Prevention Science

, Volume 16, Issue 3, pp 408–419 | Cite as

Preventing Weight Gain and Obesity: Indirect Effects of the Family Check-Up in Early Childhood

  • Justin D. SmithEmail author
  • Zorash Montaño
  • Thomas J. Dishion
  • Daniel S. Shaw
  • Melvin N. Wilson


The early signs of obesity are observable in early childhood. Although the most promising prevention approaches are family-centered, few relevant early prevention programs exist. This study evaluated the effects of an evidence-based, home-visiting intervention, the Family Check-Up (FCU), on the trajectory of children’s weight gain. The FCU was designed to prevent the development of behavior problems by improving family management practices; children’s weight has not been an explicit target. On the basis of previous research and conceptual models, we hypothesized that intervention effects on parenting practices, specifically caregivers’ use of positive behavior support (PBS) strategies in toddlerhood, would mediate improvements in children’s weight trajectories. A total of 731 indigent caregiver–child dyads from a multisite randomized intervention trial were examined. Observational assessment of parenting and mealtime behaviors occurred from age 2–5 years. The child’s body mass index (BMI) was assessed yearly from age 5–9.5 years. Path analysis with a latent growth model revealed a significant indirect effect of the FCU on the trajectory of BMI in later childhood. Improvements in caregivers’ PBS in toddlerhood, which was related to the nutritional quality of the meals caregivers served to the child during the mealtime task, served as the intervening process. Furthermore, findings indicate that the FCU prevents progression to overweight and obese status amongst at-risk children. These study results add to existing evidence that has demonstrated that family-based interventions aimed at improving general family management skills are effective at preventing weight gain. Future directions are discussed.


BMI Family intervention Latent growth model Pediatric obesity Translational research 



This research was supported by National Institute on Drug Abuse grant DA016110 to the third, fourth, and fifth authors. The second author was supported by minority fellowship SM60563-40 from the Department of Health and Human Services. Seed funding from the College of Liberal Arts and Sciences at Arizona State University awarded to Thomas Dishion supported the first and second authors. The authors also gratefully thank Charlotte Winter and Shannon McGill for assistance with the data management, Cheryl Mikkola for editorial support, the observational coding team at the Child and Family Center, the rest of the Early Steps team in Eugene, Pittsburgh, and Charlottesville, and the families who have participated in the study.

Conflict of Interest

Justin D. Smith, Zorash Montaño, Thomas J. Dishion, Daniel S. Shaw, and Melvin N. Wilson have no conflicts of interest or financial relationships relevant to this article to disclose.


  1. Asparouhov, T., & Muthén, B. O. (2010). Bayesian analysis using Mplus: Technical implementation. Mplus Technical Report. Retrieved from
  2. August, G. P., Caprio, S., Fennoy, I., Freemark, M., Kaufman, F. R., Lustig, R. H., & Montori, V. M. (2008). Prevention and treatment of pediatric obesity: An endocrine society clinical practice guideline based on expert opinion. Journal of Clinical Endocrinology & Metabolism, 93, 4576–4599. doi: 10.1210/jc.2007-2458.CrossRefGoogle Scholar
  3. Barlow, S. E. (2007). Expert committee recommendations regarding the prevention, assessment, and treatment of child and adolescent overweight and obesity: Summary report. Pediatrics, 120, S164–S192.CrossRefPubMedGoogle Scholar
  4. Bentler, P. M. (1992). On the fit of models to covariances and methodology to the bulletin. Psychological Bulletin, 112, 400–404. doi: 10.1037/0033-2909.112.3.400.CrossRefPubMedGoogle Scholar
  5. Biglan, A., Flay, B. R., Embry, D. D., & Sandler, I. N. (2012). The critical role of nurturing environments for promoting human well-being. American Psychologist, 67, 257–271. doi: 10.1037/a0026796.PubMedCentralCrossRefPubMedGoogle Scholar
  6. Bradley, R. H., Corwyn, R. F., McAdoo, H. P., & Garcia-Coll, C. (2001). The home environments of children in the United States. Part I: Variations by age, ethnicity, and poverty status. Child Development, 72, 1844–1867. doi: 10.1111/1467-8624.t01-1-00382.CrossRefPubMedGoogle Scholar
  7. Brennan, L. M., Shelleby, E. C., Shaw, D. S., Gardner, F. E. M., Dishion, T. J., & Wilson, M. N. (2013). Indirect effects of the family check-up on school-age academic achievement through improvements in parenting in early childhood. Journal of Educational Psychology, 105, 762–773. doi: 10.1037/a0032096.CrossRefGoogle Scholar
  8. Bronfenbrenner, U., & Evans, G. W. (2000). Developmental science in the 21st century: Emerging questions, theoretical models, research designs and empirical findings. Social Development, 9, 115–125. doi: 10.1111/1467-9507.00114.CrossRefGoogle Scholar
  9. Brotman, L. M., Dawson-McClure, S., Huang, K.-Y., Theise, R., Kamboukos, D., Wang, J., & Ogedegbe, G. (2012). Early childhood family intervention and long-term obesity prevention among high-risk minority youth. Pediatrics, 129, e621–e628. doi: 10.1542/peds.2011-1568.PubMedCentralCrossRefPubMedGoogle Scholar
  10. Browne, W. M., & Cudeck, R. (1993). Alternative ways of assessing model fit. In K. A. Bollen & J. S. Long (Eds.), Testing structural equation models. Newbury Park, CA: Sage.Google Scholar
  11. Carr, E. G., Dunlap, G., Horner, R. H., Koegel, R. L., Turnbull, A. P., Sailor, W., & Fox, L. (2002). Positive behavior support: Evolution of an applied science. Journal of Positive Behavior Interventions, 4, 4–16. doi: 10.1177/109830070200400102.CrossRefGoogle Scholar
  12. Casey, P. H., Szeto, K., Lensing, S., Bogle, M., & Weber, J. (2001). Children in food-insufficient, low-income families: Prevalence, health, and nutrition status. Archives of Pediatrics & Adolescent Medicine, 155, 508–514. doi: 10.1001/archpedi.155.4.508.CrossRefGoogle Scholar
  13. Chambers, E. C., Duarte, C. S., & Yang, F. M. (2009). Household instability, area poverty, and obesity in urban mothers and their children. Journal of Health Care for the Poor and Underserved, 20, 122–133. doi: 10.1353/hpu.0.0110.CrossRefPubMedGoogle Scholar
  14. Cullen, K. W., Baranowski, T., Owens, E., Marsh, T., Rittenberry, L., & de Moor, C. (2003). Availability, accessibility, and preferences for fruit, 100 % fruit juice, and vegetables influence children′s dietary behavior. Health Education & Behavior, 30, 615–626. doi: 10.1177/1090198103257254.CrossRefGoogle Scholar
  15. Dishion, T. J., Hogansen, J., Winter, C., & Jabson, J. M. (2004). The coder impressions inventory. Unpublished coding manual. Available from the Child and Family Center, 6217 University of Oregon, Eugene, OR 97403.Google Scholar
  16. Dishion, T. J., Shaw, D. S., Connell, A., Gardner, F. E. M., Weaver, C., & Wilson, M. (2008). The Family Check-Up with high-risk indigent families: Preventing problem behavior by increasing parents′ positive behavior support in early childhood. Child Development, 79, 1395–1414. doi: 10.1111/j.1467-8624.2008.01195.x.PubMedCentralCrossRefPubMedGoogle Scholar
  17. Dishion, T. J., & Stormshak, E. A. (2007). Intervening in children′s lives: An ecological, family-centered approach to mental health care. Washington, DC: American Psychological Association.CrossRefGoogle Scholar
  18. Drewnowski, A., & Specter, S. (2004). Poverty and obesity: The role of energy density and energy costs. The American Journal of Clinical Nutrition, 79, 6–16.PubMedGoogle Scholar
  19. Ebbeling, C. B., Pawlak, D. B., & Ludwig, D. S. (2002). Childhood obesity: Public-health crisis, common sense cure. The Lancet, 360, 473–482. doi: 10.1016/S0140-6736(02)09678-2.CrossRefGoogle Scholar
  20. Fiese, B. H., & Jones, B. L. (2012). Food and family: A socio-ecological perspective for child development. Advances in Child Development and Behavior, 42, 307–337. doi: 10.1016/B978-0-12-394388-0.00009-5.CrossRefPubMedGoogle Scholar
  21. Forgatch, M. S., & Patterson, G. R. (2010). Parent management training-Oregon model: An intervention for antisocial behavior in children and adolescents. In J. R. Weisz & A. E. Kazdin (Eds.), Evidence-based psychotherapies for children and adolescents (pp. 159–178). New York, NY: Guilford Press.Google Scholar
  22. Gallagher, K. C. (2002). Does child temperament moderate the influence of parenting on adjustment? Developmental Review, 22, 623–643. doi: 10.1016/S0273-2297(02)00503-8.CrossRefGoogle Scholar
  23. Hu, L., & Bentler, P. M. (1999). Cutoff criteria for fit indexes in covariance structure analysis: Conventional criteria versus new alternatives. Structural Equation Modeling: A Multidisciplinary Journal, 6, 1–55. doi: 10.1080/10705519909540118.CrossRefGoogle Scholar
  24. Institute of Medicine. (2011). Early childhood obesity prevention policies. Washington, DC: The National Academies Press.Google Scholar
  25. Institute of Medicine and National Academies. (2005). Preventing childhood obesity: Health in the balance: National Academies PressGoogle Scholar
  26. Jabson, J. M., Dishion, T. J., Gardner, F. E. M., & Burton, J. (2004). Relationship Process Code V-2.0 (RPC) training manual: A system for coding relationship interactions. Unpublished coding manual. Available from the Child and Family Center, 195 W. 12th Ave., Eugene, OR 97401–3408.Google Scholar
  27. Jo, B. (2002). Statistical power in randomized intervention studies with noncompliance. Psychological Methods, 7, 178–193. doi: 10.1037/1082-989X.7.2.178.CrossRefPubMedGoogle Scholar
  28. Kazak, A. E., Simms, S., & Rourke, M. T. (2002). Family systems practice in pediatric psychology. Journal of Pediatric Psychology, 27, 133–143. doi: 10.1093/jpepsy/27.2.133.CrossRefPubMedGoogle Scholar
  29. Kitzman-Ulrich, H., Wilson, D., George, S., Lawman, H., Segal, M., & Fairchild, A. (2010). The integration of a family systems approach for understanding youth obesity, physical activity, and dietary programs. Clinical Child and Family Psychology Review, 13, 231–253. doi: 10.1007/s10567-010-0073-0.PubMedCentralCrossRefPubMedGoogle Scholar
  30. Komro, K. A., Flay, B. R., & Biglan, A. (2011). Creating nurturing environments: A science-based framework for promoting child health and development within high-poverty neighborhoods. Clinical Child and Family Psychology Review, 14, 111–134. doi: 10.1007/s10567-011-0095-2.PubMedCentralCrossRefPubMedGoogle Scholar
  31. Lee, S., & Song, X. (2004). Evaluation of the Bayesian and maximum likelihood approaches in analyzing structural equation models with small sample sizes. Multivariate Behavioral Research, 39, 653–686. doi: 10.1207/s15327906mbr3904_4.CrossRefGoogle Scholar
  32. Liang, J., Matheson, B., Kaye, W., & Boutelle, K. (2013). Neurocognitive correlates of obesity and obesity-related behaviors in children and adolescents. International Journal of Obesity, 1–13. doi:  10.1038/ijo.2013.142
  33. Lovejoy, M. C., Graczyk, P. A., O′Hare, E., & Neuman, G. (2000). Maternal depression and parenting behavior: A meta-analytic review. Clinical Psychology Review, 20, 561–592. doi: 10.1016/S0272-7358(98)00100-7.CrossRefPubMedGoogle Scholar
  34. Lunkenheimer, E. S., Dishion, T. J., Shaw, D. S., Connell, A. M., Gardner, F. E. M., Wilson, M. N., & Skuban, E. M. (2008). Collateral benefits of the Family Check-Up on early childhood school readiness: Indirect effects of parents′ positive behavior support. Developmental Psychology, 44, 1737–1752. doi: 10.1037/a0013858.PubMedCentralCrossRefPubMedGoogle Scholar
  35. Mamun, A. A., O′Callaghan, M. J., Cramb, S. M., Najman, J. M., Williams, G. M., & Bor, W. (2009). Childhood behavioral problems predict young adults′ BMI and obesity: Evidence from a birth cohort study. Obesity, 17, 761–766. doi: 10.1038/oby.2008.594.CrossRefPubMedGoogle Scholar
  36. Matheny, A. P., Wachs, T. D., Ludwig, J. L., & Phillips, K. (1995). Bringing order out of chaos: Psychometric characteristics of the Confusion, Hubbub, and Order scale. Journal of Applied Developmental Psychology, 16, 429–444. doi: 10.1016/0193-3973(95)90028-4.CrossRefGoogle Scholar
  37. McGovern, L., Johnson, J. N., Paulo, R., Hettinger, A., Singhal, V., Kamath, C., & Montori, V. M. (2008). Treatment of pediatric obesity: A systematic review and meta-analysis of randomized trials. Journal of Clinical Endocrinology & Metabolism, 93, 4600–4605. doi: 10.1210/jc.2006-2409.CrossRefGoogle Scholar
  38. Montaño, Z., Smith, J. D., Dishion, T. J., Shaw, D. S., & Wilson, M. N. (manuscript submitted for publication). Longitudinal relations between observed parenting behaviors and dietary quality of meals from ages 2 to 5.Google Scholar
  39. Muthén, B. O. (2010). Bayesian analysis in Mplus: A brief introduction. Los Angeles, CA: Technical Report. Muthén & Muthén.Google Scholar
  40. Muthén, L. K., & Muthén, B. O. (2013). Mplus (version 7.1). Los Angeles, CA: Muthén & Muthén.Google Scholar
  41. Nader, P. R., O′Brien, M., Houts, R., Bradley, R., Belsky, J., Crosnoe, R., & Network, H. D. E. C. C. R. (2006). Identifying risk for obesity in early childhood. Pediatrics, 118, e594–e601. doi: 10.1542/peds.2005-2801.CrossRefPubMedGoogle Scholar
  42. Ogden, C. L., Carroll, M. D., Curtin, L. R., McDowell, M. A., Tabak, C. J., & Flegal, K. M. (2006). Prevalence of overweight and obesity in the United States, 1999–2004. JAMA, 295, 1549–1555. doi: 10.1001/jama.295.13.1549.CrossRefPubMedGoogle Scholar
  43. Ogden, C. L., Carroll, M. D., Kit, B. K., & Flegal, K. M. (2014). Prevalence of childhood and adult obesity in the United States, 2011–2012. JAMA, 311, 806–814. doi: 10.1001/jama.2014.732.CrossRefPubMedGoogle Scholar
  44. Onis, M. D., Onyango, A. W., Borghi, E., Siyam, A., Nishida, C., & Siekmann, J. (2007). Development of a WHO growth reference for school-aged children and adolescents. Bulletin of the World Health Organization, 85, 660–667. doi: 10.1590/S0042-96862007000900010.PubMedCentralCrossRefPubMedGoogle Scholar
  45. Radloff, L. S. (1977). The CES-D scale. Applied Psychological Measurement, 1, 385–401.CrossRefGoogle Scholar
  46. Rhee, K. E. (2008). Childhood overweight and the relationship between parent behaviors, parenting style, and family functioning. The ANNALS of the American Academy of Political and Social Science, 615, 11–37. doi: 10.1177/0002716207308400.CrossRefGoogle Scholar
  47. Rhee, K. E., Lumeng, J. C., Appugliese, D. P., Kaciroti, N., & Bradley, R. H. (2006). Parenting styles and overweight status in first grade. Pediatrics, 117, 2047–2054. doi: 10.1542/peds.2005-2259.CrossRefPubMedGoogle Scholar
  48. Rothbart, M. K., Ahadi, S. A., Hershey, K. L., & Fisher, P. (2001). Investigations of temperament at three to seven years: The Children′s Behavior Questionnaire. Child Development, 72, 1394–1408. doi: 10.1111/1467-8624.00355.CrossRefPubMedGoogle Scholar
  49. Scaramella, L. V., & Leve, L. D. (2004). Clarifying parent–child reciprocities during early childhood: The early childhood coercion model. Clinical Child and Family Psychology Review, 7, 89–107. doi: 10.1023/B:CCFP.0000030287.13160.a3.CrossRefPubMedGoogle Scholar
  50. Schmitz, K. H., Lytle, L. A., Phillips, G. A., Murray, D. M., Birnbaum, A. S., & Kubik, M. Y. (2002). Psychosocial correlates of physical activity and sedentary leisure habits in young adolescents: The teens eating for energy and nutrition at school study. Preventive Medicine, 34, 266–278. doi: 10.1006/pmed.2001.0982.CrossRefPubMedGoogle Scholar
  51. Shelleby, E. C., Shaw, D. S., Cheong, J., Chang, H., Gardner, F. E. M., Dishion, T. J., & Wilson, M. N. (2012). Behavioral control in at-risk toddlers: The influence of the Family Check-Up. Journal of Clinical Child & Adolescent Psychology, 41, 288–301. doi: 10.1080/15374416.2012.664814.CrossRefGoogle Scholar
  52. Smith, J. D., Dishion, T. J., Shaw, D. S., Wilson, C., Winter, C., & Patterson, G. R. (in press). Coercive family process and early-onset conduct problems from age 2 to school entry. Development and psychopathology. doi:  10.1017/S0954579414000169
  53. Smith, J. D., Dishion, T. J., Shaw, D. S., & Wilson, M. N. (2013). Indirect effects of fidelity to the Family Check-Up on changes in parenting and early childhood problem behaviors. Journal of Consulting and Clinical Psychology, 81, 962–974. doi: 10.1037/a0033950.CrossRefPubMedGoogle Scholar
  54. Smith, J. D., Montaño, Z., Dishion, T. J., Shaw, D. S., & Wilson, M. N. (manuscript submitted for publication). Engagement in the Family Check-Up reduces children′s weight gain from age 2 through 9.Google Scholar
  55. Smith, J. D., Stormshak, E. A., & Kavanagh, K. (2014). Results of a pragmatic effectiveness-implementation hybrid trial of the Family Check-Up in community mental health agencies. Administration and Policy in Mental Health and Mental Health Services Research, Available ahead of print. doi: 10.1007/s10488-014-0566-0.Google Scholar
  56. Stormshak, E. A., Margolis, K., Huang, C. Y., & Dishion, T. J. (2012). Implementation of a family-centered, school-based intervention to prevent student academic and behavioral problems. In B. Kelly & D. F. Perkins (Eds.), Handbook of implementation science for psychology in education (pp. 264–276). New York, NY: Cambridge University Press.CrossRefGoogle Scholar
  57. Trentacosta, C. J., Hyde, L. W., Shaw, D. S., Dishion, T. J., Gardner, F. E. M., & Wilson, M. N. (2008). The relations among cumulative risk, parenting, and behavior problems during early childhood. Journal of Child Psychology and Psychiatry, 49, 1211–1219. doi: 10.1111/j.1469-7610.2008.01941.x.PubMedCentralPubMedGoogle Scholar
  58. Van Ryzin, M. J., & Nowicka, P. (2013). Direct and indirect effects of a family-based intervention in early adolescence on parent–youth relationship quality, late adolescent health, and early adult obesity. Journal of Family Psychology, 27, 106–116. doi: 10.1037/a0031428.PubMedCentralCrossRefPubMedGoogle Scholar
  59. Wang, Y., & Beydoun, M. A. (2007). The obesity epidemic in the United States—gender, age, socioeconomic, racial/ethnic, and geographic characteristics: A systematic review and meta-regression analysis. Epidemiologic Reviews, 29, 6–28. doi: 10.1093/epirev/mxm007.CrossRefPubMedGoogle Scholar
  60. Wardle, J., Cooke, L. J., Gibson, E. L., Sapochnik, M., Sheiham, A., & Lawson, M. (2003). Increasing children′s acceptance of vegetables; a randomized trial of parent-led exposure. Appetite, 40, 155–162. doi: 10.1016/S0195-6663(02)00135-6.CrossRefPubMedGoogle Scholar
  61. Webster-Stratton, C., & Reid, M. J. (2010). The Incredible Years parents, teachers, and children training series: A multifaceted treatment approach for young children with conduct disorders. In J. R. Weisz & A. E. Kazdin (Eds.), Evidence-based psychotherapies for children and adolescents (2nd ed., pp. 194–210). New York, NY: Guilford Press.Google Scholar
  62. Whitlock, E. P., O′Connor, E. A., Williams, S. B., Beil, T. L., & Lutz, K. W. (2010). Effectiveness of weight management interventions in children: A targeted systematic review for the USPSTF. Pediatrics, 125, e396–e418. doi: 10.1542/peds.2009-1955.CrossRefPubMedGoogle Scholar
  63. Young, K. M., Northern, J. J., Lister, K. M., Drummond, J. A., & O′Brien, W. H. (2007). A meta-analysis of family-behavioral weight-loss treatments for children. Clinical Psychology Review, 27, 240–249. doi: 10.1016/j.cpr.2006.08.003.CrossRefPubMedGoogle Scholar
  64. Zeller, M. H., Reiter-Purtill, J., Modi, A. C., Gutzwiller, J., Vannatta, K., & Davies, W. H. (2007). Controlled study of critical parent and family factors in the obesigenic environment. Obesity, 15, 126–126. doi: 10.1038/oby.2007.517.CrossRefPubMedGoogle Scholar

Copyright information

© Society for Prevention Research 2014

Authors and Affiliations

  • Justin D. Smith
    • 1
    • 5
    Email author
  • Zorash Montaño
    • 1
  • Thomas J. Dishion
    • 1
    • 2
  • Daniel S. Shaw
    • 3
  • Melvin N. Wilson
    • 4
  1. 1.REACH InstituteArizona State UniversityPhoenixUSA
  2. 2.Child and Family CenterUniversity of OregonEugeneUSA
  3. 3.University of PittsburghPittsburghUSA
  4. 4.University of VirginiaCharlottesvilleUSA
  5. 5.Department of Psychology and NeuroscienceBaylor UniversityWacoUSA

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