See discussions, stats, and author profiles for this publication at: https://www.researchgate.

net/publication/7428840

Family-based behavioural treatment of obesity: Acceptability and

effectiveness in the UK

Article  in  European Journal of Clinical Nutrition · June 2006

DOI: 10.1038/sj.ejcn.1602353 · Source: PubMed

CITATIONS READS

47 100

6 authors, including:

Dasha Nicholls Helen Croker

University College London University College London
85 PUBLICATIONS   3,572 CITATIONS    86 PUBLICATIONS   2,169 CITATIONS   

SEE PROFILE SEE PROFILE

Russell Viner
University College London
297 PUBLICATIONS   9,057 CITATIONS   

SEE PROFILE

Some of the authors of this publication are also working on these related projects:

Development of a brief Appetitive Trait Tailored Intervention (ATTI) in a sample of overweight and obese adults. View project

Reliability and convergent validity of the ‘Adult Eating Behaviour Questionnaire’ in an adolescent sample View project

All content following this page was uploaded by Helen Croker on 19 March 2014.

The user has requested enhancement of the downloaded file.

 European Journal of Clinical Nutrition (2006) 60, 587–592
& 2006 Nature Publishing Group All rights reserved 0954-3007/06 $30.00
www.nature.com/ejcn

ORIGINAL ARTICLE
Family-based behavioural treatment of obesity:
acceptability and effectiveness in the UK
C Edwards1, D Nicholls2, H Croker1, S Van Zyl3, R Viner2 and J Wardle1

1
Cancer Research Health Behaviour Unit, Department of Epidemiology and Public Health, University College London, London, UK;
2
Great Ormond Street Hospital, University College London, London, UK and 3Department of Psychology, University College London,
London, UK

Objective: To assess the acceptability and impact of family-based behavioural treatment (FBBT) for childhood obesity in a
clinical setting in the UK.
Design: Pre- and post-treatment assessment for four consecutive treatment groups.
Setting: Treatment groups took place at Great Ormond Street Hospital, London.
Patients: Participants were 33 families with obese (BMI X98th centile for age and sex) children aged 8–13 years.
Intervention: FBBT was delivered over 12 sessions.
Main outcome measures: Overweight (percentage BMI), self-esteem, mood and eating attitudes were assessed before and
after treatment; overweight was re-assessed at 3-month follow-up for those who completed treatment.
Results: The FBBT programme materials translated easily to the UK setting and the programme was well-liked by participants.
Twenty-seven out of 33 families (82%) completed the sessions. Children lost 8.4% BMI over the time of treatment, and this was
maintained at 3-month follow-up. Self-esteem and depression improved significantly and there was no change in food pre-
occupation, anorexia or bulimia on the ChEAT.
Conclusions: These results establish that FBBT is feasible and acceptable in a clinical setting in Britain. They indicate that
significant loss of overweight can be achieved using the programme without adverse psychological consequences.
European Journal of Clinical Nutrition (2006) 60, 587–592. doi:10.1038/sj.ejcn.1602353; published online 7 December 2005

Keywords: obesity; treatment; behavioural; family

Introduction are overweight or obese according to data from the 1998

The rise in the prevalence of childhood obesity has been well
documented: 17% of boys and 23.6% of girls aged 7–11 years
Correspondence: Professor J Wardle, Cancer Research Health Behaviour Unit,
Department of Epidemiology and Public Health, University College London,
Gower Street, London WC1E 6BT UK. E-mail: j.wardle@ucl.ac.uk
Guarantor: J Wardle.
Contributors: JW directed the overall programme and supervised the data
analysis, interpretation, drafting, and editing of the paper. CE was the
principal investigator; she devised the intervention and design and was
responsible for implementing the programme, data collection, data analysis,
and drafting of the paper. DN contributed to the programme design,
implementation, drafting of the paper, and took clinical responsibility for
families. HC contributed to the programme design, implementation and
editing of the paper. SZ contributed to the programme design, implementa-
tion, data collection, analysis, and drafting of the paper. RV was responsible for
medical aspects of the programme, and contributed to the writing and editing
of the paper.
Received 12 April 2005; revised 12 September 2005; accepted 3 October
2005; published online 7 December 2005
Health Survey for England (Lobstein et al., 2003). Obesity is
associated with considerable risks to the child’s physical
health, with increases in hyperlipidaemia, hypertension,
impaired glucose tolerance, type 2 diabetes, orthopaedic
complications, and sleep apnoea reported (Summerbell et al.,
2003). Obesity can also impact on psychosocial well-being,
particularly through weight-related teasing (Puhl and Brow-
nell, 2001). Despite increasing concern among health
professionals about the rise in the prevalence of obesity
among children, there remains scarce evidence for effective
treatment approaches. The most frequently cited interven-
tion approach in the literature is family-based behavioural
treatment (FBBT), developed by Epstein et al. (1985a) in the
US. Several studies have identified good short and long-term
efficacy for FBBT (Epstein et al., 1985a, b, 1990a, b, 1995).
However, evidence of generalization across settings is
required for FBBT to be considered a ‘well-established
treatment’ (Chambless and Hollon, 1998). British reviewers
 Childhood obesity treatment
C Edwards et al
588
have concluded that there is a ‘limited amount of quality
data on childhood obesity programmes’ (Summerbell et al.,
2003).
We set out to examine the acceptability of FBBT to British
families and health professionals within a specialist hospital,
to assess whether the impact on children’s overweight was
comparable to results reported from the original studies in
the US, and to explore the feasibility of using the programme
within the UK NHS. We also examined possible adverse
effects of FBBT on eating attitudes.
Participants and methods
Thirty-seven children aged 8–13 were assessed following
referral from general practitioners, paediatricians, school
nurses and dietitians for treatment of ‘simple’ obesity. They
were not eligible to participate if they had type 2 diabetes or
an identifiable medical cause of their obesity such as Prada
Willi Syndrome. Children were also excluded if they were
receiving any other obesity treatment or psychological
therapy. To be eligible, at least one of the child’s parents
had to be willing to participate in treatment and be able to
read and understand English. Four of the referred families
felt unable to attend treatment (maternal health; travelling
distance). Thirty-three obese (BMI X98th centile for age and
sex) children, 10 boys and 23 girls, aged from 8 to 13 years,
started the programme. Mean age was 10.1 (s.d. 1.6). The
majority of parents who attended treatment sessions with
their child were mothers (94%). Two-thirds (66.7%) of the
sample were white, 24.2% African-Caribbean, 6.1% Indian
and Pakistani and 3% mixed race. In all, 33.3% of families
had both parents in employment, 30.3% just the mother,
18.2% just the father, and in 18.2% of families no-one was in
employment. This latter group are likely to be the least
affluent.
Treatment sessions took place at Great Ormond Street
Hospital between February 2002 and September 2003, in four
groups of 6–10 families, for eight weekly then four fort-
nightly sessions over a 4-month period. Children were
weighed at each session and heights were measured at
sessions 1 and 12 using a Harpenden stadiometer. Children
completed questionnaire measures of self-esteem, depression
and eating attitudes at sessions 1 and 12. Families were asked
to complete satisfaction questionnaires at the end of
treatment. Programme completers were invited for follow-
up 3 months after the last session when weights and heights
were measured. Efforts were made to contact families not
completing treatment in order to explore the factors
contributing to dropping out.
Family-based behavioural treatment
FBBT has two components: (i) advice on whole family
lifestyle change to modify the micro-environment of the
home, and (ii) a behavioural weight control programme for
European Journal of Clinical Nutrition
the overweight child. The family environment targets are the
foods bought, stored, and served to the family, as well as
modes of travel and leisure pastimes. Sessions in the parent
groups focussed on strategies for making changes in these
aspects of family life.
The behavioural programme is based on learning theory
and uses behaviour modification techniques such as self-
monitoring (keeping daily food and activity diaries), goal
setting, positive reinforcement, stimulus control, and relapse
prevention, in order to modify the child’s eating and exercise
behaviours. Parents are instructed in behaviour management
principles to support their child’s behaviour change. Cogni-
tive components of the programme include managing
teasing and problem-solving.
The nutritional component of the treatment consisted of
regularization of eating patterns, consumption of a healthy
balanced diet (Hunt et al., 1995) and portion control.
Healthy eating was taught to parents and children using
the simple concept of a traffic light system (Epstein and
Squires, 1988). Foods are categorized into red (stop and
think), yellow (approach with caution), and green (go) foods
on the basis of their nutritional value and energy density.
The exercise component emphasized both reductions in
sedentary behaviours and increases in lifestyle and pro-
grammed activity in line with the current recommendation
of 60 min a day (Cavill et al., 2001).
FBBT was delivered in 12 separate, but concurrently run,
parent and child group sessions, each of 112 h duration.
Before the group session, each parent–child dyad was seen
briefly (15 min) to review food and activity diaries and to be
weighed. The information provided at each session was
supported by written materials for the child and the parent.
Homework was assigned in the group each week and
children earned points for completing homework and
session attendance, which were exchanged for small gift
items.
Outcome measures
In order to take account of children’s growth during the
programme, and because there is variation in the literature
in the way that overweight status is expressed, we used two
indices: (1) change in BMI standard deviation score (BMI
SDS) according to the UK 1990 growth reference (Cole et al.,
1990); and (2) change in percentage of ideal body mass,
expressed as percentage of BMI median centile for age, sex
and height (%BMI). Percentage BMI is comparable to the US
concept of percentage of ideal bodyweight (IBW).
In addition to absolute changes in %BMI, we wished to
examine how many children achieved a ‘clinically signifi-
cant’ reduction in their level of overweight. Percentage BMI
has been identified as an appropriate unit with which to
measure adiposity change in children (Cole et al., 2005), but
a review of the literature revealed no agreement as to the
clinically significant level to aim for. For example, the SIGN
guidelines suggest weight maintenance as an appropriate

outcome in most obese children (SIGN, 2003). An interna-
tional consensus conference concluded that any reduction
in BMI z-score is encouraging, but the long-term objectives
should be to reduce it to o2 (Speiser et al., 2004). Eliakim
et al. (2002) advise that maintenance of BMI be considered a
success. In adult obesity interventions, a 5–10% reduction in
weight is commonly used to indicate a clinically significant
weight change. Treatment goals in children, however, must
take into account age, stage of growth and development,
degree of overweight, and the presence of comorbidities
(Barlow and Dietz, 1998). In the absence of any clear
guidance, we have used three indices of clinically significant
BMI change: maintenance of %BMI, a reduction in %BMI of
five points, and a reduction of 10 points.
The Piers–Harris Self Concept Scale (PH; Piers, 1984) was
used to assess changes in how children viewed themselves
after the programme. The Piers–Harris is an 80-item self-
report measure designed to assess self-concept in children
and adolescents. It consists of six subscales: behaviour,
physical appearance and attributes, anxiety, popularity,
intellectual and school status and happiness and satisfaction.
We examined changes in total scores, with higher scores
reflecting more positive self-evaluations. Test–retest relia-
bility has been reported as ranging from 0.42–0.96 and
internal consistency from 0.88–0.93.
Depression was assessed using the Children’s Depression
Inventory (CDI; Kovacs, 1980): a self-rated scale designed for
use with school-aged children and adolescents. The 27-item
CDI incorporates subscales of negative mood, interpersonal
problems, ineffectiveness, anhedonia and negative self-
esteem. Each item consists of three statements and the child
is asked to indicate the one that matches most closely how
he/she has felt in the past 2 weeks. Raw scores are converted
into t-scores, with higher scores indicating more severe
symptoms of depression. Internal consistency ranges from
0.71–0.89 and test–retest reliability from 0.38–0.87 (Kovacs,
1980).
The Children’s Eating Attitudes Test (ChEAT; Maloney et al.,
1988) is a 26-item, six-point, forced-choice, self-report
inventory that assesses food preoccupation, dieting patterns
and eating attitudes in children. Scores range from 0–78,
with higher scores indicating greater disturbance. Internal
consistency is reported as 0.76 and test–retest reliability
as 0.81.
Parents and children were asked to complete a satisfaction
questionnaire at the end of the treatment. They were asked
how pleased they were to have attended and how helpful
they found the written information. Parents were addition-
ally asked how helpful they found the individual feedback at
the start of each session.
Statistical analysis
Data were analysed with SPSS version 11.2. Paired t-tests were
used to assess change over the treatment period, and
repeated measures analysis of variance (ANOVA) for pretreat-
Childhood obesity treatment
C Edwards et al
589
ment through to follow-up. Correlations were used to
examine associations between baseline characteristics and
% BMI reduction, and between % BMI change and change in
wellbeing.
Results
The FBBT materials were easy to ‘translate’ for British
lifestyles and culture, and families were keen to take part.
The health professionals involved in delivering the pro-
gramme judged it as well-suited to most of the client group.
Three changes to the programme were necessary to make it
culturally acceptable. The calorie goals were replaced with
goals for food types and portion sizes in response to a climate
of opinion among health professionals in the UK which is
somewhat against asking children to ‘count calories’. The
nutritional information relating to food choices was rewrit-
ten to be appropriate for British families. The recommenda-
tion for daily weighing also met professional reluctance
because of its association with excessive preoccupation with
weight. The importance of regular weighing was empha-
sized, but we allowed families to choose the frequency. Other
elements were faithful to the original treatment model.
The programme produced good retention rates: of 33
children who started, 27 (81.8%) completed the intervention
phase. The only significant difference between completers
and non-completers was a trend for non-completers to be
more overweight than completers at baseline (212.4 vs
187.6% BMI, P ¼ 0.07). There were no significant differences
in either initial weights or loss of overweight between the
four treatment groups, so data were pooled for analysis.
Degree of overweight at each time point for the four
treatment groups combined is shown in Figure 1. Because
%BMI and BMI-SDS are highly correlated, results are
discussed only for % BMI. Changes in BMI-SDS are reported
in Table 1.
210
Degree of overweight (%BMI)
200
190
180
170
160
pre-treatment post-treatment follow-up
Figure 1 Mean degree of overweight over time (95% CI).
European Journal of Clinical Nutrition
 Childhood obesity treatment
C Edwards et al
590
Table 1 Weight, height, degree of overweight and psychological well- tic about the programme. These positive reactions were
being before and after treatment for children who completed the
reinforced by the good retention rates. Feedback from the
programme (n ¼ 27)
satisfaction questionnaire was obtained from 18 children
Pretreatment Post-treatment t P and 20 parents. The majority of parents (18/20) and children
mean (s.d.) mean (s.d.)* (16/18) were very pleased that they had attended the
programme. Out of 20,14 parents considered the written
Weight (kg) 74.7 (17.2) 73.3 (17.4) 2.6 0.01
Height (cm) 151.2 (9.9) 152.6 (8.8) 1.3 o0.001 information to be very helpful, as did 9/18 children, the
%BMI 187.6 (26.4) 179.2 (27.1) 6.2 o0.001 remainder found it quite helpful. Fifteen parents found the
BMI-SDS 3.23 (0.48) 3.08 (0.53) 4.6 o0.001 individual feedback session very helpful and four quite
Piers–Harris (T-score) 52.0 (8.4) 56.3 (10.9) 2.9 0.01
helpful.
CDI (T-score) 49.8 (11.2) 44.5 (7.9) 3.8 0.001
ChEAT-score 14.2 (8.6) 17.1 (8.4) 2.0 [0.06] Despite efforts made to follow-up families who dropped
out of treatment, only minimal information could be
%BMI, percentage of body mass index median centile for age, sex and height; collected. Feedback from clinicians working with families
BMI-SDS, BMI standard deviation score; Piers–Harris self-concept scale; CDI,
indicated that the most common reasons for drop out were
children’s depression inventory; ChEAT, children’s eating attitudes test.
*NB 25 children completed psychological measures at post-treatment. the occurrence of family events resulting in the programme
becoming less of a priority and families having under-
estimated the demands of the programme.

For children who completed treatment, overweight re-

duced significantly (8.4 %BMI (s.d. 7.1), range þ 2.3% to
27.3%; t(26) ¼ 6.2, Po0.001). Loss of overweight during
treatment was not related to age (r ¼ 0.13, P ¼ 0.52), gender
(r ¼ 0.12, P ¼ 0.55) or initial %BMI (r ¼ 0.04, P ¼ 0.85).
Twenty families attended the follow-up assessment at 3
months post-treatment. Attendance at follow-up was not
related to either end of treatment %BMI (t ¼ 0.95, P ¼ 0.35)
or % weight loss over treatment (t ¼ 1.56, P ¼ 0.13). Loss of
overweight was maintained in these families (start to follow-
up loss of overweight ¼ 9.7 %BMI (s.d. 10.0), range þ 8.5%
to 28.6%, F(1, 19) ¼ 18.7, Po0.001).
Using the three defined levels of %BMI change (main-
tenance, five-point reduction, 10-point reduction) to indi-
cate a ‘clinically significant’ weight change, 24/27 children
either maintained or reduced their %BMI over the course
of treatment. 18/27 children achieved at least a five-point
reduction in %BMI and 9/27 children achieved at least a 10-
point reduction in %BMI.
Changes in self-esteem, depression and eating attitudes are
shown in Table 1. Children who completed treatment had
significant increases in self-esteem and reductions in de-
pressed mood. Change in %BMI during treatment was not
correlated significantly with change in depression (r ¼ 0.02,
P ¼ 0.94), or with change in self-esteem (r ¼ 0.54, P ¼ 0.07),
although the trend was in the direction of a greater
improvement in self-esteem among children whose %BMI
reduced more.
Changes in ChEAT scores approached significance. This
was entirely attributable to scores on the dieting behaviour
subscale (t(24) ¼ 2.0, P ¼ 0.06); specifically, the items ‘I stay
away from foods with sugar in them’, ‘I eat diet foods’ and ‘I
have been dieting’, all of which increased (all Pso0.05).
None of the items assessing abnormal eating behaviours and
attitudes (food preoccupation, anorexia or bulimia) changed
significantly during treatment.
Running the groups was a positive experience for the
health professionals and families were extremely enthusias-
Discussion
The results showed that FBBT translated successfully to a
British setting. The materials were easy to modify, and
acceptability to families and health professionals was high.
The 8.4% loss of overweight that we achieved was lower than
the previously published findings from the US, which show
an average loss of 17% IBW (Kazdin and Weisz, 1998). The
difference may be owing to the shorter duration of the
intervention (4 vs 6 months), greater initial degree of
overweight of our participants, or to our decision not to
prescribe specific calorie intake goals and daily weighing.
However, the reductions in overweight we observed should
be sufficient to produce health gains, and were maintained
at short-term follow-up.
Examination of the proportion of children achieving a
‘clinically significant’ weight change revealed the majority
(24/27) either maintained or reduced their %BMI. Two-thirds
(18/27) achieved at least a five-point reduction in %BMI.
Despite these indices not being clearly defined in the
literature, these results are encouraging as even BMI main-
tenance is considered a successful outcome in childhood
obesity interventions.
Completing the programme was associated with increased
self-esteem and reduced depressive symptoms, although
these improvements were unrelated to change in weight
status. Parental involvement in the programme, socialization
with children with similar difficulties, and increased self-
efficacy for weight control may be factors contributing to the
positive effects.
Children’s eating attitudes changed slightly during treat-
ment, with dieting behaviours (avoiding sugary foods, eating
diet foods and dieting) increasing during the intervention
phase. Although FBBT emphasizes making permanent life-
style changes rather than ‘going on a diet’, these findings are
not surprising, and indeed expected, given that families are
asked specifically to reduce their intake of ‘red’ and increase

European Journal of Clinical Nutrition


their intake of ‘green’ foods. Albeit in line with the ‘Balance
of Good Health’, children (and adults) may perceive such
changes as evidence that they are ‘dieting’. This goes along
with the habit, picked up by families and health profes-
sionals involved, to refer to the programme as the ‘Traffic
Light Diet’. Importantly, and in line with previous research
(Epstein et al., 2001; Levine et al., 2001), there was no change
in items assessing eating pathology and therefore no
indication that the programme increased risk of eating
disorders.
The programme was evaluated very positively in terms of
acceptability to parents and children. Almost all parents
and children found the materials helpful. Families reported
that support from other families in a similar situation was
extremely valuable, but the majority also rated the indivi-
dual feedback at the start of each session as very helpful. This
supports the role of both the group and individual elements
of the programme.
The study has several limitations. Children and parents
had chosen to take part in the programme, which may
explain our relatively low drop-out rate. These families were
a selected group, but this same limitation would apply if
the treatment were available in routine practice. In the
absence of a control group, we are unable to be certain that
the outcomes we observed were owing to FBBT and not some
other aspect of the treatment process, such as attention from
interested health professionals. It is also not possible at this
stage of the research to identify the particular trial compo-
nents that relate to a positive outcome. Although loss of
overweight remained stable over the 3-month follow-up, we
recognize that this is a short follow-up period and our future
studies will include longer follow-up to explore the longer-
term effectiveness of treatment. It is likely that those who
dropped out between treatment and follow-up would have
regained weight, and would be an interesting group for
further study. The feedback obtained regarding drop out
provides some useful insights, and indicates the need for a
comprehensive assessment prior to treatment and fully
briefing families on the demands of the programme. Future
work will aim to examine this in greater depth, although it
must be recognized that following up drop outs from any
treatment programme is difficult.
Future work needs to address the feasibility of delivering
FBBT in a health service context, both in terms of
practicalities and cost-effectiveness. A particular challenge
in obesity management is the maintenance of loss of
overweight after treatment and this requires more attention.
Interest in the use of novel approaches for the maintenance
phase is increasing and there have been suggestions that
they could include newsletters, telephone calls, the internet,
e-mails, and text messages if these technologies were
accessible to the populations targeted in interventions.
The current pilot study confirms that FBBT is an acceptable
treatment for British families and translates to a culturally
and socially diverse British sample. A randomized-controlled
trial of FBBT is now underway in order to consider whether
Childhood obesity treatment
C Edwards et al
591
FBBT can move on from the position of ‘probably efficacious’
(Summerbell et al., 2003).
Acknowledgements
Professor Len Epstein, State University of New York at
Buffalo, made his treatment manual available and advised
on the intervention. The research was funded by Cancer
Research UK and Weight Concern. Ethical approval was
obtained from University College London Hospitals and
Great Ormond Street Hospital Ethics Committees.
References
Barlow SE, Dietz WH (1998). Obesity evaluation and treatment:
Expert Committee Recommendations. Pediatrics 102, E29.
Cavill N, Biddle S, Sallis JF (2001). Health-enhancing physical
activity for young people: statement of the United Kingdom
Expert Consensus Conference. Pediatric Exercise Science 13, 12–25.
Chambless DL, Hollon SD (1998). Defining empirically supported
therapies. J Consult Clin Psychol 66, 7–18.
Cole TJ, Faith MS, Pietrobelli A, Heo M (2005). What is the best
measure of adiposity change in growing children: BMI, BMI%,
BMI z-score or BMI centile? Eur J Clin Nutr 59, 419–425.
Cole TJ, Freeman JV, Preece MA (1990). Body mass index reference
curves for the UK. Arch Dis Child 73, 25–29.
Eliakim A, Kaven G, Berger I, Friedland O, Wolach B, Nemet D
(2002). The effect of a combined intervention on body mass index
and fitness in obese children and adolescents – a clinical
experience. Eur J Pediatr 161, 449–454.
Epstein LH, McCurley J, Wing RR, Valoski A (1990a). Five-year
follow-up of family-based behavioral treatments for childhood
obesity. J Consult Clin Psychol 58, 661–664.
Epstein LH, Paluch RA, Saelens BE, Ernst MM, Wilfley DE (2001).
Changes in eating disorder symptoms with pediatric obesity
treatment. J Pediatr 139, 58–65.
Epstein LH, Squires S (1988). The Stoplight Diet for Children. Little,
Brown and Company: Boston, MA.
Epstein LH, Valoski AM, Vara LS, McCurley J, Wisniewski L,
Kalarchian MA et al. (1995). Effects of decreasing sedentary
behavior and increasing activity on weight change in obese
children. Health Psychol 14, 109–115.
Epstein LH, Valoski AM, Wing RR, McCurley J (1990b). Ten-year
follow-up of behavioral, family-based treatment for obese chil-
dren. JAMA 264, 2519–2523.
Epstein LH, Wing RR, Penner BC, Kress MJ (1985a). Effect of diet and
controlled exercise on weight loss in obese children. J Pediatr 107,
358–361.
Epstein LH, Wing RR, Woodall K, Penner BC, Kress MJ, Koeske R
(1985b). Effects of family-based behavioral treatment on obese
5-to-8-year-old children. Behav Ther 16, 205–212.
Hunt P, Rayner M, Gatenby S (1995). A national food guide for the
UK background and development. J Hum Nutr Dietetics 8, 315–322.
Kazdin AE, Weisz JR (1998). Identifying and developing empirically
supported child and adolescent treatments. J Consult Clin Psychol
66, 19–36.
Kovacs M (1980). Children’s Depression Inventory. Multi-Health
Systems, Inc: Toronto.
Levine MD, Ringham RM, Kalarchian MA, Wisniewski L, Marcus MD
(2001). Is family-based behavioural weight control appropriate for
severe pediatric obesity? Int J Eat Disord 30, 318–328.
Lobstein TJ, James WPT, Cole TJ (2003). Increasing levels of excess
weight among children in England. Int J Obes 27, 1136–1138.
Maloney MJ, McGuire JB, Daniels SR (1998). Reliability testing of a
children’s version of the Eating Attitude Test. J Am Acad Child
Adolesc Psychiatry 27, 541–543.
European Journal of Clinical Nutrition
 Childhood obesity treatment
C Edwards et al
592
Piers EV (1984). Piers-Harris Children’s Self-Concept Scale, Revised
Manual. Western Psychological Services: CA.
Puhl R, Brownell KD (2001). Bias, discrimination, and obesity. Obes
Res 9, 788–805.
Scottish Intercollegiate Guidelines Network, SIGN (2003). Manage-
ment of obesity in children and young people. A national clinical
guideline. SIGN, Royal College of Physicians: Edinburgh.
Speiser PW, Rudolf MCJ, Anhalt H, Camacho-Hubner C, Chiarelli F,
Eliakim A et al. (2004). Consensus development: childhood
obesity. J Clin Endocrinol Metab 90, 1871–1887.
Summerbell CD, Ashton V, Campbell KJ, Edmunds L, Kelly S, Waters
E (2003). Interventions for treating obesity in children. In:
Cochrane Collaboration (ed). Cochrane Review. The Cochrane
Library: Oxford. p 3.

European Journal of Clinical Nutrition

View publication stats