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The prevalence of childhood obesity continues to increase, and clinic-based treatment options have failed to demonstrate effectiveness. One of the strongest predictors of child weight is parent weight. Parental treatment for weight loss may indirectly reduce obesity in the child. We have previously demonstrated the effectiveness among adults of a fully automated, evidence-based digital weight loss intervention (Track). However, it is unknown if it is feasible to deliver such a treatment directly to parents with obesity who bring their child with obesity to a weight management clinic for treatment.
The objective of our study was to evaluate the feasibility of and engagement with a digital weight loss intervention among parents of children receiving treatment for obesity.
We conducted a 6-month pre-post feasibility trial among parents or guardians and their children aged 4-16 years presenting for tertiary care obesity treatment. Along with the standard family-based treatment protocol, parents received a 6-month digital weight loss intervention, which included weekly monitoring of personalized behavior change goals via mobile technologies. We examined levels of engagement by tracking completed weeks of self-monitoring and feasibility by assessing change in weight.
Participants (N=48) were on average 39 years old, mostly female (35/42, 82% ), non-Hispanic Black individuals (21/41, 51%) with obesity (36/48, 75%). Over a quarter had a yearly household income of <US $25,000, and about a third had the equivalent of a high school education. Children were on average 10 years old and had a body mass index of 29.8 kg/m2. The median percentage of weeks participants tracked their behaviors was 77% (18.5/24 total weeks; interquartile range [IQR] 6.3 to 100). The median number of attempts via phone or text message (short message service) required to complete one tracking week was 3.3 (IQR 2.6 to 4.9). Nearly half (23/48, 48%) had high levels of engagement, completing 80% (19/24) or more weeks of tracking. Of the 26 participants with weight measurements reported at 6 months, of which 81% (21/26) were self-reported, there was a median 2.44 kg (IQR −6.5 to 1.0) decrease in weight.
It is feasible to deliver an evidence-based digital weight loss intervention to parents or guardians whose children are enrolled in a weight management program. Given the feasibility of this approach, future studies should investigate the effectiveness of digital weight loss interventions for parents on child weight and health outcomes.
The prevalence of obesity among children has increased since 1999, and rates among non-Hispanic black and Hispanic children are consistently higher compared with non-Hispanic White children [
Recent recommendations from the US Preventive Services Task Force suggest children aged 6 and older with obesity be referred to intensive lifestyle-based weight loss programs [
Obesity is highly comorbid in families [
Digital health approaches capitalize on the ubiquitous utilization of mobile technologies [
We delivered a 6-month pre-post feasibility trial called Families on Track to parents or guardians of children seeking treatment for weight management. We recruited participants from the Duke Healthy Lifestyles clinic. Healthy Lifestyles is a referral-based pediatric weight management program located in Durham, NC, which serves a population that is racially and ethnically diverse; 57% are female, 61% are black individuals, 29% are Hispanic individuals, and 70% of patients have public health insurance. The Healthy Lifestyles clinical protocol, patient demographics, and outcomes have been previously described [
Participants included parents or guardians of children aged 4-16 years with an age- and gender-specific BMI of ≥95th percentile presenting for obesity treatment to the Duke Healthy Lifestyles clinic. Eligibility criteria included parents or guardians aged 18-60 years with BMI between 25 and 50 kg/m2. We required that participants have English fluency, own a mobile phone and be willing to send and receive multiple short message service (SMS) text messages per day, and reside in the same household as the patient attending Healthy Lifestyles. We excluded participants who were pregnant or lactating; had prior or planned bariatric surgery; were participating in other obesity trials; had a history of heart attack, stroke, bipolar disorder, schizophrenia or recent cancer diagnosis; or had plans to relocate within 1 year. We recruited a convenience sample of 50 participants; 2 were excluded (1 did not meet BMI criteria and 1 declined). A total of 48 participants were consented and enrolled by a trained research assistant, who then collected baseline data.
The Families on Track intervention included the Healthy Lifestyles program plus a 6-month modified version of Track, a digital weight loss intervention for adults that was conducted in the primary care setting. The Healthy Lifestyles program has been described in detail elsewhere [
The intervention utilized the Interactive Obesity Treatment Approach (iOTA), which results in weight loss through the modification of everyday obesogenic behaviors [
We measured user engagement with the intervention both quantitatively and qualitatively. Using quantitative measures, we tracked the frequency of weekly self-monitoring across the 24-week intervention. Participants were expected to self-monitor daily via paper log and weekly using the IVR system or through SMS text message. Each week, participants received an automated prompt from the Families on Track intervention system to track adherence to behaviors goals. These prompts were delivered either via IVR or SMS text message. The IVR system called intervention participants weekly to request self-monitoring data and provided automated tailored feedback on the 4 goals. Participants who did not respond to IVR attempts were sent a SMS text message prompting them to communicate their weekly tracking data via SMS text messages (
Example of a self-monitoring SMS text message sent weekly to participants in Families on Track (Interactive Obesity Treatment Approach [iOTA], Duke Global Digital Health Science Center).
A trained nurse in the Healthy Lifestyles clinic collected parent and guardian height and weight at baseline and at 6 months; we measured height using a stadiometer (Model: Healthometer Professional CE No 92977) and weight using a digital scale (Model: Seca CE No 96990). A high percentage of participants did not return to the Healthy Lifestyles clinic for follow-up appointments despite email, phone, and SMS text message reminders. Therefore, we experienced difficulties in scheduling the 6-month visits. Thus, we also collected weights via self-report. Self-reported weights were sent to the study staff via email, SMS text message, or phone from participants who were unable to complete their in-clinic study visit. To verify self-reported weights, participants were asked to SMS text message or email the study staff a photo of their feet on their study-issued or personal scale with a visible weight reading.
Sociodemographic variables were measured using standard questionnaires completed by the parent or guardian at the baseline clinic visit.
We used descriptive statistics to characterize participants and examine tracking completion rate and weight change over the 6-month period. Characteristics were summarized using frequencies and proportions for categorical variables and mean (SD) for continuous variables. We used medians and interquartile ranges (IQR) to summarize intervention engagement and weight change owing to its highly skewed distribution. We conducted bivariate analyses to examine potential predictors of intervention engagement using Wilcoxon-Mann-Whitney and Kruskal Wallis tests for continuous data and chi-square and Fisher’s exact tests for categorical data. We used Poisson regression with a robust variance to examine sociodemographic differences among those with higher levels of tracking engagement (80% or more weeks of tracking) and estimate risk ratios (RRs) and 95% CIs. To assess intervention feasibility, we assessed differences in weight change among high and low engagers using the Wilcoxon-Mann-Whitney test. We conducted all analyses using Stata 14 for Mac (StataCorp, College Station, TX) with an alpha value of <.05 to assess statistical significance.
At baseline (N=48), participants were on average 39.4 years old (SD 7.3) with a mean BMI of 36.5 kg/m2 (
At least half of the participants engaged in tracking their behaviors in each study week, as measured by a complete IVR call or SMS text message (
Among the included participants, 40% (19/48) completed the post intervention satisfaction survey. Those with complete surveys completed more weeks of tracking, 21.3 (SD 3.8) versus 9.9 (SD 10.2) with
Baseline characteristics of parents or guardians participating in a digital weight loss intervention.
Characteristics at enrollment | Value | ||
Non-Hispanic black | 21 (51) | ||
Hispanic | 5 (12) | ||
Non-Hispanic white | 11 (27) | ||
Other | 2 (5) | ||
Declined | 2 (5) | ||
Age (N=42), mean (SD) | 39.4 (7.9) | ||
Female | 35 (83) | ||
Mother | 34 (83) | ||
Father | 6 (15) | ||
Grandmother | 1 (2) | ||
Employed (N=41), n (%) | 33 (81) | ||
<US $25,000 | 10 (26) | ||
US $25,000-34,999 | 13 (34) | ||
≥ US $35,000 | 15 (40) | ||
High School equivalent | 13 (35) | ||
Tech or community college | 9 (24) | ||
College degree or more | 15 (41) | ||
Married (N=41), n (%) | 21 (51) | ||
Household size (N=42), mean (SD) | 4.2 (1.3) | ||
BMIa (N=48), mean (SD) | 36.5 (8.0) | ||
Non-Hispanic black | 25 (52) | ||
Hispanic | 6 (13) | ||
Non-Hispanic white | 9 (19) | ||
Pacific Islander | 1 (2) | ||
Other | 5 (10) | ||
Declined | 2 (4) | ||
Age (N=48), mean (SD) | 10.0 (3.4) | ||
Female | 27 (56) | ||
BMI (N=48), mean (SD) | 29.8 (7.9) |
aBMI: body mass index.
Proportion of participants with a complete tracking week as measured by a completed IVR call or SMS text message, by study week (N=48). IVR: interactive voice response; SMS: short message service.
The percent of tracking weeks completed was positively associated with education and income (
Proportion of participants with a complete tracking week as measured by a completed IVR call or SMS text messages, by study week and income level (N=38).
Proportion of participants with a complete tracking week as measured by a completed IVR call or SMS text message by study week and education level (N=37).
At the 6-month intervention completion point, weight was recorded from 54% (26/48) of the participants. Of those, 81% (21/26) were self-reported. There were no significant sociodemographic differences among those with a self-reported weight versus those who were missing weight measurements at 6 months. Those who reported weight at 6 months tracked significantly more weeks than those who did not report weight, 17.3 (SD 8.7) versus 11.0 (SD 10.4),
Change in weight among participants with complete pre and post weight data participating in a digital behavioral weight loss intervention (N=26).
These findings suggest that we can feasibly recruit and engage parents or guardians who are attending a pediatric weight management program for their child with obesity in a digital weight loss intervention. Almost half of the participants (23/48, 48%) were high engagers, tracking behaviors for 80% (19/24) or more study weeks. What is most notable about this study is the parent focus. We aimed to recruit a sample of parents who were interested in obesity treatment for their children, but what we found is that some parents did not engage in self-monitoring of behaviors that result in weight loss for themselves, despite presenting for treatment for their children. We were able to recruit and engage parents, but we had difficulties retaining them and asking them to complete study assessments for evaluation. However, our study did demonstrate favorable behavioral outcomes. Most of the participants who reported weight upon study completion experienced weight loss and found the intervention easy to participate in with accurate goals and helpful feedback. Although this study was not designed to establish efficacy, it is promising that among this group of participants with relatively high engagement, there was significant weight loss.
The results from the Families on Track study are similar to what we found in the Shape Plan trial, which aimed to test the feasibility of delivering daily SMS text messages tracking behavioral goals [
Our findings are comparable to reported engagement outcomes from other similar behavioral interventions using SMS text messaging or other digital health modalities. Among breast cancer survivors who were overweight and participated in a 10-week multifaceted mobile health study, engagement with SMS text messaging was 86% [
Studies show that mobile phones can be an effective tool in weight loss interventions, given the increased ease in self-monitoring behaviors compared with using typical paper logs [
Involving parents in weight-related behavior change interventions has demonstrated effectiveness in reducing child overweight or obesity [
Our study was not immune to the disparities or inequalities in engagement seen in other digital health interventions [
Limitations to our feasibility study include a small sample size and lack of a control group. We felt it would be difficult to withhold treatment from parents who are already presenting for their child’s treatment. An additional limitation is that parents or guardians that attend tertiary care clinics for their children may have different motivations, especially given they are presenting for their children and not themselves. Future studies are needed to assess true generalizability among parents within the general population and also within primary care clinics. Although the results of this study show promise having achieved high engagement, more research is needed to assess behavioral changes as a result of engagement in this population. A large limitation is that our weight change and qualitative user engagement data are not complete given the lack of returning clinic visits. We also collected postintervention weight primarily through self-report. As mentioned earlier, we provided this option because it was difficult to have participants return for assessment visits. This is likely because of the way the Healthy Lifestyle program is structured—children do not present for treatment often after the initial treatment is provided in the first month. It may be that parents were not interested in attending if their children were not attending for their own treatment. As a result, it is possible our results are biased toward a larger effect. However, previous evidence does suggest that self-reported weights provide a reasonably accurate measurement among adults [
In this feasibility study, we demonstrate that it is possible to engage parents or guardians of children with obesity in a digital weight loss intervention aimed at reducing parent weight. The digital intervention engaged a population of parents who are hard to reach through in-person visits and shows promise for reaching and engaging parents in future family-based obesity treatment interventions, an important aspect of intervention fidelity.
body mass index
Interactive Obesity Treatment Approach
interquartile range
interactive voice response
risk ratios
short message service
The authors acknowledge the Healthy Lifestyles clinic staff and research assistants, specifically Jacob Christy, for their help in completing this project.
GGB is on the Nutrisystem advisory board and has equity in Coeus Health, LLC.