Child & Family Behavior Therapy, 32:3450, 2010

Copyright # Taylor & Francis Group, LLC

ISSN: 0731-7107 print=1545-228X online
DOI: 10.1080/07317100903539873

Development of a Multi-Disciplinary
Intervention for the Treatment of
Childhood Obesity Based on
Cognitive Behavioral Therapy
EIRINI BATHRELLOU, MSc and MARY YANNAKOULIA, PhD
Department of Nutrition and Dietetics, Harokopio University, Athens, Greece

KATERINA PAPANIKOLAOU, MD, PhD

Department of Child Psychiatry, University of Athens Medical School, Agia Sophia
Childrens Hospital, Athens, Greece

ARTEMIOS PEHLIVANIDIS, MD, PhD

Department of Psychiatry, Cognitive Therapy Unit, University of Athens Medical School,
Eginition Hospital, Athens, Greece

PANAGIOTA PERVANIDOU, MD, PhD and

CHRISTINA KANAKA-GANTENBEIN, MD, PhD
Unit of Endocrinology, Metabolism and Diabetes, First Department of Pediatrics, University
of Athens Medical School, Agia Sophia Childrens Hospital, Athens, Greece

JOHN TSIANTIS, MD, PhD

Department of Child Psychiatry, University of Athens Medical School, Agia Sophia
Childrens Hospital, Athens, Greece

GEORGE P. CHROUSOS, MD, PhD

Unit of Endocrinology, Metabolism and Diabetes, First Department of Pediatrics, University
of Athens Medical School, Agia Sophia Childrens Hospital, Athens, Greece

LABROS S. SIDOSSIS, PhD

Department of Nutrition and Dietetics, Harokopio University, Athens, Greece

Along the lines of the evidence-based recommendations, we

developed a multi-disciplinary intervention for overweight children
7- to 12-years-old, primarily aiming at helping children to adopt
Received 5 January 2009; revised 30 April 2009; accepted 11 May 2009.
Address correspondence to Labros S. Sidossis, PhD, Department of Nutrition and
Dietetics, Harokopio University, 70 El. Venizelou Avenue, 176 71 Athens, Greece. E-mail:
lsidossis@hua.gr
34

Development of a Childhood Obesity Intervention

35

healthier eating habits and a physically active lifestyle. The

program combined nutrition intervention, based on a non-dieting
approach, with physical activity intervention, implemented
through the basic principles of Cognitive Behavioral Therapy
(CBT), along with parental support. The program was conducted
by dieticians with the collaboration of child psychiatrists and
pediatricians. Training and regular supervision upon CBT priniciples application was intended to enhance dieticians efficiency.
The intervention is currently being evaluated to determine its
effectiveness in treating childhood obesity.
KEYWORDS children, cognitive behavioral techniques, nondieting approach, obesity, parental involvement, supervision

Childhood obesity is considered to be an uncontrolled worldwide epidemic

(Wang & Lobstein, 2006) and a major health problem; a picture depicted by
newly introduced terminology, such as globesity (Deitel, 2002). The great
concern for this health entity lies in its many short- and long-term effects:
childhood obesity affects almost every system of the body (Freedman, Dietz,
Srinivasan, & Berenson, 1999; Reilly et al., 2003; Weiss et al., 2004), has
harmful psychosocial (Strauss & Pollack, 2003; Decaluwe, Braet, & Fairburn,
2003) and economic consequences (Wang & Dietz, 2002), and tracks into
adulthood (Whitaker, Wright, Pepe, Seidel, & Dietz, 1997; Deshmukh-Taskar
et al., 2006). Therefore, a large number of attempts to combat childhood
obesity have been made, producing diverse results. Evidence supporting
the long-term efficacy of non-invasive intervention programs suggests that
principle components include dietary and physical activity intervention,
applied through behavioral modification techniques, along with family
changes (Barlow, 2007; Young, Northern, Lister, Drummond, & OBrien,
2007). The fact that these components differ among treatment programs
(Collins, Warren, Neve, McCoy, & Stokes, 2006; Snethen, Broome, & Cashin,
2006; Gibson, Peto, Warren, & dos Santos Silva, 2006), combined with the
difficulty of isolating a single component to assess its effectiveness, has led
to no current consensus on the most effective type of intervention. Hence,
the need for the development, implementation, and evaluation of widely
applicable therapeutic measures is still substantial.
We aimed at developing a program for the management of childhood
obesity addressing multiple factors known to contribute to the problem,
based on the use of Cognitive Behavioral Therapy (CBT) principles, which
can be implemented by trained dieticians. As currently no such program is
available on a local level, where obesity is on the rise (Papadimitriou,
Kounadi, Konstantinidou, Xepapadaki, & Nicolaidou, 2006), the need for
its development becomes more imperative. A detailed description of the

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E. Bathrellou et al.

protocol and its components, after a brief review of the evidence on which it
is based, is provided for future reference or replication.

METHODOLOGY DEVELOPMENT
Building on Evidence-Based Recommendations
DIETARY INTERVENTIONS
Although evidence evaluating the single effect of diet on managing
overweight in children is lacking, inclusion of a dietary component in the
treatment seems to add a therapeutic benefit (Collins et al., 2006). Energy
restriction is fundamental in achieving weight regulation, and energy deficit
has been achieved either by administrating hypocaloric diets, or by using
non-dieting approaches. The most common hypo-caloric diet is the traffic
light diet, first developed by Epstein and colleagues (1981): Foods are
divided into three groups based on their energy and fat content, and greens
can be consumed freely, oranges should be consumed with caution, and reds
should be avoided. A daily or weekly number of servings for each of these
food groups is then recommended. Less restrictive dietary interventions have
been successfully used, promoting the notion of eating differently, not
necessarily less (Braet, 1999), focusing on food choices (Gehling, Magarey,
& Daniels, 2005) or proposing ad libitum low-glycemic diets (Ebbeling et al.,
2005). The need for less restrictive interventions is also posed by implications
showing that flexible rather than rigid dietary restraint is associated with
lower Body Mass Index (BMI) values and a more successful long-term weight
control, both in adults and children (Westenhoefer, 2002; Westenhoefer,
Stunkard, & Pudel, 1999), while it is further enhanced by concerns that obese
children are at high risk for developing eating disorders or showing resistance to therapy (Decaluwe & Braet, 2005). Furthermore, according to evidence from observational studies which point to eating patterns and
different types of foods as a link to overweight in children (Moreno &
Rodriguez, 2007), current recommendations suggest dietary treatments
should focus on food behaviorssuch as breakfast skipping and meal frequency, eating out and portion size (Spear et al., 2007)rather than energy
intake (total calories) and macro-nutrient composition (percentage of
carbohydrate, fat, and protein to total calories).
PHYSICAL ACTIVITY INTERVENTIONS
Apart from having been associated with lower obesity risk in children
(Abbott & Davies, 2004; Berkey, Rockett, Gillman, & Colditz, 2003), physical
activity has also been proven crucial in weight loss maintenance and in
decreasing cardiovascular and diabetes risks, even independently of weight

Development of a Childhood Obesity Intervention

37

reduction (Meyer, Kundt, Lenschow, Schuff-Werner, & Kienast, 2006; Nassis

et al., 2005). Conversely, physical inactivity, especially as television viewing,
has been shown to be a risk factor for obesity in pediatric populations
(Obarzanek et al., 1994; Andersen, Crespo, Bartlett, Cheskin, & Pratt, 1998;
Crespo et al., 2001). According to the behavioral economics model, physical
activity and sedentary activities are the two sides of the same coin and may
be seen as substitutes, meaning that a reduction in one parameter is expected
to result in at least some increase in the other (Epstein & Roemmich, 2001).
Based on this assumption, both an increase in physical activity and a
decrease in sedentary activities have been tested in laboratory and field
studies for the treatment of childhood obesity. Evidence from a 10-year
follow-up study suggests that physical activity as a lifestyle change is a promising, feasible, and convenient way for managing overweight in children
(Epstein, Valoski, Wing, & McCurley, 1990), while both structured and
non-structured activities have been beneficial in reducing BMI in children
(Berkey et al., 2003). Alternatively, targeting sedentary activities has been
proven at least as (Epstein, Paluch, Gordy, & Dorn, 2000) or even more
(Epstein et al., 1995) effective in reducing percent overweight in children
compared to targeting an increase in physical activity per se. Moreover, greater increases in physical activities or decreases in sedentary activities did not
add any further benefit, meaning that changes in physical activity profile in
children reach a plateau (Epstein et al., 2000). Recommendations regarding
physical activity in children target a generally active lifestyle, and suggest
at least 60 minutes of moderate intensity physical activity, if possible everyday, and not exceeding 2 hours of screen time daily (Spear et al., 2007).
Within school settings, individual or team non-competitive sports, and recreational activities are recommended (American Academy of Pediatrics,
2000), as well as an active participation in physical education classes (Carrel
et al., 2005).
BEHAVIORAL CHANGE INTERVENTIONS
Both parameters of energy balancethat is, energy intake and energy
expenditureare directly affected by behaviors related to dietary intake
and physical activity choices, exemplifying why studying behavior in the
context of combating obesity has attracted great scientific interest. CBT has
been originally proposed for the treatment of emotional and behavioral
disorders, such as depression and anxiety (Beck, 1991). The efficacy, the
defined methodology, and the replication of findings inspired its application
to a wide range of patient populations and conditions, including pediatric
population with chronic diseases, like obesity (Powers, Jones, & Jones,
2005). CBT is recognized as a methodology for the systematic modification
of eating, exercise, or other behaviors thought to contribute to or maintain
obesity (Foreyt & Poston, 1998b). Features of CBT relevant to a dietary

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E. Bathrellou et al.

intervention involve the structure of the session, the therapeutic relationship,

and related techniques. A typical outline of a CBT session includes checking
on mood, reviewing homework, setting the agenda, assigning homework,
and summarizing while giving feedback (Beck, 1995; Friedberg & McClure,
2002). The breakthrough relating to CBT refers to the relationship between
the therapist and the patient. By introducing collaborative empiricism and
guided discovery, it altered the therapeutic relationship, from a didactic
advising to a collaborative one, minimizing defensive attitude, conflicts,
and resistance (Wright, Beck, & Thase, 2003). Aiming at helping the patient
not only to implement, but also maintain behavioral change, the techniques
most commonly used in CBT interventions are self-monitoring, goal setting,
stimulus control, problem solving, relapse prevention, cognitive restructuring, and social support (Foreyt & Poston, 1998a). The beneficial effect of
adding behavioral modification techniques in a conventional program for
the treatment of childhood obesity has been originally described in the early
1990 s (Epstein, Wing, Steranchak, Dickson, & Michelson, 1980; Epstein et al.,
1985), and has been confirmed many times ever since (Jelalian & Saelens,
1999). Although it is difficult to isolate a specific technique and assess its
effectiveness, some of the CBT techniques have been evaluated and proven
to have a positive effect in pediatric populationssuch as self-monitoring
(Kirschenbaum, Germann, & Rich, 2005), stimulus control (Golan, Fainaru,
& Weizman, 1998), and problem solving (Graves, Meyers, & Clark, 1988).
Behavioral programs for childhood obesity integrate some or most of these
CBT techniques.
PARENTAL INVOLVEMENT
Parents affect childrens eating and physical activity patterns by several
means; namely, formulating childrens environment, being role models,
and controlling their dietary intake (Johnson-Taylor & Everhart, 2006).
Participation of parents in a program that aims at modifying the childs eating
habits and reducing overweight is considered necessary, hence a great body
of research addresses the question of the most effective parental role. Epstein
and colleagues (1990) highly support the role of parents as targets for
managing their own weight along with their childs weight, as results from
10 years of follow-up show a significantly higher reduction in percent overweight of children when both parents and children were targeted for weight
loss compared to when only children were targeted. On the other hand,
training children in self-regulatory techniques compared to assigning parents
most responsibility for change was proven essential in maintaining percent
overweight loss after treatment (Israel, Guile, Baker, & Silverman, 1994). In
the studies of Golan and Crow (2004), parents as exclusive agents of change,
without any direct children involvement, were found to be more efficient in
managing childrens weight when compared to children being the exclusive

Development of a Childhood Obesity Intervention

39

agents. Evidently, studies are not conclusive in regard to the most effective
parental role or the exact degree of parental involvement. Recommendations
so far suggest a generally supportive role of parents, with descending
involvement as the child gets older (Barlow, 2007), and this seems to be the
approach most widely adopted (Graves et al., 1988; Nuutinen, 1991; Duffy &
Spence, 1993; Flodmark, Ohlsson, Ryden, & Sveger, 1993; Braet & Van
Winckel, 2000; Levine, Ringham, Kalarchian, Wisniewski, & Marcus, 2001;
Reinehr, Kersting, Alexy, & Andler, 2003; Jiang, Xia, Greiner, Lian, &
Rosenqvist, 2005; Korsten-Reck, Kromeyer-Hauschild, Wolfarth, Dickhuth, &
Berg, 2005; Nemet et al., 2005).

Procedures: Detailed Description of Program

Components and Structure
Along the lines of the aforementioned evidence, we developed a dietary
intervention addressing multiple factors known to contribute to childhood
obesity in regard to diet and physical activity for children aged 7 to 12 years
old. The aim of the program is to encourage children adopt both healthier
eating habits and a less sedentary lifestyle, and thus regulate their body
weight. The program consists of 12 weekly 1-hour sessions, conducted individually. Topics concerning both dietary- and physical activity-related issues
are introduced at each session, the agenda of which is briefly presented in
Table 1. At the beginning of the program, more emphasis is put on the
dos rather than the donts; for example, children are initially requested
to add salad at meals or increase everyday physical activity rather than
decrease sweet intake or TV viewing. Goals are set depending on the childs
current habits and readiness to change, with progressively increased intensity, while previous goals achieved are maintained or further enhanced.
The dietary intervention is based on a non-dieting approach, which
encourages flexible dietary control, focuses on problematic eating behaviors,
and fosters a more or less as opposed to an everything or nothing
approach (Westenhoefer, 2002). Different aspects of dietary habits are
addressed emphasizing dietary quality and meal patterns, without using a
pre-determined dietary plan or a calorie limit. Complete meals are the first
dietary issue discussed, referring to the quality of meals, and virtually aiming
at encouraging consumption of fruits and vegetables throughout the day. A
complete meal is defined as that including a source of protein, a source of
starch, and a fruit or vegetable, distinguishing from incomplete or less
balanced meals (Lennernas & Andersson, 1999). Other issues include breakfast consumption, snack at school, consumption of high energy dense food,
total eating episodes, portion size, and eating conditionsor 5 onlys as
mentioned elsewhere (Golan et al., 1998), which confine eating only when
seated, without doing something else, at the right place, with proper utensils,
and when hungry. Regarding physical activity, both an increase in energy

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E. Bathrellou et al.

TABLE 1 Agenda of the Main Topics Addressed in Each Session of the Program
Session
1.

2.

3.

4.
5.

6.

7.

8.
9.

10.
11.
12.

Agenda
Establishing rapport
Exploring motives
Nutrition goal:
- Improving meal quality: complete meals (including a source of starch, a source of
protein and a fruit or vegetable)
Nutrition goals:
- Regular breakfast consumption
- Eating condition only seated, and not while standing or lying
Physical activity goals:
- Increase in everyday physical activities, such as going to school on foot, playing
during school time or after school, walking the dog
Nutrition goals:
- Inclusion of a healthy school and afternoon snack
- Eating condition without doing something else, such as watching TV
Physical activity goals:
- Gradual decline in time allocated to screen; i.e., TV viewing, computer games,
video, as recreational activity
- Exploring possibilities of attending a sports team
Revision and problem detection
Recording of physical activity with a pedometer, used as a self-monitoring tool
Nutrition goals:
- Meal sizereducing food portion by a quarter, excluding fruits or vegetables
- Eating condition from proper size utensils; e.g., getting served from different
dishes or big packaging exactly the amount wanted
Physical activity goals:
- Set a tailored budget of screen time per day or week, desired final goal of
12 hours screen time per day, or 12 hours per week
- Using pedometer recording to enhance physical activity
Nutrition goals:
- Reduction of sweets and other energy dense, high sugar, and fat foods: set a
tailored weekly budget, desired final goal of 23 per week
- Eating condition only when hungry, and not when seeing or smelling food, or
feeling lonely or upset
Physical activity goals:
- Comparing pedometer records between 2 last weeks exploring if and how
much reducing TV viewing resulted in an increase in pedometer measurements,
discussion on possible solutions to further enhance result
Nutrition goals:
- Practicing of stimulus controlalternative solutions
- Eating condition only in the kitchen or dining room, and not; e.g., in the
bedroom
Physical activity goals:
- Active participation in the physical education school curriculum and sports
Revision and problem detection
Emphasis on less achieved goals
Nutrition goals:
- Healthy meal patterns: total number of meals and snacks per day
Physical activity goals:
- Sports attendance
Relapse prevention
Projection to the future
Revision and feedback
Importance of follow-up

Development of a Childhood Obesity Intervention

41

expending activities and a decrease in sedentary behaviors are targeted. An

active lifestyle is supported, primarily achieved by everyday non-structured
activities and further enhanced by sports engagement. Being active during
schooli.e., playing in break time and participating in physical education
classesis also dealt with. On the other hand, a budget of TV viewing hours
is agreed upon, leaving the child free to choose what to watch and decide
how to best distribute available time. In order to encourage childrens
self-monitoring and efforts to increase physical activity, pedometers recording the number of total steps taken daily are being used, and comparisons
between active and sedentary days form the basis for discussion. All dietary
and physical activity aspects are placed in the context of energy balance.
Taking into consideration developmental issues, the sessions have a
playful character, integrating games, reference to childrens favorite heroes,
role-playing, appropriate use of open and close questions, and translation
of abstract notions into concrete and tangible examples. For instance,
education on complete meals is carried out with the use of three dolls, each
one representing a food group. The dolls, as tall as a 6-year-old child, have a
funny name and hold a basket with food models of each food group
described. Moreover, for explaining the eating conditions, cards presenting
the desirable and the undesirable conditions have been specifically designed
for the needs of the program. In general, every goal set is clearly defined and
examples are done to ensure an adequate level of understanding.
Most of the specific CBT techniques incorporated into programs targeting childhood obesity are appliedsuch as goal setting, self-monitoring,
rewarding, problem solving, food-related stimulus control, cognitive restructuring, and relapse prevention. At each session, an average of 3 to 5 goals are
set, related to both diet and physical activity. Goals are individualized,
realistic, and specific. Children are asked to self-monitor their behavior every
day. A monitoring sheet is given where they can either tick or write comments regarding the goals set, while on return three areas are being discussed
and recorded: what was achieved, barriers met, and solutions to achieve
more next time. Finding alternatives and overcoming barriers to change
are highly valued, and guided discovery is the principal technique used for
their accomplishment, as well as for goal setting. As research on the use of
rewarding has proposed that oral rather than tangible rewards, small rather
than large ones, and rewards for the quality rather than the quantity of the
behavior seem to be more successful (Eisenberger & Cameron, 1996); children
are rewarded for their progress with a sticker of their favorite hero, whereas
oral support is given throughout the program. Moreover, as long-term adoption of the desired habits is the goal, the oral rewarding given is combined
with what the child benefited from the changes he=she made, so that the
changes would act as intrinsic reinforcers (Foreyt & Goodrick, 1993). However, in highly resistant children an extra reward is given in the form of a
present, bought by the parent. All techniques are applied in the context of

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E. Bathrellou et al.

a collaborative relationship, establishing a sound alliance, and promoting

active participation of the child.
Parents have been assigned a supportive role. Before the beginning of the
program, the parent or caregiver is informed on the scope and the methods of
the program, the realistic goals regarding weight change, and the commitments she or he will be called to fulfil. Parents have to provide a supportive
environment in terms of food availability and accessibility, meal frequency,
practices used to control the childs dietary intake, atmosphere during mealtime, opportunities to exercise, and of course punctuality to the appointments.
The last 10 minutes of each session, the parent is being informed on the topics
discussed, and is asked to suggest ways of supporting the child to implement
the goals set, or even modifying the goals if considered unrealistic, and work
together with the child in order to enhance its effectiveness.
The program is being implemented by dieticians, who are supported by
a team of pediatricians and child psychiatrists from a major public childrens
hospital. Dieticians are appropriately trained on the application of CBT
techniques by a 4-day seminar conducted prior to the beginning of the
program, and supervision is provided on a bi-weekly basis. The seminar
includes training on (a) the basic principles of CBTsuch as cognitive
model, the notion of collaborative empiricism and guided discovery, and
specific CBT techniques; (b) specific developmental issues for youngsters;
and (c) the application of the above principles to the study protocol.
Moreover, throughout the program, supervision of the dietitians takes
place every 2 weeks. The aim of the supervision is to support dieticians in
handling issues concerning the therapeutic relationship as well as in implementing CBT techniques in order to increase childrens compliance to the
intervention protocol. Seminars and supervision are being carried out by a
child psychiatrist and a psychiatrist highly experienced in CBT training
(Pehlivanidis et al., 2006).
In order to enhance the therapeutic effect, booster sessions are scheduled after the intensive treatment phase. Booster sessions aim at lengthening
the time during which behavioral change is maintained, as well as gradually
fading the degree of therapeutic contact (Wing, Epstein, Marcus, & Koeske,
1984). Following the 12 weekly sessions of the core program, 8 booster sessions are planned, the first 6 of which on a monthly basis, and the remaining
2 in 6-month intervals.

DISCUSSION AND CONCLUSIONS

Building on evidence-based recommendations for the treatment of
childhood obesity, we developed an intervention addressing multiple factors
implicated in the development and maintenance of overweight and obesity
in children. A standardized dietary and physical activity intervention

Development of a Childhood Obesity Intervention

43

implemented with the application of CBT techniques is proposed, aiming at

improving habits and achieving lifestyle changes in the long-term. A detailed
description of the structure and the key components of the program are
provided, considered necessary for results interpretation, comparison with
other approaches, or replication.
Application of flexible behavioral control constitutes one of the basic
characteristics of the program. In regard to both dietary and physical activity
changes, children are asked to control their behavior in a flexible rather than
rigid way, primarily by achieving relative changes based on their current
habits, by setting goals to gradually improve the latter, and at last by
assuming a feasible budget within which they could manage their behavior. Flexible behavioral control may be seen as an approach to increase
internal locus of control, namely the extent to which individuals believe that
they can influence events through their own actions (Rotter, 1966). Recent
findings suggest that a stronger sense of control over ones life in childhood
is associated with a reduced risk of overweight and obesity in adult life, as
well as with a better self-rated health (Gale, Batty, & Deary, 2008). Moreover,
in accordance to the four parenting styles proposed, based on the strategies
parents raise their children, and their implication in childrens weight status
(Rhee, Lumeng, Appugliese, Kaciroti, & Bradley, 2006), flexible behavioral
control seems to promote the authoritative style on behalf of the child, combining freedom of choice with setting limits. Avoiding the application of rigid
control also fits better the context of the collaborative relationship, thus it is
expected to increase childrens concordance and compliance to instructions.
As long-term efficacy of therapeutic interventions in pediatric obese
populations remains a challenge, an emerging need has been recognized
to address weight loss maintenance post-intervention. To this direction,
extension of treatment contact or content has been proposed by adult
studies, either by lengthening the treatment period (Jeffery et al., 2000),
which has been successfully tested in children as well (Wilfley et al.,
2007), or by planning booster sessions (Wing et al., 1984). To our knowledge, no intervention targeting childhood obesity has so far included booster
sessions. The current approach has incorporated booster sessions as an
integral part of the protocol, anticipating an enhancement of the therapeutic
effect gained over the intense treatment program.
The program is being conducted by dieticians with the collaboration of
other health professionalsnamely psychiatrists and pediatriciansas a
team approach is recommended for a more intensive therapeutic intervention (Barlow, 2007). Literature suggests dieticians should improve their
skills in regard to behavioral change accomplishment (Foreyt & Poston,
1998a; Rapoport, 1998; Stewart, Houghton, Hughes, Pearson, & Reilly,
2005), and CBT is a methodology offering such an opportunity (Stunkard,
1996). In this direction, dieticians of the program are trained by both attending a seminar on CBT issues and receiving regular supervision upon their

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E. Bathrellou et al.

application. A short training in CBT techniques has a rather limited influence,

as it cannot provide guidance in handling issues, which are likely to appear
throughout the program. Supervision, however, may be seen as an ongoing
training, based on specific examples requesting immediate solution and
been, in a way, tailored to the participants features. This is the first time
supervision is applied in an intervention targeting childhood obesity. Psychiatrists are responsible for the dieticians training in CBT issues and their
supervision, and pediatricians for the medical assessment and support, as
well as for subject recruitment.
The intervention developed is currently being evaluated. Children are
being recruited from a major childrens public hospital in Athens, where they
undergo a full clinical and biochemical assessment before entering the program. The primary inclusion criteria are age between 7- to 12-years-old and
presence of overweight or obesity, defined by using the age- and sex-specific
BMI cut-off points for children and adolescents adopted by the International
Obesity Task Force (Cole, Bellizzi, Flegal, & Dietz, 2000). The outcome measures assessed are shown in Table 2. All parameters will be evaluated at the
beginning of the program, at 6-months follow-up and every year afterwards,
with the exception of dietary and physical activity parameters which are also
measured immediately after the completion of the program (i.e., at 3 months
TABLE 2 Selected Outcome Measures for Assessing the Effectiveness of the Intervention
Developed
Parameters
Anthropometric
Dietary intake

Dietary behavior
Physical activity

Biochemical &
metabolic
Psychological

Outcome measures
Percent overweight,aweight, height, Body Mass Index,b percent body fat
(assessed by dual energy X-ray absorptiometry)
Energy and macro-nutrient intake, consumption of specific food groups
(e.g., fruits, vegetables, sweets), meal pattern (e.g., breakfast
consumption, number of eating episodes), (all assessed by two
consecutive 24-hour recalls)
Eating in response to external stimuli, emotional cues, or restraint
(assessed by the Dutch Eating Behavior Questionnaire, completed by
the parents for their children)c
Time allocated to moderate-to-vigorous intensity physical activities, and
weighted-activity-metabolic-equivalent (WAMET) score (an index of
physical activity adjusted for the intensity of exercise), total screen
time (i.e., time spent on TV viewing, videogames, computer) (all
assessed by a physical activity checklist)d
Fasting glucose, lipid and lipoprotein profile (e.g., triglycerides,
cholesterol esters and their lipoproteins), hormonal and inflammatory
markers (e.g., insulin, cortisol, IL-6, TNF-a, adiponectin)
Self-esteem, depression, anxiety, behavior problems (in children)e
Depression, family function (in parents)f

Note. a[(current BMI BMI cut-off for overweight)=BMI cut-off for overweight]  100, where BMI cut-offs
are based on Cole et al., 2000; bweight (kg)=height2 (m2); cBraet & Van Strien, 1997; dGioxari et al., 2005;
e
Battle, 1981; Kovacs, 1985; Liakos & Giannitsi, 1984; Roussos et al., 1999, respectively; fBeck & Steer,
1993; Miller, Epstein, Bishop, & Keitner,1983, respectively.

Development of a Childhood Obesity Intervention

45

from baseline), and body weight and height which are additionally measured
every 2 weeks during the intervention phase. In order to assess the effectiveness of the intervention proposed as a favorable alternative to the standard
care, and to further examine the impact of parental involvement, children
receiving the intervention will be compared to a group receiving the usual
care provided in the childrens public hospital, and to a group of children
receiving the same intervention but differing only in the degree of parental
participation. Results are anticipated in order to verify or dispute our
expectation for a successful therapeutic approach for childhood obesity. As
obesity has become a major health issue among youths, developing multidisciplinary approaches targeting the various factors known to be involved
in the etiology of childhood obesity will likely help clinicians and practitioners in the management of childhood obesity.

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