Sensible Treatment of Obesity in Rural Youth (STORY): Design and methods

Abstract

Project STORY is a 3-arm, randomized, planning and feasibility study assessing the effectiveness of two behavioral weight management interventions in an important and at-risk population, overweight children and their parents in medically underserved rural counties. Participants will include 90 parent–child dyads from rural counties in north central Florida. Families will be randomized to one of three conditions: (a) a Family-Based Behavioral Group Intervention, (b) a Parent-Only Behavioral Group Intervention, and (c) a waitlist control condition. Child and parent participants will be assessed at baseline (month 0), post-treatment (month 4) and follow-up (month 10). Assessment and intervention sessions will be held at Cooperative Extension offices within each local participating county. The primary outcome measure is change in child body mass index (BMI) z-score. Additional key outcome measures include child dietary intake, physical activity, self-esteem, body image, and parent BMI.

The goals of the study are to (a) assess the feasibility of recruitment in rural settings, (b) develop and evaluate training protocol for group leaders, (c) determine strategies to increase adherence to monitoring and goal setting protocol, (d) evaluate strategies for participant retention, (e) assess the relative cost-effectiveness of the interventions, (f) assess the acceptability of the intervention to families and Cooperative Extension administrators and personnel, and (g) if successful, estimate the sample size needed for a full-scale trial. This research has potential implications for medically underserved rural communities with limited resources and preventive health care services. If successful, a Parent-Only intervention program may provide a cost-effective and practical intervention for families in underserved rural communities.

Introduction

The rate of childhood obesity is increasing at an alarming rate. Over 37% of children ages 6 to 11 years are either overweight or at-risk for overweight [1], an increase of over 15% from 2001–02 to 2003–04. Childhood obesity has been linked to type 2 diabetes [2], [3], insulin resistance and abnormal glucose tolerance [4], and cardiovascular risk factors [5], [6], [7]. Obesity-associated annual hospital costs specific to children ages 6 to 17 have increased threefold over the last 20 years [8]. The social and psychological effects of obesity are profound as obese youth are more likely to experience peer victimization, behavior problems, lower self-esteem, and greater body dissatisfaction than their non-overweight peers [9], [10], [11], [12], [13].

Children from rural communities are at particular risk for the deleterious, long-term complications associated with obesity. Families from rural areas are one of the largest medically underserved populations in the country. Rural counties have higher rates of poverty [14] and greater percentages of patients with chronic diseases [15]. Rural communities often lack facilities or the environment to promote healthy lifestyles (e.g., playgrounds, walking paths, exercise gyms). Families are also often required to travel longer distances to meet with friends and attend school than their non-rural counterparts. This can make organizing casual play opportunities for children or quick bike rides to a friend's house more difficult. Quality supermarkets and food outlets are also more dispersed. Thus, high quality food products (i.e., fresh fruits and vegetables) can be more expensive or more difficult to obtain for families in rural areas. In addition, the extended distance needed to travel to medical providers also makes it difficult to coordinate family schedules, which ultimately affects all aspects of health care [16]. These factors add an additional level of barriers that make adopting healthier lifestyles challenging for families in rural communities. Nor surprisingly, compared to their urban counterparts, residents in rural areas engage in fewer healthy lifestyle behaviors related to obesity, such as reducing dietary fat intake and decreasing sedentary activities [17]. Consequently, children and adults living in rural communities have higher rates of obesity [18], [19], [20].

Venues for establishing health promotion programs for families in rural areas are limited. One alternative is the Cooperative Extension Service (CES) network. Nationally, Cooperative Extension is a partnership between the U.S. Department of Agriculture (USDA) and land-grant universities to ensure that “practical applications of research in agriculture, home economics and rural energy” are provided in every county in the United States. Cooperative Extension programs currently provide services to residents across the U.S. The programs of the Florida Cooperative Extension are generally designed by the faculty at the University of Florida in response to community needs as identified by county extension agents and local advisory groups. The CES network offers a unique opportunity in that it provides the infrastructure, stature within rural communities, and knowledge of local communities to support preventive services to families in rural communities.

Behavioral Family-Based interventions including both children and their parent(s) have demonstrated success in producing weight loss in children [21], [22]. While the main focus of behavioral family interventions is to impact the child's weight status, these interventions commonly target both the child and parent for weight loss by including both children and parents in group-based intervention sessions. The existing research is limited, however, with respect to its generalizability to diverse community settings. Most weight management trials have consisted of efficacy studies conducted with middle-class participants and delivered in “optimal” (i.e., academic research) venues with a multidisciplinary team of experts, rather than in “real world”, community settings.

There is a growing body of research suggesting that working only with the parents(s) to encourage changes in their child's dietary and physical activity patterns may lead to similar or greater weight loss for children than Family-Based interventions that work with parents and children together. [23], [24]. Exclusively targeting the parent(s) in behavioral weight-loss interventions for children in rural settings may hold several advantages over Family-Based interventions. Given the extended distance needed to travel to providers for families in rural settings, a Parent-Only intervention may make it easier for families to coordinate schedules allowing for better attendance. Parent-Only interventions may also be more cost-effective as they require less staff and materials, which is critical for rural communities with limited resources. Unfortunately, only one study to date has published data comparing Family-Based and Parent-Only interventions in a randomized controlled trial. Golan et al. reported that children of parents who participated in a Parent-Only intervention targeting weight loss demonstrated greater weight change at post-treatment than children who participated with their parents in the Family-Based intervention program (9.5% versus 2.4% decrease in percentage overweight) [25]. Like most other trials in this area, this intervention was also conducted in an academic health center. Given the scope and seriousness of obesity in rural America, the lack of intervention studies highlights the pressing need for a clinical trial targeting weight management for children and families in underserved rural settings.