RESEARCH Research and Professional Briefs
An Adolescent Weight-Loss Program Integrating Family Variables Reduces Energy Intake HEATHER KITZMAN-ULRICH, PhD; ROBERT HAMPSON, PhD; DAWN K. WILSON, PhD; KATHERINE PRESNELL, PhD; ALAN BROWN, PhD; MARY O’BOYLE, PhD
ABSTRACT Family variables such as cohesion and nurturance have been associated with adolescent weight-related health behaviors. Integrating family variables that improve family functioning into traditional weight-loss programs can provide health-related benefits. The current study evaluated a family-based psychoeducational and behavioral skill-building weight-loss program for adolescent girls that integrated Family Systems and Social Cognitive Theories. Forty-two overweight (ⱖ95th percentile) female adolescent participants and parents participated in a 16-week randomized controlled trial comparing three groups: multifamily therapy plus psychoeducation (n⫽15), psychoeducation-only (n⫽16), or wait list (control; n⫽11) group. Body mass index, energy intake, and family measures were assessed at baseline and posttreatment. Adolescents in the psychoeducation-only group demonstrated a greater decrease in energy intake compared to the multifamily therapy plus psychoeducation and control groups (P⬍0.01). Positive changes in family nurturance were associated with lower levels of adolescent energy intake (P⬍0.05). No significant effects were found for body mass index. Results provide preliminary support for a psychoeducational program that integrates family variables to reduce energy intake in overweight adolescent girls. Results indicate that nurturance can be an important family variable to target in future adolescent weight-loss and dietary programs. J Am Diet Assoc. 2009;109:491-496.
H. Kitzman-Ulrich is a research assistant professor and D. K. Wilson is a professor, Department of Psychology, University of South Carolina, Columbia. R. Hampson is an associate professor, K. Presnell is assistant professor, A. Brown is a professor, and M. O’Boyle is an instructor, Department of Psychology, Southern Methodist University, Dallas, TX. Address correspondence to: Heather Kitzman-Ulrich, PhD, Department of Psychology, University of South Carolina, 1233 Washington St, 9th floor, Columbia, SC 29201. E-mail:
[email protected] Manuscript accepted: July 3, 2008. Copyright © 2009 by the American Dietetic Association. 0002-8223/09/10903-0009$36.00/0 doi: 10.1016/j.jada.2008.11.029
© 2009 by the American Dietetic Association
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besity has become an epidemic health problem in the Unites States in recent decades (1), and recent reports indicate 15% of adolescents are considered overweight (2). Previous studies have found that family variables, including cohesion and nurturance, have been associated with childhood overweight (3-5), therefore, incorporating family variables into traditional weight-loss programs could provide additional health-related benefits. Family variables, based on Family Systems Theory, refer to aspects of family functioning, including cohesion, nurturance, and conflict resolution (6). Family variables, such as nurturance (eg, connectedness, warmth, and caring) (7), have been directly related to the adolescent health behaviors of eating breakfast (3), fruit and vegetable intake (3,8), self-esteem, and body satisfaction (9), and inversely related to negative weightcontrol behaviors (9). In addition, a survey of girls found lower levels of parental nurturance in overweight compared to normal-weight girls (5). Family cohesion, defined as closeness and emotional bonding between family members (10), was found in a large survey to be lower in overweight girls (4). Parents’ report of family satisfaction, which is an indicator of global family competence and incorporates nurturance, cohesion, conflict resolution, and shared decision making (11), was a mediator of adolescent weight loss (12). Although these studies point to the importance of family variables, few weight-loss programs have included family variables. It is evident from the current literature that key family variables (3-5,8,9) and parental involvement (13) in adolescent weight-loss programs need further exploration. In the current study, a multifamily therapy group was utilized as a novel approach to parental involvement with the potential for improving family variables. These groups have been implemented in other adolescent health behaviors, have demonstrated improvements in family variables, and provide opportunities for families to learn and gain support from each other (14-16). This study expands on previous research by evaluating a family-based psychoeducational weight-loss program for adolescents that included components to improve family variables (family competence, nurturance, conflict resolution, and cohesion). This study also assessed the efficacy of a multifamily therapy group. In addition, this study provides information on family variables and their relationship with adolescent body mass index (BMI; calculated as kg/m2) and energy intake over time. The primary hypothesis tested was that the multifamily therapy plus psychoeducation group and the psychoeducationonly group would demonstrate greater reductions in ad-
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olescent BMI z score and energy intake as compared to the control group, with strongest effects in the multifamily therapy plus psychoeducation group. METHODS Participants Participants and family members were recruited through pediatrician offices and promotional materials. Only female adolescents were recruited because of the preliminary nature of this study and possible developmental differences in weight-related behaviors by sex. Adolescent eligibility criteria included BMI ⱖ95th percentile, 12 to 15 years of age, not participating in a weight-loss program, ability to engage in physical activity, and at least one adult family member willing to participate. Of 66 eligible families, 44 families volunteered for the study. Two families withdrew prior to randomization, resulting in 42 families. Procedures The study was a prospective, 16-week, randomized trial with three groups: multifamily therapy plus psychoeducation, psychoeducation-only, and control (wait-list control group did not participate in any intervention during the 4-month study period). The study was conducted in two cohorts between December 2002 and June 2003 and was approved by the Institutional Review Board of The Cooper Institute and Southern Methodist University. Informed consent and assent were collected and participants were randomized through letters containing group assignment. Psychoeducational Curriculum. Participants and their parents in the multifamily therapy plus psychoeducation and psychoeducation-only groups received the psychoeducational curriculum during 16 weeks that included behavioral skill-building and psychosocial components (see Figure) facilitated by master-level family therapists and trained graduate students. The psychoeducational curriculum was previously used in studies to increase exercise in sedentary adults (17) and was adapted for the present study based on Social Cognitive (18) and Family Systems (6) theories for adolescent weight-loss behaviors and parental involvement. The psychoeducational curriculum did not include a specific caloric restriction because many adolescents do not comply with self-monitoring of daily food intake (19). For that reason, adolescents were encouraged to monitor food-group servings with a pictorial goal sheet to achieve a healthful diet within their recommended calorie range based on the Food Guide Pyramid (20). Facilitator Training. All facilitators attended a 1-day training workshop and were given facilitator guides for each session. A senior marriage and family therapist and a coinvestigator with previous experience conducting weight-loss programs provided supervision. Multifamily Therapy Group. In addition to the psychoeducational curriculum, the multifamily therapy plus psychoeducation group attended a multifamily therapy group that lasted approximately 45 minutes. Facilitators were given discussion points based on the psychoeducational curriculum and followed principles of group therapy facilitation, such as positively reinforcing desired behavior
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and keeping families on task (21). Families were able to discuss implementing the psychoeducational curriculum in their home environment and to share successes, frustrations, and coping strategies in the multifamily therapy plus psychoeducation group. Participants in the psychoeducation-only group did not participate in a multifamily therapy group. To be consistent with intervention attention, participants in the psychoeducation-only group played interactive games related to health behaviors during this time. Fidelity. Participants completed satisfaction surveys at the end of each session. Average attendance was 42.6% for the multifamily therapy plus psychoeducation group and 45.6% for the psychoeducation-only group during the 16-week program. Measures. All measures were collected by trained staff prior to randomization at baseline and at 16 weeks postintervention. BMI. Weight and height was collected on a balance beam scale with stadiometer (seca700, SECA, Hamburg, Germany) and were used to calculate BMI. BMI z score was calculated with EpiInfo (version 3.4.3., 2007, Centers for Disease Control and Prevention, Atlanta, GA) based on the Centers for Disease Control sexspecific 2000 reference curves. Diet Measure. Dietary intake in adolescent participants was measured with the 24-hour diet recall administered by a registered and licensed dietitian and two trained dietetics graduate students. The registered dietitian provided supervision and conducted observations of graduate student recalls. The 24-hour diet recall is a structured interview that assesses food intake from the previous day and has high correlations to validation standards (eg, chemical analysis) (22), and has demonstrated ability to detect dietary change between groups (23). It has also been shown to be advantageous to other self-report measures of dietary intake, such as food records (24). Three 24-hour multiple-pass recalls (2 weekdays and 1 weekend) were collected using established procedures (25) at baseline and postintervention. The initial recall was collected in person and remaining recalls were collected on random days by telephone. Food models and illustrations were provided to aid in reporting of food intake over the telephone. Diet recall data was entered into the Food Intake Analysis System (version 3.99, 2000, University of Texas-Houston School of Public Health, Houston). Family Measures. The Self-Report Family Inventory (SFI), a 36-item self-report questionnaire, was used to measure family variables (11). The SFI has acceptable rates of reliability and validity and corresponds well with other self-report questionnaires measuring family variables (11). Items are rated on a 5-point scale, with higher scores indicating greater family dysfunction. In the current study, Cronbach’s ␣ for the SFI subscales was .91 for Health/Competence, .71 for Cohesion, and .81 for Conflict. The Health/Competence subscale contains 19 items and is a global measure of family health or satisfaction (11). The current study also included the conflict resolution subscale because adolescence is often a difficult developmental period (7). The conflict resolution subscale, containing 12 items, measures the family’s ability to effectively resolve conflict. The cohesion subscale has five
Title Session 1 Getting started
Session 2 Substituting healthful alternatives Session 3 Benefits and barriers Session 4 Goal setting and rewarding yourself Session 5 Communication skills
Session 6 Social support
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Session 7 Energy balance
Session 8 Body image
Session 9 Media literacy
Session 10 High-risk situations Session 11 Stress and time management, celebration and wrap-up
Social Cognitive and Family System Theories variables ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ● ●
Nurturance Cohesion Self-monitoring Increasing knowledge Increasing healthful opportunities Increasing knowledge Substituting healthful alternatives Self-monitoring Comprehend benefits Increasing healthful opportunities Self-monitoring Increasing knowledge Comprehend benefits Caring about consequences to others Comprehend benefits Goal-setting Shared decision making Competence Conflict resolution Cohesion Nurturance Self-monitoring Goal-setting Increasing healthful opportunities Caring about consequences to others Self-monitoring Increasing healthful opportunities Increasing knowledge Enlisting social support Increasing self-esteem Increasing knowledge Goal-setting
● ● ● ● ● ● ● ● ● ● ● ● ●
Self-monitoring Goal-setting Increasing healthful opportunities Caring about consequences to others Increasing self-esteem Nurturance Competence Shared decision making Nurturance Comprehend benefits Increasing knowledge Substituting alternatives Increasing healthful opportunities
● ● ● ● ●
Warning of risks Increasing knowledge Substituting alternatives Reminding yourself Increasing healthful opportunities
Content
Application
Activities
● ● ● ●
Environmental contributors to obesity Discuss typical day Creating a supportive environment (parents only) Motivations for weight loss (girls only)
Complete supportive environment handout (break-out session parents) Complete you and your weight handout (breakout session girls)
Introduction Icebreaker— Getting to know you
● ● ● ●
Moderate-intensity physical activity Basics of healthful eating Cues for activity and inactivity Cues for making healthful food choices
Lifestyle log
Moderate-intensity walk
● Barriers and benefits ● Problem-solving barriers ● Healthful choices, portion sizes—food groups ● How to set effective goals ● Rewarding yourself
Assessing barriers and benefits handout Think about physical activity this coming week Set goals for physical activity, media, and nutrition Set rewards for self and reciprocal rewards
● Fruit group ● Fitting fruit into your diet, benefits of fruit ● Effective communication skills (reflective listening, “I” statements, honoring different perspectives)
How I see my family activity (evaluate family communication and compare answers in family dyads, group discussion on family activity)
Easy fruit drinks Plan one family meal during next week
● Vegetable group ● Social support ● How to deal with bullies and saboteurs
Recruiting my support troops handout (determine type of support needed, who can provide, and how to ask for it)
Role-play how to deal with saboteurs/bullies
● Milk group ● Strategies for getting recommended number of servings per day, healthful choices ● Energy expenditure ● Moderate intensity physical activities ● Meat group ● Healthful choices and serving sizes ● Building self-esteem ● Deconstructing the ideal body—girls ● Possible contributors to weight gain—parents ● Healthful eating vs dieting ● The tip of the Food Guide Pyramid (moderation, serving sizes) ● All foods can fit ● Media Literacy—girls (group discussion on advertisements) ● Media Literacy—parents (setting boundaries, monitoring)
Recall of a typical day’s food intake, calculate calories for the whole day Recall of a typical day’s activity, calculate calories expended
Taste test Burning calories equation
Persuasion strategies Group discussion on all foods can fit Breakout session girls Breakout session parents
Show commercial videos and discuss as a group
● ● ● ● ● ● ● ●
Assessing high-risk situations handout
Pick healthful meals from menus
Are you stressed worksheet
Physical activity and nutrition jeopardy
Relapse prevention High-risk situations Fast food and eating out Stress management Time management Quick and easy meal ideas Celebration Assess long-term goals
Building self-esteem worksheet (breakout session girls) The Ideal Body Matrix Possible contributors to weight gain worksheet (breakout session parents)
Figure. Psychoeducational curriculum: Theoretical constructs and intervention content used in a study evaluating a family-based psychoeducational and behavioral skill-building weight-loss program for adolescent girls.
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Table. Mean (standard deviation) change in energy intake and body mass index (BMI) z score from baseline to post-intervention by group among adolescent girls in a study evaluating a family-based psychoeducational and behavioral skill-building weight-loss program Variable BMI z score Energy intakea Baseline BMI z score Energy intake Postintervention BMI z score Energy intake Change score BMI z score Energy intake
Multifamily therapy ⴙpsychoeducation
Psychoeducation only
Control
4™™™™™™™™™™™™™™™™™™™™™™™™ n ™™™™™™™™™™™™™™™™™™™™™™™™3 14 13 8 8 9 7 4™™™™™™™™™™™™™™™™ mean (standard deviation) ™™™™™™™™™™™™™™3 2.2 (0.4) 2.3 (0.3) 2.3 (0.3) 1,512.6 (622.3) 1,555.5 (493.8) 1,095.1 (372.1) 2.2 (0.4) 1,574.0 (515.1) 0.0 (0.1) 61.44 (423.9)b
2.2 (0.3) 1,190.4 (296.3) ⫺0.1 (0.1) ⫺365.1 (456.7)b
2.3 (0.3) 1,422.5 (430.5) 0.0 (0.1) 327.4 (402.0)b
a
Participants with fewer than two recalls at baseline were not included. P⬍0.01.
b
items and measures feelings of closeness and emotional bonding between family members. Family nurturance comprises feelings of warmth and caring and has been found to be related to health behaviors in adolescents (3,8). Therefore, a new 7-item subscale of the SFI was developed for this study to specifically assess nurturance (Cronbach’s ␣⫽.82). Statistical Analyses All data was entered by trained study staff using double data entry to reduce errors. Analysis of covariance controlling for race was used to test for differences between groups for BMI z score, energy intake, and family variable change scores (SAS, version 9.1, 2002-2003, SAS Institute, Inc, Cary, NC). Change scores for BMI z score and energy intake were calculated by subtracting baseline from postintervention with a negative score indicating a reduction in energy intake or BMI z score. Family variable change scores were calculated by subtracting postintervention from baseline with a positive score indicating an improvement in family variables. Based on a large effect size and an ␣ level of .05, 66 subjects were needed for adequate power (0.80) to detect differences between three groups and 42 subjects were needed to detect differences between two groups. RESULTS AND DISCUSSION Baseline data were collected on 42 adolescent females (mean age⫽13.3 years; mean BMI⫽33.6; 55% white), 42 mothers (mean age⫽42.9 years; mean BMI⫽33.0; mean educational level⫽14.6 years), and 26 fathers (mean age⫽45 years; mean BMI⫽34.9). Analysis of variance indicated that the psychoeducation-only group had considerably higher SFI Nurturance scores (mean⫽2.5, standard deviation [SD]⫽0.7) compared to the control group (mean⫽1.6, SD⫽0.8) at baseline, indicating lower levels of nurturance in the psychoeducation-only as compared to
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the control group. There were no other significant differences in baseline values between groups. Eighty-three percent of families completed baseline and 16-week measures (n⫽35), however, diet recall data was limited to adolescents who completed at least two recalls at baseline (n⫽24, of which 96% completed three recalls at baseline and 80% completed three recalls at post). At postintervention, three of the 24 participants with baseline recall data completed only one recall. Findings did not change when these participants were removed. Seven families did not complete postintervention measures (three families dropped out at baseline and four families were lost to follow-up). Analyses comparing completers vs noncompleters revealed that noncompleters were significantly older (mean⫽14.0, SD⫽1.2) than completers (mean⫽13.1, SD⫽1.0) (P⬍0.05). Adolescent baseline, postintervention, and change scores are shown in the Table for BMI z score and energy intake. Analysis of covariance found a significant difference in energy intake (F⫽6.68, P⬍0.01), indicating a significant reduction in energy intake from baseline to postintervention in the psychoeducation-only group (leastsquares mean⫽⫺381.1, standard error [SE]⫽136.8), compared to the multifamily therapy plus psychoeducation (least-squares mean⫽66.8, SE⫽128.9) and control (leastsquares mean⫽338.8, SE⫽146.2) groups. This finding is consistent with previous studies that incorporated lifestyle approaches to improve health behaviors (26,27) and provides preliminary support for incorporating lifestyle approaches in adolescent weight-loss and dietary programs. No significant effects were found for BMI z score. This could be due to the short duration of the study, as previous successful weight-loss studies were longer (28-30). In addition, because this study focused on a healthful diet instead of a specific calorie restriction, a longer duration may be needed to demonstrate changes in BMI. A partial correlation controlling for baseline energy intake and race indicated that positive changes in nur-
turance were associated with lower levels of energy intake at postintervention (r⫽⫺0.60; P⬍0.05). This is consistent with previous studies that have found nurturance to be related to adolescent weight-related behaviors (3,8). Yet, improvements in overall family variables were not demonstrated in this study, which could be attributed to families improving in some but not all family variables. More intensive treatment may be necessary to improve overall family functioning and demonstrate changes in family variables. Interestingly, analysis of covariance found a significant worsening of conflict in the multifamily therapy plus psychoeducation group (least-squares mean⫽⫺0.43, SE⫽0.15) compared to the psychoeducation-only (leastsquares mean⫽0.22, SE⫽0.15) and control (least-squares mean⫽0.20, SE⫽0.19) groups (F⫽5.76; P⬍0.01). In addition, the multifamily therapy plus psychoeducation group did not lead to greater improvements as hypothesized and did not demonstrate reductions in energy intake. Increases in conflict within the family could have attenuated any affect of the psychoeducational curriculum on energy intake. Furthermore, conflict issues may have arisen without sufficient time to resolve them during the multifamily therapy group. These findings are inconsistent with previous adolescent health studies, such as eating disorders, that have reported multifamily therapy groups as a positive experience (14,15). Larger studies are needed to determine whether multifamily therapy groups could be beneficial in weight-loss programs. There are several limitations of the present study that need to be addressed. Although our study is consistent with other weight-loss studies that have demonstrated modest levels of attendance (31), modest attendance rates were an issue that could have reduced the impact of the intervention. Further research is needed to determine how to improve attendance rates in weight-loss studies. Another limitation of the study was that although the psychoeducation-only group produced a substantial reduction in energy intake, corresponding changes in BMI were not seen. Most likely, the reduction in energy intake demonstrated at postintervention was a cumulative effect of the intervention and, therefore, a longer measurement period would have been useful to further evaluate changes in BMI. However, reducing dietary intake in overweight youth is an important first step to weight loss and may provide the confidence for continued behavior change. Power to detect effects was limited due to the small sample size in the present study. A final limitation of the present study concerns the accuracy of the 24-hour dietary recall methods. Although there was substantial variability in this measure in the present study, the variability of the dietary recalls was consistent with other published studies in youth (32,33). Future research is needed to replicate the findings of this study in a larger sample of youth. CONCLUSIONS This study evaluated a psychoeducational weight-loss program for overweight female adolescents that integrated family variables and a multifamily therapy group as a novel approach to parental involvement. The findings from this study provide preliminary support for a family-based psychoeducational weight-loss program
that integrated family variables to reduce energy intake in overweight (⬎95th percentile) adolescent girls. Reductions in energy intake are an important component of the energy balance equation and weight loss. Another key finding was that family nurturance was associated with lower levels of energy intake and may be an important family variable to consider in future family-based weightloss programs. This study was funded by the Hogg Foundation for Mental Health. References 1. Troiano RP, Flegal KM. Overweight children and adolescents: Description, epidemiology, and demographics. Pediatrics. 1998;101(Pt 2):497-504. 2. Ogden CL, Flegal KM, Carroll MD, Johnson CL. Prevalence and trends in overweight among US children and adolescents, 1999-2000. JAMA. 2002;288:1728-1732. 3. Mellin AE, Neumark-Sztainer D, Story M, Ireland M, Resnick MD. Unhealthy behaviors and psychosocial difficulties among overweight adolescents: The potential impact of familial factors. J Adolesc Health. 2002;31:145-153. 4. Mendelson BK, White DR, Schliecker E. Adolescents’ weight, sex, and family functioning. Int J Eat Disord. 1995;17:73-79. 5. Turner HM, Rose KS, Cooper MJ. Schema and parental bonding in overweight and nonoverweight female adolescents. Int J Obes. 2005; 29:381-387. 6. Broderick CB. Understanding Family Process: Basics of Family Systems Theory. Thousand Oaks, CA: Sage Publications; 1993. 7. Mackey SK. Nurturance: A neglected dimension in family therapy with adolescents. J Marital Fam Ther. 1996;22:489-508. 8. Neumark-Sztainer D, Story M, Resnick MD, Blum RW. Correlates of inadequate fruit and vegetable consumption among adolescents. Prev Med. 1996;25:497-505. 9. Fulkerson JA, Strauss J, Neumark-Sztainer D, Story M, Boutelle K. Correlates of psychosocial well-being among overweight adolescents: The role of the family. J Consult Clin Psychol. 2007;75:181186. 10. Snyder, Cozzi, Mangrum. Conceptual issues in assessing couples and families. In: Liddle H, Santisteban D, Levant R, Bray J, eds. Family Psychology: Science Based Interventions. Washington, DC: APA; 2002. 11. Beavers WR, Hampson RB. Successful Families: Assessment and Intervention. New York, NY: W.W. Norton & Company; 1990. 12. White MA, Martin PD, Newton RL, et al. Mediators of weight loss in a family-based intervention presented over the internet. Obes Res. 2004;12:1050-1059. 13. McLean N, Griffin S, Toney K, Hardeman W. Family involvement in weight control, weight maintenance and weight-loss interventions: A systematic review of randomised trials. Int J Obes Relat Metab Disord. 2003;27:987-1005. 14. Colahan M, Robinson PH. Multi-family groups in the treatment of young adults with eating disorders. J Fam Ther. 2002;24:17-30. 15. Dare C, Eisler I. A multi-family group day treatment programme for adolescent eating disorder. Eur Eat Disord Rev. 2000;8:4-18. 16. Dickerson AD, Crase SJ. Parent-adolescent relationships: The influence of multi-family therapy group on communication and closeness. Am J Fam Ther. 2005;33:45-59. 17. Kohl HW 3rd, Dunn AL, Marcus BH, Blair SN. A randomized trial of physical activity interventions: Design and baseline data from project active. Med Sci Sports Exerc. 1998;30:275-283. 18. Bandura A. Social Foundations for Thought and Action. Englewood Cliffs, NJ: Prentice-Hall; 1986. 19. Saelens BE, McGrath AM. Self-monitoring adherence and adolescent weight control efficacy. Child Health Care. 2003;32:137-152. 20. USDA. Food Guide Pyramid. http://www.cnpp.usda.gov/Publications/ MyPyramid/OriginalFoodGuidePyramids/FGP/FGPPamphlet.pdf. Accessed April 15, 2008. 21. Yalom ID, Leszcz M. The Theory and Practice of Group Psychotherapy. 5th ed. New York, NY: Basic Books; 2005. 22. McPherson RS, Hoelscher DM, Alexander M, Scanlon KS, Serdula MK. Dietary assessment methods among school-aged children: Validity and reliability. Prev Med. 2000;31:S11-S33. 23. Buzzard IM, Faucett CL, Jeffery RW, McBane L, McGovern P,
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28. Brownell KD, Kelman JH, Stunkard AJ. Treatment of obese children with and without their mothers: Changes in weight and blood pressure. Pediatrics. 1983;71:515-523. 29. Coates TJ, Killen JD, Slinkard LA. Parent participation in a treatment program for overweight adolescents. Int J Eat Disord. 1982;1: 37-48. 30. Mellin LM, Slinkard LA, Irwin CE Jr. Adolescent obesity intervention: Validation of the SHAPEDOWN program. J Am Diet Assoc. 1987;87:333-338. 31. Blue CL, Black DR. Synthesis of intervention research to modify physical activity and dietary behaviors. Res Theory Nursing Pract: An Int J. 2005;19:25-61. 32. Fiorito LM, Ventura AK, Mitchell DC, Smiciklas-Wright H, Birch LL. Girls’ dairy intake, energy intake, and weight status. J Am Diet Assoc. 2006;106:1851-1855. 33. Savage, JS, Mitchell DC, Smiciklas-Wright H, Downs DS, Birch LL. Plausible reports of energy intake may predict body mass index in pre-adolescent girls. J Am Diet Assoc. 2008;108:131-135.
