Psychological Treatment Of Childhood Obesity: Main Principles And Pitfalls

ALSO AVAILABLE:

Author(s):

	Caroline Braet
	Caroline Braet, Ph.D., is a professor in the Department of Developmental, Personality, and Social Psychology at Ghent University in Belgium.
	View Author’s Full Biography

	Ellen Moens
	Ellen Moens graduated in July 1999 as a Clinical Psychologist at Ghent University (Ghent, Belgium).
	View Author’s Full Biography

	Julie Latomme
	Julie Latomme graduated in July 2014 as an Experimental Psychologist at Ghent University (Ghent, Belgium).
	View Author’s Full Biography

Before treatment can be initiated, as with all chronic diseases, a complete multidisciplinary evaluation of the patient is indicated. The recommendations for treatment will differ according the history, the degree of overweight, comorbidities and age (Hampl et al., 2023). First, based on the Cochrane review (Luttikhuis et al., 2009), for children under 8 years, treatment exclusively focuses on parents. From 8 years on, children can be involved in treatment although, until the age of 12, parents have to be considered as major agents of change. Next, comorbidities, history and degree of overweight should be evaluated (see also the assessment chapter in this ebook and Braet et al., 2014). When eating pathologies and/or emotional problems are detected during screening, individual care will be needed. For instance, dealing with binge eating episodes asks for a specialized care, combining two treatment protocols (see the binge eating chapter in this ebook). When the child suffers from severe depression or another serious mental psychopathology is detected, a redirection to mental health care will be necessary before working towards weight control. On the other hand, when no psychological contra-indicators are found, a multidisciplinary lifestyle program is indicated, specifically for children (8-12 years) with upcoming to moderate obesity and this will be conducted in an outpatient center with a standardized protocol to support a healthy lifestyle in long term. The number of sessions are recommended in Hampl et al. (2023). This can be in a group format and consists of a combination of nutritional, physical and psychological consults. We will discuss this program in detail. It is based on the work of Braet, Joossens, Mels,  Moens, & Tanghe, A. (2007). Table 1 gives an overview of all techniques. The program is well-evaluated till 8 years later (Moens et al., 2010). Of note, recently, Stasia Hadjiyannakis and her group (2016) published the Edmonton Obesity Staging System for pediatric obesity, which can be used as a handy tool to personalize the treatment according a child’s metabolic indicators, mental health factors and the social environment (Hadjiyannakis, et al., 2016).

Treating children with moderate obesity: main components and overview of interventions

Nutritional and physical activity advices.  The foundation of any treatment plan includes education about what constitutes a healthy lifestyle, with an emphasis on simple, sustainable changes. For instance, encouraging children to drink water during meals instead of sugary drinks, selecting low-fat food products, maintaining a structured eating pattern, having healthy snacks, and consuming a balanced breakfast are fundamental steps. These recommendations align with the guidelines set by various health authorities (American Academy of Pediatrics, see Hampl et al., 2023; U.S. Department of Health and Human Services, 2020;  the World Health Organization, WHO, 2022). Incorporating physical activity is another essential component of obesity management. Current guidelines recommend at least 60 minutes of low to moderate-intensity activities daily (CDC, 2023; WHO, 2020), such as walking, biking, swimming, or dancing. In addition to planned physical activities, simple lifestyle changes can significantly increase a child’s overall activity level. Examples include taking the stairs instead of the elevator, helping with household chores, or walking instead of driving short distances. These small yet impactful changes help children and their families to make physical activity a regular part of their daily routines. While these guidelines are primarily directed at children, it is beneficial when the entire family adopts these healthy habits, as it creates a supportive environment that encourages adherence to lifestyle changes (Tomayko et al., 2021). Finally, these nutritional, physical, and lifestyle changes should be translated into small, achievable treatment goals.

Cognitive behavioral strategies. According to clinical guidelines, the main components of a lifestyle program include always some crucial cognitive behavioral strategies: self-monitoring (completion of diet and/or physical activity records), stimulus control techniques (to reorganize the environment), problem solving techniques, goal setting and contingency management  (Bejarano,  et al., 2019; see also NICE, 2023). These interventions are aimed to support the main treatment goals: (1) to learn the child to self-regulate its behavior and to resist temptation; (2) the installation of a healthy lifestyle in the long-term.

The concept of self-monitoring refers to observing and tracking targeted behaviors and serves as a precondition for the execution of new adaptive behaviors (Kanfer, 1970). Therefore, diet, physical activity, and/or weight monitoring constitutes an essential component of many behavioral weight loss interventions (Greaves et al., 2012). Self-monitoring requires individuals to understand and be aware of their actions, which is the first crucial step for developing strong self-regulation skills (Burke et al., 2011). Dietary intake is one of the most common behaviors self-monitored in behavioral weight control treatment that predicts successful weight loss (Laitner et al., 2016; Peterson et al., 2014).  The patient keeps record of his eating and drinking behavior on a daily basis. This is an evaluation method but also has a therapeutic goal. It helps the patient to gain insight in his or her eating pattern and behavior, which is necessary to work towards self-control. This food diary will guide goal setting or initiate problem solving through the whole program and will be discussed in every session. In adults Burke et al. (2011) conducted a systematic review and found consistent, notable associations between self-monitoring and weight loss and more recently, Raber et al. (2021) found the majority of studies in adults using high- and low-intensity self-monitoring strategies demonstrated statistically significant weight loss in intervention groups compared with control groups. In a review of eHealth weight management interventions targeting young adults conducted by Willmott et al. (2019) all studies reporting positive weight-related outcomes implemented some form of self-monitoring (eg, frequent self-weighing, monitoring physical activity, or dietary intake). In children, Darling and Sato (2017) conducted a meta-analysis that focused only on mobile health technologies using self-monitoring for weight management finding small but significant effects on weight status and diet. Another meta-analysis among adolescents with Overweight/Obesity found internet-based self-monitoring to have a small impact on reducing adolescents’ BMI (Ho et al., 2018). In addition to conventional paper and pen methods, monitoring may now be performed on a variety of platforms including mobile apps and websites. Applications have been created to make recording intake theoretically easier for participants to achieve and to provide richer feedback data for users weight loss intervention. In particular, the use of technology for self-monitoring has been suggested as a way of lessening the burden of self-monitoring and enhancing adherence (Burke et al. 2011). In many cases they also offer the possibility of having reminders to motivate the users to stay on track and increase self-monitoring rates (Greaney et al. 2012).

Goal Setting. Managing nutritional and physical activity advices encompasses assessments focused on achievable steps (Gross et al., 2023). Each session encourages setting new, realistic goals, ensuring they are meaningful and attainable within a reasonable timeframe. This goal setting, as part of the CBT tools, involves also a contingency management plan (with small rewards) whereby the specific behavioral targets must be tailored to the individual’s needs and capabilities. Then, in order to enhance self-control, patients are empowered to set their own goals, track their dietary habits through food diaries, report their physical activities, evaluate their progress, and reinforce themselves with compliments for the positive changes. Meanwhile, children benefit from structured behavioral contracts with significant others that outlines clear goals and rewards for achieving progress designed to enhance motivation and adherence to healthier habits (Sagar and Gupta, 2018). By emphasizing practical, personalized goal-setting and reinforcement strategies, this approach supports sustainable lifestyle changes essential for effective weight management.

Another technique that has proven effective in treatment and is integral to cognitive behavioral approaches for addressing obesity is stimulus control. It aims to modify both internal and external cues associated with eating and exercising behaviors. Children and adolescents are taught to reshape their immediate environments, such as at home and school, to support behavioral changes (Butryn et al., 2011). For instance, patients are recommended to eat only at the kitchen table, store food in designated places, and/or follow fixed meal times. By following this guidelines, the association between cues and eating behaviors weakens over time, making it easier to resist unhealthy impulses. The environment greatly impacts children’s eating and activity patterns (Jelaian et al., 2009) and recent research identifies changes in the home food setting as pivotal in promoting child weight loss (Boutelle et al., 2021). For instance, access to fruits and vegetables increases their consumption, while the presence of outdoor play areas encourages physical activity (Spurrier et al., 2008). Conversely, availability of sugary drinks and sedentary activities, like computer games, at home fosters unhealthy habits (Spurrier et al., 2008). In this line, a recent systematic review highlighted environmental restructuring as a key component among six effective strategies for modifying physical activity and eating behaviors to prevent or manage childhood obesity (Martin et al., 2013). Therefore, creating an environment that supports healthy choices is crucial for combating childhood obesity. For example, encouraging outings to parks instead of malls can boost physical activity levels while reducing opportunities for unhealthy food consumption typically found in malls.

Like in other cognitive behavioral interventions, also in this program problem-solving skills are taught (from the age of 8). Problem-solving enables people to find effective solutions to everyday challenges (D’Zurilla and Goldfried, 1971) so they can adapt to changes and adjust their lifestyle. It is especially important for weight loss because it helps individuals to manage obstacles, like social situations and/or high-risk periods (e.g., holidays), and to prevent relapses. Studies show that people with obesity often struggle with problem solving, planning, and decision-making (Fitzpatrick et al., 2013). Those who successfully lose and keep off weight tend to use better problem-solving strategies, while those who regain weight often rely on less effective methods like avoidance or denial (Reyes et al., 2012). Training these skills helps to analyze difficult situations and formulate plans.

Using problem-solving includes the following 8 steps: maintaining a positive orientation towards the problem, defining the problem, brainstorming solutions, evaluating different alternatives, setting achievable goals, and trying out solutions through trial and error and always evaluate what went good or wrong. These steps of the problems solving skills training are guided by self-instructions that can be written on cue cards (to support the learning process). More advanced cognitive techniques are administered to identify and record thoughts and emotions related to eating and physical activity habits (Kang and Kwack, 2020). These thoughts and assumptions are challenged in order to formulate alternative (more helpful) cognitions. Some themes to be handled within the treatment of overweight are, dysfunctional thoughts on what and when to eat and not to eat (for instance ‘skipping breakfast is good’), on the ‘fake news’ (for instance realizing weight loss by severe restrained eating), on self-image (for instance only tall people are beautiful) and self-efficacy (for instance I’m too big, I must be lazy), and on weight loss expectations (for instance if I’m not losing 10 kg, I’m a looser) among others.

How to involve the parents

Because the home environment is the principal learning environment to establish a healthy lifestyle, several reviews plead for the involvement of parents in the treatment of obesity in children (Davison, Monocello, Lipsey & Wilfley, 2023; Halmp et al., 2023) . In 2012, Moens & Braet  evaluated a program in which parents were targeted as the exclusive agents of change. The program consists of 6 biweekly sessions in group format (Moens & Braet, 2012). The sessions are led by a dietician and a child psychologist. While the dietician gives nutritional advices, the psychologist supports behavioral change in the long term. Next to the above described cognitive behavioural techniques also parenting skills are included in this format. The ultimate goal is to install a supportive family climate in which all members follow the new healthy lifestyle. Therefore, parents have to be positively involved towards their children on the one hand, but also be structured and set boundaries on the other hand. The psychologist will focus on general parenting skills to guide this process in each family. Parents learn to observe their children and learn how they can teach their children to cope with problems, both for difficult eating situations (like birthday parties), physical activities (like it is dark outside or raining) as well as emotional situations (like coping with being bullied). These new parenting skills demand a lot of practice. In this context, working in groups is ideal and role play is  recommended in every session. Outcome evaluation showed a significant decrease in adjusted BMI over a 6-month period for the intervention group. Parents reported significant positive changes in children’s eating behaviour and a significant positive increase in familial health principles (see Moens & Braet, 2012). The review of Davison et al. (2023) concluded that a parent-only behavioral treatment can be considered as a ‘Well-established treatment’ for both children and adolescents with weight problems.

Pitfalls in the treatment of childhood obesity and how to overcome them

Although studies show positive outcomes in treating childhood obesity (see the systematic revies of Al‐Khudairy et al., 2017; Baygi et al., 2023; Mead et al., 2017), significant challenges continue to impede overall success. Firstly, despite the availability of effective interventions, low participation rates among families with overweight children remain a major obstacle, and the need to enhance engagement and participation has consistently been highlighted (Smith et al., 2020). For instance, in a study children who have lower levels of adherence to an obesity intervention program showed fewer improvements in their BMI, self-esteem, and eating habits (Hardy et al., 2015).

There can be practical barriers such as cost, distance, or scheduling (Dhaliwal et al., 2014; Staiano et al., 2017; Naets et al., 2020). However, low access to services can also be attributed to an underestimation of children’s overweight (Lydecker & Grillo, 2016), or to a general lack of awareness about the severity and long-term implications of childhood obesity (Lundahl et al., 2014; Vittrup et al., 2018), leading to fewer families seeking professional help. The limited recognition of obesity as an urgent health issue may explain why many parents do not seek therapeutic interventions for their children. The barriers in terms of the quality and transmission of information regarding obesity and the available services are very important (Naets et al., 2020). Moreover, the stigma associated with obesity and its treatments further discourages both children and parents from attending initial sessions (Kelleher et al., 2017; Wild et al., 2020).

Even when families do participate in treatment programs, maintaining engagement throughout the course of therapy remains a significant challenge and high dropout rates are a major concern, with some studies reporting alarming figures. For example, a review by Dhaliwal et al. (2014) indicated that up to 83% of those enrolled in lifestyle interventions for weight management dropped out prematurely. This high attrition rate severely diminishes the effectiveness of these interventions, making it essential to understand and address the underlying reasons for dropout. Additionally, not all children achieve the desired weight loss outcomes, with some experiencing minimal progress or even regaining weight over time (Butryn et al., 2011).

Therefore, identifying barriers and facilitators in the treatment of childhood obesity is crucial. However, individual and interpersonal factors contributing to adherence, maintenance and progress in pediatric obesity interventions remain poorly understood, presenting an ongoing challenge for researchers and clinicians (Rojo et al., 2022; Spence et al., 2017) and even less is known about ways to address them.

Regarding individual factors, research has shown that a higher Body Mass Index (BMI) and weight-related health problems increase the likelihood of a patient discontinuing treatment (Skelton & Beech, 2011).As the APA suggests, we must offer patients older then 12 with a high Body Mass Index (BMI) alternative treatments like medication (Halmp et al., 2023).  This is important as unrealistic weight goals and low self-efficacy can significantly affect behaviors related to weight maintenance and the risk of relapse (Byrne et al., 2002). This finding is consistent with another review that highlights factors like low self-efficacy or motivation (often due to a history of failed weight loss attempts) as obstacles to successful weight loss (Teixeira et al., 2005). A lack of motivation and perceived lack of progress in adolescents also play a role (Dhaliwal, 2017; Naets et al., 2020).  The perception of costs, the fear, or lack of desire of changing to healthy lifestyle are some key themes (Staniford et al., 2018). These cognitive and behavioral challenges can hinder a child’s ability to adhere to treatment plans and make lasting lifestyle changes. Besides, this subgroup also suffers from cognitive control skills:  Van Egmond-Froehlich et al. (2013) found that lower levels of attention and higher levels of hyperactivity or impulsivity in adolescents are linked to less long-term success following residential treatment.

Furthermore, the effectiveness of obesity treatment in children and adolescents is greatly influenced by family factors. Children from families where both parents have weight problems tend to fare worse in treatment (Fassihi et al., 2012). Caregivers’ lack of readiness and motivation to make lifestyle changes (Dhaliwal et al., 2014) and problems with setting limits for children and with role modeling behavioral changes (Silver & Croning, 2019) also serve as barriers to care. A perceived lack of family support has been cited in some cases as a reason for discontinuing treatment (Dhaliwal et al., 2017) and lower family functioning has shown to be significantly associated with higher odds for early and late dropouts (Park et al., 2020). On the other hand, a higher self-assessed health status of the family system is associated with lower short-term dropout rates, and greater parental involvement in intervention sessions correlates with lower long-term dropout rates (Spence et al., 2017). Family factors, such as social support, positive reinforcement in parenting, and increased parental involvement during treatment, are key to the effectiveness of childhood obesity interventions (Cislak et al., 2012; Niemeier et al., 2012; Staniford et al., 2018). Adolescents who place a high value on family support could be more likely to remain in treatment (Rhodes et al., 2017). Parental concern for a child’s psychological well-being is crucial, as parents are the primary decision-makers regarding whether their family will participate in a childhood weight management program (Kelleher et al., 2017).

Addressing these challenges is essential for improving treatment adherence and overall success, underscoring the need for tailored strategies that consider the individual’s psychological and behavioral profile. This concern has led researchers to investigate drop out in the treatment of obesity. Braet and colleagues (2010) examined all forms of drop-out, also when the drop-out took place before or during the diagnostic screening phase. Out of the 117 notifications during that year – apart from 9 study refusals, i.e. people who did not want to take part in the study – 36 patients did not qualify for the treatment because they did not meet the inclusion criteria of the clinic (weight criterion, language, or living at too long a distance of the hospital). Another 24 patients did not start with the treatment, even though they were eligible (they did not longer show up during or after the first intake session). Thus, 48 people eventually started with the treatment, of which 38 completed treatment (Jeannin et al., 2010).  Based on clinical experiences and funded within scientific insights into predictors of treatment failure, factors that are associated with failures will be discussed and how to overcome them.

Realistic expectations about the treatment goals

Jeffery et al. (2000) showed that patients with a more realistic expectation had a better likelihood of reaching their goals. With realistic expectations in an outpatient setting, it is meant that children accomplish weight control (and thus that they don’t gain weight) and that they adhere to lifestyle adjustments despite public opinion, which persists in believing in crash diets and ‘slimming 20 kg in 10 weeks’. Indeed, a strong anti-diet movement arose in the academic world since the publication of Wilson (1994). Caloric restriction upset the metabolism and cause the body to switch to a lower usage, whereby after an initial weight loss during the diet, the  patient with obesity gains weight even faster when resuming his initial eating pattern (Hawks, Madanat & Christley, 2008).

For people who ask for assistance and immediately want to see big changes, realistic weight goals are disappointing. A second problem is that they often minimize the risks of their overweight. Some patients choose to ‘wait’ until they qualify for a third line care like for example inpatient treatment or bariatric surgery. The consequence of this is that people drop out soon after they heard the realistic rationale of outpatient treatment. Here, motivational interviews are indicated.

Good communication about the rational of the treatment

A good treatment includes a ‘paradigm shift’, where the focus is no longer on weight loss, but on behavioral change. Therapists should be trained in good communication of this rationale. An example:

‘Because drastic diets and weight loss do not guarantee long-term success, our aim is to narrow the medical risks that has been shown to decrease when adopting a healthier lifestyle. In other words, our treatment goal mainly comprises lifestyle adjustments. Only ambulatory programs that strive for achievable goals in the area of health, by following the national recommendations for diet and exercise, are acceptable. These are currently included in all guidelines for a good evidence-based obesity treatment. This treatment consists of multiple weekly sessions with a gradual lifestyle modification. This leads to weight control or to limited weight loss, with an acceptable maximum decrease of 10 – 15% of your adjusted BMI  over a period of one year (because you are growing the calculated BMI can change). This rationale of weight control goes for about 90% of all  patients with obesity seeking for help for the first time. This means that children with obesity problems always will have some overweight, but that this overweight no longer increases and the health risks decline significantly.’

Time should be spent on good communication and challenging the patient’s cognitions on the pros and cons of weight control via cognitive behavioral techniques.

Promoting a supportive network

Recent studies highlight the criticial role of social support in the treatment of childhood obesity, emphasizing the importance not only from parents and friends but also from healthcare providers. When children are asked about their motivation to lose weight and maintain behavioral changes, they often cite  emotional support and their parents’ recognition of the problem as most important (Murtagh et al., 2006). Parental involvement and support are key elements in the effectiveness of childhood obesity interventions (Cislak et al., 2012; Niemeier et al., 2012; Staniford et al., 2018).  However, parents are often insufficiently involved in the treatment process, which can hinder its long-term success. Greater parental involvement in treatment correlates with continued engagement and lower long-term dropout rates (Spence et al., 2017). Introducing digital tools to support parents could help them become more engaged in the treatment process, thereby improving overall outcomes (Desmet et al., 2024). Therefore, the motivation of younger patients should always be considered in relation to the collaboration and support of their family members. Additionally, support from friends and peers influences treatment outcomes (Sampat et al., 2014). Promoting not only parental support but also the support of friends and peers is essential. Lastly, by creating a safe and supportive environment, healthcare providers empower children and their families to make sustainable lifestyle changes, ultimately leading to more successful treatment outcomes.

Build in extra motivational techniques

It is important to invest in motivating the patient and his environment and in keeping them motivated in the initial stages of a treatment. This is certainly the case for patients who have (repeatedly) attempted and failed treatment before (Texeira et al., 2005). This calls for the introduction of a motivational stage, where, besides paying attention to problem insight, the focus lies on increasing the patient’s self-efficacy.

Whether someone is sufficiently motivated, can be tested in different ways. For example, carefully filling in a food diary, is a good indicator. Research showed that a simple checklist completed by the treatment team is also a good predictor of the treatment result (Braet et al., 2010). For this, the entire team can be asked by default to make a prediction about the treatment result, based on a Visual Analogue Scale. When several team members fill in an unfavorable prediction, it can be decided to start with focusing on the motivation. Useful motivational techniques are: the cost-benefit analysis, value-directed working, future-oriented writing and the motivational interview.

For instance, the cost-benefit analysis includes that two columns are constructed: a column with the advantages and one with the disadvantages of the weight loss. While focusing on the desired effect, the column with benefits offers a list of motivators, such as ‘feeling fitter’, ‘having more energy’, ‘choosing nice clothes’, while the column with disadvantages offers a list with pitfalls, such as ‘no longer being able to eat what I want’, ‘difficult to sustain’. If necessary, a weight factor can be assigned to each argument. Next, it’s investigated whether the disadvantages of the persistent complaints are in proportion to the benefits of losing weight. This technique can be applied in children from 8 years of age.

Correct evaluation of the severity of the weight problem and comorbid problems

Correct evaluation of the severity of the weight problem, along with any associated comorbidities, is crucial in the management and treatment of pediatric obesity. Accurate assessment ensures that healthcare providers can tailor interventions to meet the specific needs of the patient, addressing both the physical and psychological aspects of obesity.

One important aspect of this evaluation is the use of comprehensive staging systems, such as the Edmonton Obesity Staging System for Pediatrics (EOSS-P), which goes beyond traditional measures like BMI (Hadjiyannakis et al., 2016). The EOSS-P stratifies patients based on the severity of their obesity-related health conditions and obstacles to weight management across four domains: metabolic, mechanical, mental health, and social milieu. Each domain assesses different aspects of the child’s health:

• Metabolic: Evaluates the presence of metabolic conditions like prediabetes or lipid abnormalities.
• Mechanical: Assesses physical complications such as joint pain or sleep apnea.
• Mental Health: Considers the psychological impact of obesity, including conditions like depression or low self-esteem.
• Social Milieu: Looks at the social environment, including factors like bullying or socio-economic barriers to health improvement.

Using the EOSS-P to assess the severity of the problem allows for a more nuanced understanding of the child’s overall health, guiding more effective and individualized treatment plans (Hadjiyannakis et al., 2016).

Early detection and management of comorbidities on different domains can prevent further health deterioration and improve long-term outcomes (see also: Braet et al., 2014). Therefore, a thorough and multidimensional assessment is key to the successful treatment of pediatric obesity, ensuring that both the weight problem and its related health issues are effectively managed.

Psychiatric co-morbidity demands careful evaluation and selection of which disorder has to be treated first.

When treating childhood obesity, careful evaluation of psychiatric co-morbidities is essential. In general, consistent findings have established that childhood obesity is linked with psychological comorbidities, especially with binge eating and depression and anxiety (Smith & Mason, 2022) but also with poorer perceived quality of life, low self-esteem and other emotional and behavioral disorders (Rankin et al. 2016). However, obesity and comorbid psychiatric disorders often go unaddressed in pediatric obesity centers (Panzer et al., 2012). Determining which psychiatric disorder should be addressed first can significantly impact the effectiveness of the treatment. It is important to distinguish between general mental health issues and specific psychiatric diagnoses, such as anxiety disorders, depression, or eating disorders. A comprehensive clinical interview can help identify whether a DSM diagnosis is appropriate.

Research by Braet (2006) indicates that the presence of an eating pathology in children before starting a residential obesity treatment can negatively affect weight loss outcomes two years later. Additionally, it was found that the presence of psychiatric disorders enhances the risk of drop out (Baimeister & Heatherton, 1996) and children with obesity-related health conditions and comorbid psychiatric diagnoses have higher healthcare utilization and costs (Janicke et al., 2009).

At the same time, it is crucial to recognize the limitations of psychiatric labeling in children and adolescents. Rather than focusing solely on categorical diagnoses, psychological assessments should describe symptoms along a dimensional continuum, emphasizing their impact on daily functioning. For instance, if a child struggles to attend school, engage in leisure activities, or interact appropriately with others, it may indicate more severe psychological impairment that requires consideration and possibly psychiatric intervention.

The relationship between obesity and psychiatric disorders is intricate and dynamic, with ongoing research exploring this interplay (Kang & Kwack, 2020; Rankin et al. 2016). For example, binge eating  (see the chapter of Binge Eating) may either precede or result from weight issues, potentially linked to depressive symptoms or ineffective dieting strategies. When binge eating disorder is diagnosed, it is important to evaluate whether addressing these eating problems should take precedence or occur simultaneously with weight management efforts. This also suggests that for adolescents, it may be beneficial to initiate targeted treatment for eating disorders either before or concurrently with the weight loss program.

A need for multifaceted treatment strategies that address both obesity and mental health issues in children is emphasized (Small & Aplasca, 2016). A study suggests that children with psychological disorders may benefit from receiving both obesity and mental health treatment in a coordinated manner. Specifically, it was found that treating these conditions at the same outpatient clinic could be a success factor, as it facilitated a comprehensive approach to both issues (Danielsson et al., 2016). Addressing these co-occurring issues in a timely manner can enhance overall treatment efficacy and support long-term success (Kang & Kwack, 2020). There are several common elements between approaches to managing childhood obesity and mental health concerns (Small & Aplasca, 2016). For instance, a recent study by O’Hara et al. (2020) highlights that considering the shared mechanisms between pediatric obesity and ADHD may lead to interventions that benefit both disorders simultaneously. This multidisciplinary approach suggests that providers should collaborate in implementing shared assessment and treatment strategies for co-occurring conditions, thereby improving health outcomes and coordination in the management of these complex diagnoses.

Estimating the patients’ strength

Review studies on successful behavior change in obesity interventions in adults show that strong self-regulation skills are the best predictors of beneficial weight and health outcomes (Texeira et al., 2015).  Already in 1996, Baumeister and Heatherton (1996) introduced a strength model in which impulse control is a resource that can diminish and be amplified again. However, this ‘amplification’ becomes more difficult when the person faces a lot of burden, such as an accumulation of stress factors. Several studies have demonstrated that in families with obesity problems, there is more stress (Wojcik et al., 2023). These stress factors are not only situated on a familial level, but also on a broader socio-economical and environmental-societal level. These factors result in a burden for families, diminishing their strengths and therefore stress represents an important pitfall for treatment. Based on the strengths model, failure can be seen as a consequence of demanding too much: the system is overloaded (Kazdin, 1996). In order to prevent failure, it is important to screen a family’s resilience to start an intervention for overweight. Questionnaires as the Barriers to Treatment Participation Scale (BTPS, Kazdin et al., 1997) can help to gain insight. -The items of the BTPS were grouped in four categories: stressors and practical obstacles that make treatment more difficult, problems with demands within treatment, observed importance of treatment, and problems within the therapeutic relationship. This list might reveal a lot of important information for the therapist with regard to the resilience versus the burden of an individual patient and his environment.

Conclusion

The benefits of a multidisciplinary approach for overweight children focusing on a healthy life style instead of on very strict diets are well established. Lifestyle interventions with cognitive behavioural modification procedures support behavioural change in the long term. However, important pitfalls in the treatment need to be considered. Relapse and drop out rates are probably highest in the treatment of obesity.

There are several reasons to keep considering processes and reasons that can explain failure in obesity treatment. One reason is that treatment failure leads to feelings of personal failure, both in patients as therapists. Moreover, there are also economical reasons. A patient who drops out, remains a risk patient who needs more medical care. They often return to health care at a later time, which doubles (or even multiplies) the costs to healthcare. On top of that, it affects the efficiency of healthcare because when people do not come to their appointment, they hinder others to come. As such, “waiting time” is not used efficiently in this way. A better insight in these reasons can lead to new interventions to increase attrition to therapy and to advance (cost) efficiency of the treatment. On the other hand, it might help put negative feelings as result of drop out into perspective, making obstacles for treatment more discussable.

References

Al‐Khudairy, L., Loveman, E., Colquitt, J. L., Mead, E., Johnson, R. E., Fraser, H., Olajide, J., Murphy, M., Velho, R. M., O’Malley, C., Azevedo, L. B., Ells, L. J., Metzendorf, M. I., & Rees, K. (2017). Diet, physical activity and behavioural interventions for the treatment of overweight or obese adolescents aged 12 to 17 years. Cochrane Database of Systematic Reviews, 2017(6), CD012691. https://doi.org/10.1002/14651858.CD012691

Baumeister, R. F., & Heatherton, T. F. (1996). Self-regulation failure: An overview. Psychological Inquiry, 7(1), 1-15. https://doi.org/10.1207/s15327965pli0701_1

Baygi, F., Djalalinia, S., Qorbani, M., Sonderlund, A. L., Andersen, M. K. K., Thilsing, T., Heitmann, B. L. & Nielsen, J. B. (2023). The effect of psychological interventions targeting overweight and obesity in school-aged children: A systematic review and meta-analysis. BMC Public Health, 23(1), 1478. https://doi.org/10.1186/s12889-023-16339-7

Bejarano, C. M., Marker, A. M., & Cushing, C. C. (2019). Cognitive-Behavioral Therapy for Pediatric Obesity. Handbook of Cognitive Behavioral Therapy for Pediatric Medical Conditions, Springer. https://doi.org/10.1007/978-3-030-21683-2_23

Boutelle, K. N., Kang Sim, D. E., Rhee, K. E., Manzano, M., & Strong, D. R. (2021). Family-based treatment program contributors to child weight loss. International Journal of Obesity, 45(1), 77-83. https://doi.org/10.1038/s41366-020-0604-9

Braet, C., Jeannin, R., Mels, S., Moens, E., & Van Winckel, M. (2010). Ending prematurely a weight loss program: The impact of child and family characteristics. Clinical Psychology & Psychotherapy, 17, 406-417. https://doi.org/10.1002/cpp.663

Braet, C., Joossens, L., Moens, E., Mels, S., & Tanghe, A. (2007). Kinderen en jongeren met overgewicht. Handleiding voor begeleiders. Garant.

Braet, C., O. Malley, G., Weghuber, D., Vania, A., A., Erhardt, E., Nowicka, P., Mazur, A., Frelut, M.L., & Ardelt-Gattinger, E (2014). The Assessment of Eating Behaviour in Children who are Obese: A Psychological Approach. A Position Paper from the European Childhood Obesity Group. Obesity Facts, 7,153-16. https://doi.org/10.1159/000362391

Braet, C. (2006). Patient characteristics as predictors of weight loss after an obesity treatment for children. Obesity, 14(1), 148-155. https://doi.org/10.1038/oby.2006.18

Burke, L. E., Wang, J., & Sevick, M. A. (2011). Self-monitoring in weight loss: A systematic review of the literature. Journal of the Academy of Nutrition and Dietetics, 111(1), 92-102. https://doi.org/10.1016/j.jada.2010.10.008

Butryn, M. L., Wadden, T. A., Rukstalis, M. R., Bishop-Gilyard, C., Xanthopoulos, M. S., Louden, D., & Berkowitz, R. I. (2010). Maintenance of weight loss in adolescents: Current status and future directions. Journal of Obesity, 2010(1), 789280. https://doi.org/10.1155/2010/789280

Butryn, M. L., Webb, V., & Wadden, T. A. (2011). Behavioral treatment of obesity. Psychiatric Clinics, 34(4), 841-859. https://doi.org/10.1016/j.psc.2011.08.006

Byrne, S. M. (2002). Psychological aspects of weight maintenance and relapse in obesity. Journal of Psychosomatic Research, 53(4), 1029-1036. https://doi.org/10.1016/S0022-3999(02)00487-7

Centers for Disease Control and Prevention (CDC). (2023). Physical Activity Basics: Guidelines for Children and Adolescents. Retrieved from https://www.cdc.gov/physicalactivity/basics/children.html

Cislak, A., Safron, M., Pratt, M., Gaspar, T., & Luszczynska, A. (2012). Family-related predictors of body weight and weight-related behaviors among children and adolescents: A systematic umbrella review. Child Care Health and Development, 38(3), 321-331. https://doi.org/10.1111/j.1365-2214.2011.01285.x

Claes, L., Jeannin, R., & Braet, C. (2022). Obesity: etiology, assessment & treatment. In Comprehensive clinical psychology: volume 8 (pp. 388-405). Elsevier. https://doi.org/10.1016/B978-0-12-818697-8.00124-2

Danielsson, P., Bohlin, A., Bendito, A., Svensson, A., & Klaesson, S. (2016). Five-year outpatient programme that provided children with continuous behavioural obesity treatment enjoyed high success rate. Acta Paediatrica, 105(10), 1181-1190. https://doi.org/10.1111/apa.13360

Davison, K. K., & Birch, L. L. (2001). Childhood overweight: a contextual model and recommendations for future research. Obesity reviews, 2(3), 159-171. https://doi.org/10.1046/j.1467-789x.2001.00036.x

Davison, G.M., Monocello, L.T., Lipsey, K. & Wilfley, D.E. (2023). Evidence base update on behavioral treatments for overweight and obesity in children and adolescents. Journal of Clinical Child & Adolescent Psychology, 52:5, 589-603. https://doi.org/10.1080/15374416.2023.2251164

Darling, K. E., & Sato, A. F. (2017). Systematic review and meta-analysis examining the effectiveness of mobile health technologies in using self-monitoring for pediatric weight management. Childhood Obesity, 13(5), 347-355. https://doi.org/10.1089/chi.2017.0038

Desmet, M., Naets, T., & Braet, C. (2024). Can we do more? The importance and pitfalls of implementing digital tools in the treatment of childhood obesity. Annals of Nutrition and Metabolism, 1-8. https://doi.org/10.1159/000541203

Dhaliwal, J., Nosworthy, N. M., Holt, N. L., Zwaigenbaum, L., Avis, J. L., Rasquinha, A., & Ball, G. D. C. (2014). Attrition and the management of pediatric obesity: An integrative review. Childhood Obesity, 10(6), 461-473. https://doi.org/10.1089/chi.2014.0060

Dhaliwal, J., Perez, A. J., Holt, N. L., Gokiert, R., Chanoine, J. P., Morrison, K. M., Legault, L. & Ball, G. D. C. (2017). Why do parents discontinue health services for managing paediatric obesity? A multi-centre, qualitative study. Obesity Research & Clinical Practice, 11(3), 335-343. https://doi.org/10.1016/j.orcp.2016.10.285

D’Zurilla, T. J., & Goldfried, M. R. (1971). Problem solving and behavior modification. Journal of Abnormal Psychology, 78(1), 107−126. https://doi.org/10.1037/h0031360

Fassihi, M., McElhone, S., Feltbower, R., & Rudolf, M. (2012). Which factors predict unsuccessful outcome in a weight management intervention for obese children? Journal of Human Nutrition and Dietetics, 25(5), 453-459. https://doi.org/10.1111/j.1365-277X.2012.01246.x

Fitzpatrick, S., Gilbert, S., & Serpell, L. (2013). Systematic review: Are overweight and obese individuals impaired on behavioural tasks of executive functioning? Neuropsychology Review, 23(2), 138-156. https://doi.org/10.1007/s11065-013-9224-7

Greaney, M. L., Sprunck-Harrild, K., Bennett, G. G., Puleo, E., Haines, J., Viswanath, K. V., & Emmons, K. M. (2012). Use of email and telephone prompts to increase self-monitoring in a Web-based intervention: Randomized controlled trial. Journal of Medical Internet Research, 14(4), e96. https://doi.org/10.2196/jmir.1981

Greaves, C. J., Sheppard, K. E., Abraham, C., Hardeman, W., Roden, M., Evans, P. H., Schwarz, P., & IMAGE Study Group. (2011). Systematic review of reviews of intervention components associated with increased effectiveness in dietary and physical activity interventions. BMC Public Health, 11, 1-12. https://doi.org/10.1186/1471-2458-11-119

Gross, A. C., & Nurmi, E. L. (2023). Behavioral treatment and psychological complications of pediatric obesity. In C. K. Fox (Ed.) Managing Pediatric Obesity Using Advanced Therapies: Practical Guide for Pediatric Health Care Providers (pp. 245-272). Springer International Publishing. https://doi.org/10.1007/978-3-031-37380-0_8

Hadjiyannakis, S., Buchholz, A., Chanoine, J. P., Jetha, M. M., Gaboury, L., Hamilton, J., … & Ball, G. D. (2016). The Edmonton Obesity Staging System for Pediatrics: a proposed clinical staging system for paediatric obesity. Paediatrics & child health, 21(1), 21-26. https://doi.org/10.1093/pch/21.1.21

Hanssen, H., Moholdt, T., Bahls, M., Biffi, A., Siegrist, M., Lewandowski, A. J., … & Tiberi, M. (2023). Lifestyle interventions to change trajectories of obesity-related cardiovascular risk from childhood onset to manifestation in adulthood: a joint scientific statement of the task force for childhood health of the European Association of Preventive Cardiology and the European Childhood Obesity Group. European Journal of Preventive Cardiology, 30(14), 1462-1472. https://doi.org/10.1093/eurjpc/zwad152

Hampi et al. (2023). Executive summary: Clinical practice guideline for the evaluation and treatment of children and adolescents with obesity. Pediatrics, 151 (2): e2022060641. https://doi.org/10.1542/peds.2022-06064

Hardy, L. L., Mihrshahi, S., Gale, J., Nguyen, B., Baur, L. A., & O’Hara, B. J. (2015). Translational research: Are community-based child obesity treatment programs scalable? BMC Public Health, 15, 1-8. https://doi.org/10.1186/s12889-015-2031-8

Hawks, S., Madanat, H. & Christley, H. (2008) Behavioral and biological associations of dietary restraint: A review of the literature. Ecology of Food and Nutrition, 47: 415-449. https://doi.org/10.1080/03670240701821444

Ho, T. J. H., Lee, C. C. S., Wong, S. N., & Lau, Y. (2018). Internet-based self-monitoring interventions for overweight and obese adolescents: A systematic review and meta-analysis. International Journal of Medical Informatics, 120, 20-30. https://doi.org/10.1016/j.ijmedinf.2018.09.019

Janicke, D. M., Harman, J. S., Kelleher, K. J., & Zhang, J. (2009). The association of psychiatric diagnoses, health service use, and expenditures in children with obesity-related health conditions. Journal of Pediatric Psychology, 34(1), 79-88. https://doi.org/10.1093/jpepsy/jsn051

Jeannin, R., Braet, C., Mels, S., Moens, E., & Van Winckel, M. (2010). Drop-out bij de behandeling van kinderen met overgewicht. Tijdschrift Klinische Psychologie, 40(4), 272-283.

Jeffery, R. W., Epstein, L. H., Wilson, G. T., Drewnowski, A., Stunkard, A. J., & Wing, R. R. (2000). Long-term maintenance of weight loss: current status. Health psychology, 19(1S), 5. https://doi.org/10.1037/0278-6133.19.Suppl1.5

Jelalian, E., & Hart, C. N. (2009). Pediatric obesity. In M. C. Roberts & R. G. Steele (Eds.), Handbook of Pediatric Psychology (4th ed., pp. 446-463). Guilford Press.

Kanfer, F. H. (1970). Self-monitoring: Methodological limitations and clinical applications. Journal of Consulting and Clinical Psychology, 35(2), 5-11. https://doi.org/10.1037/h0029874

Kang, N. R., & Kwack, Y. S. (2020). An update on mental health problems and cognitive behavioral therapy in pediatric obesity. Pediatric Gastroenterology, Hepatology & Nutrition, 23(1), 15-24. https://doi.org/10.5223/pghn.2020.23.1.15

Kazdin A.E. (1996). Dropping out of child psychotherapy: Issues for research and implications for practice. Clin Child Psychol Psy; 1: 133-156. https://doi.org/10.1177/1359104596011012

Kazdin, A.E., Holland, L., Crowley, M. & Breton, S. (1997). Barriers to treatment participation scale: Evaluation and validation in the context of child outpatient treatment. Journal of Child Psychology &  Psychiatry ; 38: 1051-1062.  https://doi.org/10.1111/j.1469-7610.1997.tb01621.x

Kelleher, E., Davoren, M. P., Harrington, J. M., Shiely, F., Perry, I. J., & McHugh, S. M. (2017). Barriers and facilitators to initial and continued attendance at community-based lifestyle programmes among families of overweight and obese children: A systematic review. Obesity Reviews, 18(2), 183-194. https://doi.org/10.1111/obr.12478

Laitner, M. H., Minski, S. A., & Perri, M. G. (2016). The role of self-monitoring in the maintenance of weight loss success. Eating Behaviors, 21, 193-197. https://doi.org/10.1016/j.eatbeh.2016.03.005

Lundahl, A., Kidwell, K. M., & Nelson, T. D. (2014). Parental underestimates of child weight: A meta-analysis. Pediatrics, 133(3), e689-e703. https://doi.org/10.1542/peds.2013-2690

Luttikhuis, H. O., Baur, L., Jansen, H., Shrewsbury, V. A., O’Malley, C., & Stolk, R. P. (2009). Interventions for treating obesity in children. Cochrane database of systematic reviews, 3, 1-57. https://doi.org/10.1590/S1516-31802009000500015

Lydecker, J. A., & Grilo, C. M. (2016). The apple of their eye: Attitudinal and behavioral correlates of parents’ perceptions of child obesity. Obesity, 24(5), 1124-1131. https://doi.org/10.1002/oby.21439

Martin, J., Chater, A., & Lorencatto, F. (2013). Effective behaviour change techniques in the prevention and management of childhood obesity. International Journal of Obesity, 37(10), 1287-1294. https://doi.org/10.1038/ijo.2013.107

Mead, E., Brown, T., Rees, K., Azevedo, L. B., Whittaker, V., Jones, D., Olajide, J., Mainardi, G. M., Corpeleijn, E., O’Malley, C., Beardsmore, E., Al‐Khudairy, L., Baur, L., Metzendorf, M. I., Demaio, A., & Ells, L. J. (2017). Diet, physical activity and behavioural interventions for the treatment of overweight or obese children from the age of 6 to 11 years. Cochrane Database of Systematic Reviews, 2017(6), CD012651. https://doi.org/10.1002/14651858.CD012651

Moens, E., Braet, C., & Van Winckel, M. (2010). An 8-year follow-up of treated obese children: children’s, process and parental predictors of successful outcome. Behaviour research and therapy, 48(7), 626-633. https://doi.org/10.1016/j.brat.2010.03.015

Moens, E. & Braet, c. (2012). Training parents of overweight children in parenting skills: a 12-month evaluation. Behavioral Cognitive Psychotherapy, 40 (1): 1-18. https://doi.org/10.1017/S1352465811000403

Murtagh, J., Dixey, R., & Rudolf, M. (2006). A qualitative investigation into the levers and barriers to weight loss in children: opinions of obese children. Archives of disease in childhood, 91(11), 920-923. https://doi.org/10.1136/adc.2005.085712

Naets, T., Vervoort, L., Tanghe, A., & Braet, C. (2020). Adherence and Barriers in E-Health Self-Control Training for Enhancing Childhood Multidisciplinary Obesity Treatment. Clinical Psychology & Psychotherapy, 27, 42-51. https://doi.org/10.1002/cpp.2405

National Institute for Health and Care Excellence. (2014). Obesity: Identification, assessment and management. Clinical guideline . Last updated July 2023. Retrieved from https://www.nice.org.uk/guidance/cg189

Niemeier, B. S., Hektner, J. M., & Enger, K. B. (2012). Parent participation in weight-related health interventions for children and adolescents: A systematic review and meta-analysis. Preventive Medicine, 55(1), 3-13. https://doi.org/10.1016/j.ypmed.2012.04.021

O’Hara, V. M., Curran, J. L., & Browne, N. T. (2020). The co-occurrence of pediatric obesity and ADHD: An understanding of shared pathophysiology and implications for collaborative management. Current Obesity Reports, 9(4), 451-461. https://doi.org/10.1007/s13679-020-00410-0

Panzer, B. M., Dhuper, S., & Gupta, N. (2012). Obesity and the dual diagnosis child: Exploring the dynamics of comorbid psychiatric disorders. Infant, Child, & Adolescent Nutrition, 4(5), 310-314. https://doi.org/10.1177/1941406412456206

Park, J., Woo, S., Ju, Y. S., Seo, Y. G., Lim, H. J., Kim, Y. M., Noh, H. M., Lee, H. J., Park, S. I., & Park, K. H. (2020). Factors associated with dropout in a lifestyle modification program for weight management in children and adolescents. Obesity Research & Clinical Practice, 14(6), 566-572. https://doi.org/10.1016/j.orcp.2020.09.002

Peterson, N. D., Middleton, K. R., Nackers, L. M., Medina, K. E., Milsom, V. A., & Perri, M. G. (2014). Dietary self‐monitoring and long‐term success with weight management. Obesity, 22(9), 1962-1967. https://doi.org/10.1002/oby.20807

Raber, M., Liao, Y., Rara, A., Schembre, S. M., Krause, K. J., Strong, L., Daniel-MacDougall, C., & Basen-Engquist, K. (2021). A systematic review of the use of dietary self-monitoring in behavioural weight loss interventions: Delivery, intensity and effectiveness. Public Health Nutrition, 24(17), 5885-5913. https://doi.org/10.1017/S136898002100358X

Rankin, J., Matthews, L., Cobley, S., Han, A., Sanders, R., Wiltshire, H. D., & Baker, J. S. (2016). Psychological consequences of childhood obesity: Psychiatric comorbidity and prevention. Adolescent Health, Medicine and Therapeutics, 125-146. https://doi.org/10.2147/AHMT.S101631

Reyes, N. R., Oliver, T. L., Klotz, A. A., LaGrotte, C. A., Vander Veur, S. S., Virus, A., Bailer, B. A., & Foster, G. D. (2012). Similarities and differences between weight loss maintainers and regainers: A qualitative analysis. Journal of the Academy of Nutrition and Dietetics, 112(4), 499-505. https://doi.org/10.1016/j.jand.2011.11.014

Rhodes, E. T., Boles, R. E., Chin, K., Christison, A., Testa, E. G., Guion, K., Hawkins, M. J., Petty, C. R., Gaffka, B. S., Santos, M., Shaffer, L., Tucker, J., & Hampl, S. E. (2017). Expectations for treatment in pediatric weight management and relationship to attrition. Childhood Obesity, 13(2), 120-127. https://doi.org/10.1089/chi.2016.0215

Rojo, M., Lacruz, T., Solano, S., Gutiérrez, A., Beltrán‐Garrayo, L., Veiga, O. L., Graell, M., & Sepúlveda, A. R. (2022). Family‐reported barriers and predictors of short‐term attendance in a multidisciplinary intervention for managing childhood obesity: A psycho‐family‐system based randomised controlled trial (ENTREN‐F). European Eating Disorders Review, 30(6), 746-759. https://doi.org/10.1002/erv.2913

Sagar, R., & Gupta, T. (2018). Psychological aspects of obesity in children and adolescents. The Indian Journal of Pediatrics, 85(7), 554-559. https://doi.org/10.1007/s12098-017-2539-2

Sampat, S., Kirschenbaum, D. S., Gierut, K. J., Germann, J. N., & Krawczyk, R. (2014). Ya gotta have friends: social support and self‐efficacy predict success following immersion treatment. Obesity, 22(12), 2579-2585. https://doi.org/10.1002/oby.20863

Silver, M. P., & Cronin, S. M. (2019). Health care providers’ perspectives on family compliance and behavior change in a childhood obesity program. Health Education & Behavior, 46(4), 582-591. https://doi.org/10.1177/1090198119831053

Srivastava, G., Browne, N., Kyle, T., O’Hara, V., Browne, A., Nelson, T., & Puhl, R. (2021). Caring for US children: Barriers to effective treatment in children with the disease of obesity. Obesity, 29(6). https://doi.org/10.1002/oby.22987

Skelton, J. A., & Beech, B. M. (2011). Attrition in pediatric weight management: A review of the literature and new directions. Obesity Reviews, 12(5), e273-e281. https://doi.org/10.1111/j.1467-789X.2010.00803.x

Small, L., & Aplasca, A. (2016). Child obesity and mental health: A complex interaction. Child and Adolescent Psychiatric Clinics, 25(2), 269-282. https://doi.org/10.1016/j.chc.2015.11.008

Smith, J. D., Fu, E., & Kobayashi, M. A. (2020). Prevention and management of childhood obesity and its psychological and health comorbidities. Annual Review of Clinical Psychology, 16(1), 351-378. https://doi.org/10.1146/annurev-clinpsy-100219-060201

Smith, K. E., & Mason, T. B. (2022). Psychiatric comorbidity associated with weight status in 9 to 10 year old children. Pediatric Obesity, 17(5), e12883. https://doi.org/10.1111/ijpo.12883

Spence, N. D., Newton, A. S., Keaschuk, R. A., Ambler, K. A., Jetha, M. M., Holt, N. L., et al. (2017). Predictors of short- and long-term attrition from the parents as agents of Change randomized controlled trial for managing pediatric obesity. Journal of Pediatric Healthcare, 31(3), 293-301. https://doi.org/10.1016/j.pedhc.2016.09.003

Spurrier, N. J., Magarey, A. A., Golley, R., Curnow, F., & Sawyer, M. G. (2008). Relationships between the home environment and physical activity and dietary patterns of preschool children: A cross-sectional study. International Journal of Behavioral Nutrition and Physical Activity, 5(1), 31. https://doi.org/10.1186/1479-5868-5-31

Staiano, A. E., Marker, A. M., Comeaux, J., Frelier, J. M., Hsia, D. S., & Broyles, S. T. (2017). Family-based behavioral treatment for childhood obesity: Caretaker-reported barriers and facilitators. The Ochsner Journal, 17(1), 83-92.

Staniford, L. J., Copeland, R. J., & Breckon, J. D. (2019). ‘What’s the point when you only lose a pound?’ Reasons for attrition from a multi-component childhood obesity treatment intervention: A qualitative inquiry. Qualitative Research in Sport, Exercise and Health, 11(3), 382-397. https://doi.org/10.1080/2159676X.2018.1474375

Teixeira, P. J., Going, S. B., Sardinha, L. B., & Lohman, T. G. (2005). A review of psychosocial pre-treatment predictors of weight control. Obesity Reviews, 6(1), 43-65. https://doi.org/10.1111/j.1467-789X.2005.00166.x

Texeira, P.J., Carraça, E.V., Marques, M.M., Rutter, H., Oppert, J, De Bourdeaudhuij, I., Lakerveld, J., & Brug, J. (2015). Succesful behavior change in obesity interventions in adults: a systematic review of self-regulation mediators. BMC Med. 16:13:84. doi: 10.1186/s12916-015-0323-6.

Tomayko, E. J., Tovar, A., Fitzgerald, N., Howe, C. L., Hingle, M. D., Murphy, M. P., Muzaffar, H., Going, S. B., & Hubbs-Tait, L. (2021). Parent involvement in diet or physical activity interventions to treat or prevent childhood obesity: An umbrella review. Nutrients, 13(9), 3227. https://doi.org/10.3390/nu13093227

U.S. Department of Agriculture and U.S. Department of Health and Human Services. (2020). Dietary Guidelines for Americans, 2020-2025 (9th Edition). Retrieved from https://www.dietaryguidelines.gov

van Egmond-Froehlich, A., Claussnitzer, G., Dammann, D., Eckstein, E., Brauer, W., & de Zwaan, M. (2013). Parent-reported inattention and hyperactivity/impulsivity as predictors of long-term weight loss after inpatient treatment in obese adolescents. International Journal of Eating Disorders, 46(1), 39-46. https://doi.org/10.1002/eat.22043

Verduci, E., Bronský, J., Embleton, N., Gerasimidis, K., Indrio, F., Köglmeier, J., de Koning, B. D., Lapillonne, A., Moltu, S., Norsa, L., & Domellöf, M. (2021). Role of Dietary Factors, Food Habits, and Lifestyle in Childhood Obesity Development: A Position Paper From the European Society for Paediatric Gastroenterology, Hepatology and Nutrition Committee on Nutrition. Journal of Pediatric Gastroenterology and Nutrition, 72(6), 769-783. https://doi.org/10.1097/MPG.0000000000003075

Vittrup, B., & McClure, D. (2018). Barriers to childhood obesity prevention: Parental knowledge and attitudes. Pediatric Nursing, 44(2), 112-120.

Vlaev, I., Taylor, M., Taylor, D., Gately, P., Gunn, L. H., Abeles, A., … & Ahmedna, M. (2021). Testing a multicomponent lifestyle intervention for combatting childhood obesity. BMC Public Health, 21, 1-15. https://doi.org/10.1186/s12889-021-10838-1

Walker, M., Nixon, S., Haines, J., & McPherson, A. (2018). Examining risk factors for overweight and obesity in children with disabilities: A commentary on Bronfenbrenner’s ecological systems framework. Developmental Neurorehabilitation, 22(5-6), 359-364. https://doi.org/10.1080/17518423.2018.1523241

Wild, C. E., Rawiri, N. T., Willing, E. J., Hofman, P. L., & Anderson, Y. C. (2023). Determining barriers and facilitators to engagement for families in a family-based, multicomponent healthy lifestyles intervention for children and adolescents: A qualitative study. Journal of Pediatric Health Care, 37(2), 208-216.

Wilfley, D. E., & Balantekin, K. N. (2018). Family-based behavioral interventions for childhood obesity. Pediatric Obesity: Etiology, Pathogenesis and Treatment, 555-567. https://doi.org/10.1007/978-3-319-68192-4_32

Wilson, G.T. (1994). Behavioural treatment of obesity: Thirty years and counting. Advances in Behaviour Research and Therapy, 16(1), 31-75. https://doi.org/10.1016/0146-6402(94)90002-7

Wójcik, M., Alvarez-Pitti, J., Kozioł-Kozakowska, A., Brzeziński, M., Gabbianelli, R., Herceg-Čavrak, V., … & Drożdż, D. (2023) Psychosocial and environmental risk factors of obesity and hypertension in children and adolescents-a literature overview. Frontiers in Cardiovascular Medicine. 20;10:1268364. https://doi.org/10.3389/fcvm.2023.1268364.

World Health Organization. (2022). Healthy Diet. Retrieved from https://www.who.int/news-room/fact-sheets/detail/healthy-diet

World Health Organization. (2020). Physical activity. WHO Newsroom Fact Sheets. https://www.who.int/news-room/fact-sheets/detail/physical-activity

World Health Organization. (2020). WHO Guidelines on Physical Activity and Sedentary Behaviour.Retrieved from https://www.who.int/publications/i/item/9789240062884

Table 1 Overview of treatment goals linked with cognitive behavioural interventions and methods for children and parents