BACKGROUND AND OBJECTIVES: Early obesity treatment seems to be the most effective, but few treatments exist. In this study, we examine the effectiveness of a parent-only treatment program with and without booster sessions (Booster or No Booster) focusing on parenting practices and standard treatment (ST). METHODS: Families of children 4 to 6 years of age with obesity were recruited from 68 child care centers in Stockholm County and randomly assigned to a parent-only program (10 weeks) with or without boosters (9 months) or to ST. Treatment effects on primary outcomes (BMI z score) and secondary outcomes (BMI and waist circumference) during a 12-month period were examined with linear mixed models. The influence of sociodemographic factors was examined by 3-way interactions. The clinically significant change in BMI z score (20.5) was assessed with risk ratios. RESULTS: A total of 174 children (mean age: 5.3 years [SD 5 0.8]; BMI z score: 3.0 [SD 5 0.6], 56% girls) and their parents (60% foreign background; 39% university degree) were included in the analysis (Booster, n 5 44; No Booster, n 5 43; ST, n 5 87). After 12 months, children in the parent-only treatment had a greater reduction in their BMI z score (0.30; 95% confidence interval [CI]: 20.45 to 20.15) compared with ST (0.07; 95% CI: 20.19 to 0.05). Comparing all 3 groups, improvements in weight status were only seen for the Booster group (20.54; 95% CI: 20.77 to 20.30). The Booster group was 4.8 times (95% CI: 2.4 to 9.6) more likely to reach a clinically significant reduction of $0.5 of the BMI z score compared with ST. CONCLUSION A parent-only treatment with boosters outperformed standard care for obesity in preschoolers. WHAT'S KNOWN ON THIS SUBJECT: Although obesity among preschoolers is common and on the rise, few existing treatment programs, including standard care, have been properly evaluated. Early treatment should be directed to parents and be of high intensity to be effective. WHAT THIS STUDY ADDS: We show that parent-only obesity treatment, including parenting skills training with follow-up booster sessions (but not without), outperformed standard treatment regarding improvements in child weight status. Thus, for successful obesity treatment in preschoolers, only parents need to be involved.

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Introduction Research on picky eating in childhood obesity treatment is limited and inconsistent, with various instruments and questions used. This study examines the role of picky eating in a randomized controlled obesity intervention for preschoolers using subscales from two instruments: The Child Eating Behavior Questionnaire (CEBQ) and the Lifestyle Behavior Checklist (LBC). Method The study includes 130 children (mean age 5.2 years (SD 0.7), 54% girls, mean Body Mass Index (BMI) z-score 2.9 (SD 0.6)) and their parents (nearly 60% of non-Swedish background, 40% with university degree). Families were randomized to a parent-group treatment focusing on evidence-based parenting practices or to standard treatment focusing on lifestyle changes. The children’s heights and weights (BMI z-score) were measured at baseline, and at 3, 6 and 12 months post baseline. At these time-points, picky eating was reported by parents using the CEBQ (Food Fussiness scale, 6 items) and 5 items from the LBC. Child food intake was reported with a Food Frequency Questionnaire (FFQ). Pearson correlation was used to study associations between baseline picky eating and baseline BMI z-scores and food intake. Mixed effects models were used to study associations between the two measurements of picky eating and changes in picky eating, to assess the effects of changes in picky eating on BMI z-scores, and to evaluate baseline picky eating as a predictor of changes in BMI z-scores. Results Neither the standard treatment nor the parent-group treatment reduced the degree of picky eating (measured with CEBQ or LBC). Baseline picky eating measured with the CEBQ was associated with a lower BMI z-score and lower intake of vegetables. Children with a higher degree of picky eating at baseline (measured with the CEBQ) displayed a lower degree of weight loss. When degree of picky eating was examined, for 25% of the children, the CEBQ and the LBC yielded diverging results. Conclusions Baseline picky eating may weaken the effectiveness of obesity treatment, and assessments should be conducted before treatment to adjust the treatment approach. Different measurements of picky eating may lead to different results. The CEBQ seems more robust than the LBC in measuring picky eating. Trial registration Clinicaltrials.gov , NCT01792531. Registered 15 February 2013 - Retrospectively registered, https://clinicaltrials.gov/ct2/show/NCT01792531

BackgroundCharacteristics of picky eaters of different weight status have not been sufficiently investigated. We used two newly developed screening cut-offs for picky eating in the Food fussiness (FF) subscale of the Child Eating Behavior Questionnaire (CEBQ) to investigate the prevalence and characteristics of picky eaters in preschool-aged children with thinness, normal weight, overweight or obesity.MethodsData for 1272 preschoolers (mean age 4.9 years) were analyzed. The parent-reported FF subscale ranges from 1 to 5, and two screening cut-offs were applied to classify children as picky eaters (3.0 and 3.33). Structural Equation Modeling was used to study associations with other factors in the CEBQ, the Child Feeding Questionnaire (CFQ) and the Lifestyle Behavior Checklist (LBC). Scores were compared separately for each weight status group.ResultsNearly half of the children were classified as moderate or severe picky eaters (cut-off 3.0) and 30% as severe (cut-off 3.33). For both cut-offs, prevalence was significantly lower in the obesity group. Still, one-third of children with obesity met the cut-off of 3.0 and 17% met the cut-off of 3.33. While picky eaters displayed similar patterns across weight status groups, some differences emerged. Food responsiveness was lower for picky eaters, but the difference was significant only among children with obesity. Slowness in eating was not as pronounced among picky eaters in the obesity group. In the overweight and obesity groups, parents of picky eaters did not report as high pressure to eat, as compared to the thinness or normal weight groups; in the obesity group, parents of picky eaters also perceived their children’s weight as lower. In all weight status groups, parents of picky eaters were more likely to report their children had too much screen time, complained about physical activity, and expressed negative affect toward food.ConclusionsPicky eating was less common but still prevalent among children with obesity. Future studies should investigate the potential influence of picky eating on childhood overweight and obesity. Moreover, as children with picky eating display higher emotional sensitivity, further research is needed to understand how to create positive eating environments particularly for children with picky eating and obesity.Electronic supplementary materialThe online version of this article (10.1186/s12966-018-0706-0) contains supplementary material, which is available to authorized users.

4Objective: Parental feeding practices shape children's relationships with food and eating. 5Feeding is embedded socioculturally in values and attitudes related to food and parenting. 6 However, few studies have examined associations between parental feeding practices and 7 migrant background. Design: Cross-sectional study. Parental feeding practices (restriction, pressure to eat, and 9 monitoring) were assessed using the Child Feeding Questionnaire. Differences were explored 10 in four subsamples grouped by maternal place of birth: Sweden, Nordic/Western Europe, 11Eastern/Southern Europe, and countries outside Europe. Crude, partly, and fully adjusted 12 linear regression models were created. Potential confounding variables included child's age, 13 gender, and weight status, and mother's age, weight status, education, and concern about child 14 overweight. 15Setting: Malmö and Stockholm, Sweden. (2) . At the same time, a steeper increase, of about 60%, has 46 been observed in emerging economies (2) . As a response to these rising rates, several studies 47 have addressed the etiology of childhood obesity, in order to inform early prevention 48 strategies (3) . When exploring the etiology of obesity much emphasis has been placed on the 49 impact of environmental and behavioral changes (3,4,5) that influence nutrition and physical 50 activity (6) . Young children are highly dependent on their parents for food provision, and 51 parental feeding practices may thus have a profound effect on children's eating behaviors and 52 weight status (7,8,9,10,11) . 54In Sweden, the prevalence of childhood obesity is about 4%, compared to about 8% in 55 Southern Europe; on the population level, childhood obesity is less pronounced in Sweden 56 compared to other Western and European countries (2) . Moreover, recent epidemiological 57 studies have found that childhood obesity is stabilizing and leveling off in Sweden although 58 the social gradient has become more evident (12,13,14) . Weight disparities between children of 59 Swedish background and children of first or second-generation migrant background persist: in 60 Sweden, children of Turkish, Iranian, and South American background have up to three times 61 higher odds of developing overweight or obesity (15,16) . 63Most research studies on obesity-related parental feeding practices focus on three constructs: 64 restriction, pressure to eat, and monitoring (17,18) . High levels of restriction, characterized by a responsiveness, and lower responsiveness to satiety cues (19,20,21,22,23) . High levels of pressure 68 to eat, a construct that describes pushing a child to eat without prioritizing his or her internal 69 satiety cues, have been related to fussiness, pickiness, and limited interest in food, along with 70 reduced appetite (22,24,25,26) . Restriction and pressure to eat have been associated with 71 children's weight status in numerous studies (27,28,29,30,31) , though a few studies have not found 72 such associations (25,32,33) . Monitoring is...