family participation. Sessionattendance ranged from child only to all or some of thesessions attended by both family member(s) and child.Most family members served to support the behaviourchange goals of the child. However, several studies encour-
aged family members, as mostly secondary audiences, tomake individual behavioural changes that would perhapsinfluence the child’s behaviour.
Some patterns that surfaced are worthy of furthercomment. Of the nine treatment studies targeting over-weight participants, five of them engaged the familymembers to change their own behaviour and not justsupport the targeted child. Wrotniak et al. (50) found thata change in parental behaviour resulting in weight loss waspredictive of their overweight child’s weight loss in threefamily-based RCT studies. Although some of the findingsfor the five studies were non-significant (possibly due to thepilot nature of most of the studies), the outcomes tended tobe more positive for weight-related behaviours and out-comes than the treatment studies that did not try to changethe family member’s behaviour. This suggests that encour-aging participating family members to change their ownbehaviour and lose weight may be an effective strategy foroverweight children to either successfully lose excessweight or prevent additional weight gain.
All but 2 of the 10 studies included in this review thatengaged family members to change their own behaviourexpected the child and participating family member(s) toattend at least some, if not all, of the sessions together. Theoutcomes of the studies do not definitively ascertain thatthis is an effective strategy to change African–Americangirls’ behaviour, but there is a promise in exploring theeffect of face-to-face interaction with children and theirfamilial support network. This face-to-face contact mayprovide opportunity to discuss and complete activities,share knowledge, or set supportive goals that may be thekey for successful change. Conducting rigorous interven-tions to test the effect of family member attendance is alogical next step in this area of research.
Three of the studies required only the child to attend theintervention sessions. As with examining the effectivenessof other levels of family involvement, the findings are weakin supporting the effectiveness of this strategy, suggestingthat more research needs to be conducted regarding thisaspect of family interventions. However, it inherentlyseems that not engaging the family member(s) in someform of face-to-face contact, which has proven to be aneffective strategy, for a family-based study, is an under-utilization of family involvement. The Wadden et al.’s (37)study finding that children engaged in a family-based inter-vention who attended intervention sessions alone did notlose as much weight as the participants whose familymembers were involved in some type of face-to-facecontact (with or without their children) lends possiblesupport to this conclusion.
Similar to family-focused interventions, behaviouralprogrammes that are culturally relevant are consideredimportant when working with ethnic minority popula-tions, and appear to be well received (51–54). The studies
obesity reviews Family interventions in African–American girls D. J. Barr-Anderson et al. 47
reviewed here reflect the variety of approaches that can beused for cultural adaptation, including recruitment of onlyAfrican–American samples and instructors, emphasizingcultural norms and traditions, preparing foods and plan-ning activities with which African Americans may befamiliar, placing African–American images on materials,incorporating focus group feedback of African Americans,and utilizing locations for intervention activities in prima-rily African–American communities. Most of the studiesincluded in this review addressed African–Americanculture through direct targeting, cultural tailoring or acombination of these approaches. The cultural tailoringmay confer familiarity and greater acceptance of the inter-vention but may not directly impact effectiveness. For thisreason, studies that compare culturally tailored with non-tailored interventions may be difficult to implement.
While the overall quality of the available evidence waslow from a study design perspective, several studiesincluded in this review developed and implemented inno-vative intervention strategies (i.e. computer technology(32,38), Internet delivery (30,45), theatre-based educationprogramme (41) and active video games) (39). The use ofcomputer technology and Internet intervention deliveryattempts to lessen the burden for families to meet outsidethe home. Utilizing digital media to increase physical activ-ity capitalizes on the higher than average digital media usein African–American youth (55). Theatre-based educationprogrammes have been used in overweight and obesityprevention in many studies (56), but this review highlightstheir use with African–American children and families.
Strengths
This is not the first review to examine obesity-related inter-ventions that included a family component; however, ourreview is unique and contributes significantly to theliterature, as we focused solely on African–Americangirls, a vulnerable population with obesity rates that areamong the highest observed among youth. Additionally,the other reviews (11–14), which made important contri-butions to the literature, had exclusions that our study didnot. Golley et al. (11) included studies that only targetedparents with children optionally involved while our studyincluded interventions that targeted and involved parents,children or both. Kitzman-Ulrich et al. (12) only includedinterventions that targeted family system components suchas parenting styles, parenting skills or family functioning,and excluded studies that minimally involved the familythrough take-home materials or contact at study-relatedevents. Because it is unknown what degree of familialinvolvement affects behavioural change, we included allstudies with any degree of family involvement. Knowldenand Sharma (13) included studies that only targeted youngchildren ages 2–7 years while our review included a wide
range of children and adolescents ages 5–18 years. Lastly,Swanson et al. (14) reviewed literature published onlyfrom 1998 to 2008, while we wanted to access all litera-ture that met our study criteria and did not restrict thetime period when the study was conducted or published.
Limitations
This review encountered several limitations in its synthesisof findings. Across the studies, comparing results was com-plicated by various methodological differences, such asintervention design, measures and reported outcomes.Many studies relied heavily on the use of subjective, self-reported measures, which are inherently biased. A majority(n = 15) of the studies were pilots with small numbers ofparticipants and short duration; few were associated withfull, longer-term studies. Also, our review focused on chil-dren aged 5 years and older. A review of studies in youngerchildren would also be of interest given that birth to pre-school age is a critical period for obesity risk development,as well as a period highly influenced by parents.
Future research
Although the studies identified in this review included avariety of approaches to family involvement, the optimalapproach or approaches with African–American girls arestill unclear. Whether these approaches differ for preventionand treatment or by age is a topic for further study. Also,the basis for choosing type and level of family involvementseems unclear or unsystematic, making it difficult tomake definitive conclusions. This is an area that needsmore attention in research design. Future studies shouldbe designed to test directly what factors related to familyinvolvement (i.e. family member designation, level ofinteraction between child and family member, and attend-ance of child and family member) are most effective inpositively influencing physical activity and dietary behav-iours. Without a clear, generalizable understanding or theo-retical framework of the function of family involvement onobesity-related behaviour change among African–Americanchildren, researchers will continue to struggle with develop-ing best practices for this area of public health. Technologi-cal approaches, including the use of social networking andmobile devices, are also worthy of further study. Finally,although this review was undertaken at a time when obesityrates were substantially higher in African–American girlsthan boys, rates in African–American boys have increased tolevels similar to those in girls. Thus, future research shouldexamine obesity interventions in both genders.
Implications for practice
To our knowledge, this review is the first to focus onempirical evidence of obesity interventions with a family
48 Family interventions in African–American girls D. J. Barr-Anderson et al. obesity reviews
component that involved African–American girls. Thereview brings to light the need for rigorously tested obesityinterventions for African–American girls that allow directinferences about whether and how to involve familymembers and that, if possible, clarify the benefits ofvarious approaches to cultural adaptation. Recognizing theurgency in addressing disparities in obesity prevalence, thisreview has sought to present more detailed explanation ofthe what and how of intervention research, rather thanfocus on only comparing outcomes of a body of inconclu-sive and often methodologically flawed evidence from theperspective of assessing effectiveness. Although no defini-tive conclusions can be made about the most promisingstrategies, the findings provide substantial guidance for andwill motivate the design and implementation of futurestudies on this important topic. The health implications ofobesity begin in childhood and are even more prevalent inadults. The prevalence of obesity among African–Americanwomen is now 59%, compared to 33% in Caucasianwomen. Progress in the prevention and treatment of obesityin African–American girls will also help to prevent themfrom being obese as adults.
Conflict of interest statement
No author has any conflicts of interest to declare.
Acknowledgements
This research was supported by the Building Interdiscipli-nary Research Careers in Women’s Health Grant (No.K12HD055887) from the Eunice Kennedy ShriverNational Institutes of Child Health and Human Develop-ment (NICHD), the Office of Research on Women’sHealth, and the National Institute on Aging, NIH, admin-istered by the University of Minnesota Deborah E. PowellCenter for Women’s Health. The content is solely theresponsibility of the authors and does not necessarily rep-resent the office views of the NICHD or NIH. Additionalfunding was provided from the General Mills Foundationand through a Robert Wood Johnson Foundation grantto the African American Collaborative Obesity ResearchNetwork (AACORN), which supported the participationof Drs. Kumanyika and DiSantis. The authors would alsolike to thank Vanessa Madieros for assistance with litera-ture searches and data extraction.
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Supporting Information
Additional Supporting Information may be found in theonline version of this article:
Appendix S1. Detailed description of interventions.
obesity reviews Family interventions in African–American girls D. J. Barr-Anderson et al. 51