1. A 2017 Cochrane review assessed the effects of diet, physical activity and behavioural interventions on overweight and obesity in children six to 11 years (1). Twenty RCTs were included, with a total of 1,142 children participating (number of children per study ranged from nine to 186). A subgroup analysis compared interventions that included parents against interventions that did not include parents and found no difference in change in BMI, BMI z-score or weight between the groups (1). Similarly, a 2015 Cochrane review of 20 RCTs (n=3057) specifically targeting the effect of parent-only interventions for childhood overweight and obesity makes a weak recommendation based on low quality evidence (using GRADE criteria) for parent-only interventions compared to no intervention (mean decrease in BMI z-score was 0.10) (2). This review found no difference in effect size between parent-only interventions compared to parent-and-child interventions (P=0.56) (2). Neither Cochrane review performed a subgroup analysis by type of parental involvement (e.g. parental cognitive behavioural therapy; parental motivational interviewing; group education targeted to parents only; education targeted to parents and children together; etc.) (1,2). A 2018 umbrella review of Cochrane reviews regarding interventions to treat overweight and obesity in children and adolescents did not include any further evidence (3).
2. A separate 2017 Cochrane review assessed the effects of diet, physical activity and behavioural interventions on overweight and obesity in adolescents 12 to 18 years (4). Forty-four RCTs (n=4781) were included, 29 of which involved parents. There was no significant difference between change in BMI between interventions involving (-1.13 kg/m²; CI -1.90 to -0.35) or not involving (-1.22 kg/m²; CI -1.76 to -0.67) parents, nor was there a significant difference in BMI z-score between interventions involving (-0.15 kg/m²; CI -0.26 to -0.03) or not involving (-0.11 kg/m²; CI -0.25 to -0.03) parents.
3. A 2020 Cochrane review of 23 RCTs and quasi-RCTs (n=12,192) examined the effect of caregiver involvement in behaviour change interventions on the success of dietary and physical activity interventions in children (aged 2-18 years) (5). The authors followed Cochrane Collaboration methodology in their review. Risk of bias was assessed using the Cochrane Collaboration Risk of Bias tool and was found to be high in at least one domain for all included studies. Evidence certainty was assessed using GRADE criteria. All studies compared an intervention involving caregivers to that same intervention excluding caregiver involvement. Most interventions evaluated school-based nutrition and/or physical activity classes, with or without additional changes to the school environment. Overall, the authors found that caregiver involvement had no effect on percentage of total energy intake from saturated fat (low certainty evidence) or sodium intake (low certainty evidence) in diet-only interventions (n=7). Other outcomes were not evaluated. Similarly, there was no effect on total (low certainty evidence) or moderate to vigorous (moderate certainty evidence) physical activity in children in physical activity-only interventions (n=6). Other outcomes were not evaluated. Finally, caregiver involvement in combined diet and physical activity interventions was associated with a small decrease in SSB intake (standard mean difference (SMD), -0.28; 95% CI, -0.44 to -0.12; 3 studies, 651 participants; moderate certainty evidence). However, there was no effect on percentage of total energy intake from saturated fat (very low certainty evidence), sodium intake (very low certainty evidence), fruit and vegetable intake (very low certainty evidence), total physical activity (low certainty evidence) or moderate to vigorous physical activity (very low certainty evidence) in combined diet and physical activity interventions. Overall, the authors concluded that caregiver involvement in behavioural interventions for overweight and obesity management was not supported by evidence. The authors identified the following limitations to their review: small number of studies for most outcomes; few studies were adequately powered; high risk of bias across trials; and imprecision across trials.
4. A 2019 umbrella review of 14 systematic reviews and meta-analyses examined the effect of family-based behavioural interventions on weight-related outcomes (e.g. body weight, BMI, body fat percentage, waist circumference) in children aged <18 years with overweight or obesity compared to no intervention or usual care (6). Family-based was defined as any intervention that directly involved “first-or second-degree relatives or caregivers cohabiting under one roof” (6). Included studies were assessed using GRADE criteria and quality ranged from “low” to “moderate”. Most studies (n=13; 93%) assessed children aged six to 13 years at baseline, and follow-up periods ranged from one month to seven years. All but one study (n=13) effectively improved weight or weight-related behaviours (e.g. dietary intake, meal patterns) in children, and the one study that did not find a significant effect examined mostly pilot studies with small sample sizes (n<50) and short duration (<12 weeks). Parent-child interventions (i.e. interventions targeting both parent and child) were more effective than either wait list control or usual care. Across included meta-analyses, BMI z-score (-0.36) and BMI percentile (-0.50) were improved from baseline at the end of the intervention compared to the control groups. Across included systematic reviews, BMI percentile (-0.18%) was improved from baseline at the end of the intervention compared to the control groups, although one trial showed no difference between groups. BMI z-score improved across 13 studies, with end-of-intervention results ranging from -0.07 to -0.24. These differences persisted at longest follow up (three months to two years), with BMI z-score at longest follow up ranging from 0.11 to 0.23 lower than control groups and BMI percentile significantly lower than control groups (P<0.01; no effect size reported). Dietary changes (e.g. reduced fast food, soft drink, and/or energy intake; increased fibre and/or vegetable intake) were significantly improved in the intervention groups compared to the control groups at the end of the intervention period in three trials, while no difference was seen between groups in one trial. No significant differences were seen between interventions that targeted the parent only or targeted both the parent and the child, which the authors concluded likely indicates that both types of intervention are equally effective. No trial reported that interventions targeting only the child were more effective than interventions that included the parent. Some effective parent-targeted strategies included: nutrition and physical activity education, parenting skills training, and/or role modelling. Limitations cited by the authors include possible bias inherent to included studies, limited reporting of behavioural outcomes (e.g. dietary intake, meal patterns), and inconsistent statistical reporting in included studies. The authors concluded that health professionals working with children who have overweight or obesity should include parents in behavioural interventions, although the evidence is not sufficient to recommend any specific intervention over another.
5. 2025 Canadian clinical practice guidelines for managing obesity in children found little evidence regarding family values and preferences regarding pediatric obesity management (7). In the absence of clear evidence, these guidelines make the following good practice points for health care providers (HCPs) when interacting with families and caregivers:
   • HCPs should use person-first language and use their clinical judgement to determine whether it is appropriate to discuss obesity in front of the child or adolescent based on their age and maturity,
   • HCPs should recognize the chronic nature of obesity and establish a positive, non-judgemental relationship with families and caregivers,
   • HCPs should use the World Health Organization (WHO) growth charts to track a child's growth and use neutral terms (e.g. weight, BMI, growth) when discussing their findings,
   • HCPs should consider the social determinants of health and recognize barriers to accessing care that is culturally appropriate for children and families,
   • HCPs can use a framework such as the "4Ms" for Assessment of Obesity (Metabolic, Mechanical, Mental Health, Social Milieu) in their assessment to identify broad outcomes of their obesity management interventions, including eating disorder risk and health status over time,
   • HCPs should encourage patient and family/ caregiver involvement using a non-stigmatizing approach,
   • HCPs can use a guide such as the "5As" of Pediatric Obesity Management (Ask, Assess, Advise, Agree, Assist) to facilitate conversation with families and caregivers,
   • HCPs should work in multidisciplinary specialist teams where possible, and
   • There is no evidence that behavioural/ psychological interventions should be proven ineffective before considering pharmacological or surgical interventions. All options should be presented to patients and families/ caregivers using a shared decision-making approach.

6. The 2024 Australian clinical practice guidelines for the management of overweight and obesity (draft) encourage the involvement of families/ caregivers in behavioural interventions for children and adolescents (8). These guidelines suggest that combined nutrition and family-based interventions, with or without a physical activity component may effectively improve weight-related health and wellbeing in children (very low to low certainty evidence according to GRADE criteria). Families can be encouraged to change their own behaviours alongside the child, which may improve adherence and decrease stigma (practice point). The following strategies for family involvement in behavioural interventions are recommended (practice point): teaching parents/ caregivers about nutrition; inviting parents/ caregivers to attend their child’s dietitian appointments; teaching parents/ caregivers about healthy food shopping and food preparation; encouraging parents/ caregivers to positively reinforce their child’s attempts at weight management behaviours; encouraging parents/ caregivers to be role models by practicing weight management behaviours; and encouraging families to transform their home environment to be supportive of healthy behaviours. Similarly, the guidelines recommend that combined nutrition, physical activity and family-based interventions, with or without a psychological component, may effectively improve weight-related health and wellbeing in adolescents (low certainty evidence). Family support is crucial for adolescents, so health care practitioners should build a supportive relationship with the families/ caregivers of their adolescent patients (practice point). The following strategies for family involvement in behavioural interventions are recommended (practice point): providing social support; being informed of the adolescent’s goals; and encouraging families to transform their home environment to be supportive of healthy behaviours.

7. The 2025 NICE guidelines for overweight and obesity management do not explicitly comment on benefits or drawbacks of family/ caregiver involvement in behavioural interventions for the management of pediatric obesity (9). However, they do suggest that all family members should follow healthy dietary and physical activity patterns as part of the intervention. The guidelines also recommend that families and caregivers (where appropriate) should be involved in problem-solving discussions and discussions about the child's progress towards their goals. The health care practitioner should regularly interact with the families/ caregivers and reinforce how important it is for them to support the child in adhering to the intervention. Finally, the NICE guidelines recommend that behavioural interventions consider family/ caregiver needs as well as the child's need in order to increase adherence. For example, interventions should be flexible and offered at facilities and times that are convenient for working family members and other children in the household.

• Ask permission from the parent(s) or caregiver(s) to discuss the child’s weight.
• Explain that weight assessment is standard practice and which variables will be measured (e.g. height, weight, waist circumference).
• Explain overweight and obesity classifications.
• Explain that if overweight or obesity is identified, the main goal of treatment is family health behaviour change.
• Consider the involvement of other professionals to assist with communication, including an interpreter and Aboriginal/Indigenous or multicultural health workers (11).

It is important to note that a systematic review from 2016 examined 49 studies (RCTs, non-randomized controlled trials and interventions) that assessed whether interventions targeting parents in the management of childhood overweight and obesity were implemented as the researchers intended (12). The researchers found that only 10% of studies reported on implementation as an outcome and posited that this makes the results of even the highest quality analyses difficult to interpret. Incomplete implementation could confound data and attribute ineffectiveness to failed intervention design, when in fact parent engagement and/or follow-through are the variables that need to be addressed.

1. Mead E, Brown T, Rees K, Azevedo LB, Whittaker V, Jones D, et al. Diet, physical activity and behavioural interventions for the treatment of overweight or obese children from the age of 6 to 11 years. Cochrane Database Syst Rev. 2017 Jun 22;6:CD012651. doi: 10.1002/14651858.CD012651. Abstract available from: https://www.ncbi.nlm.nih.gov/pubmed/28639319
2. Loveman E, Al-Khudairy L, Johnson RE, Robertson W, Colquitt JL, Mead EL, et al. Parent-only interventions for childhood overweight or obesity in children aged 5 to 11 years. Cochrane Database Syst Rev. 2015 Dec 21;(12):CD012008. doi: 10.1002/14651858.CD012008. Abstract available from: https://www.ncbi.nlm.nih.gov/pubmed/26690844
3. Ells LJ, Rees K, Brown T, Mead E, Al-Khudairy L, Azevedo L, et al. Interventions for treating children and adolescents with overweight and obesity: an overview of Cochrane reviews. Int J Obes (Lond). 2018 Nov;42(11):1823-33. doi: 10.1038/s41366-018-0230-y. Epub 2018 Oct 9. Abstract available from: https://www.ncbi.nlm.nih.gov/pubmed/30301964
4. Al-Khudairy L, Loveman E, Colquitt JL, Mead E, Johnson RE, Fraser H, et al. Diet, physical activity and behavioural interventions for the treatment of overweight or obese adolescents aged 12 to 17 years Cochrane Database Syst Rev. 2017 Jun 22;6:CD012691. doi: 10.1002/14651858.CD012691. Abstract available from: https://www.ncbi.nlm.nih.gov/pubmed/28639320
5. Morgan EH, Schoonees A, Sriram U, Faure M, Seguin-Fowler RA. Caregiver involvement in interventions for improving children's dietary intake and physical activity behaviors. Cochrane Database Syst Rev. 2020 Jan 5;1(1):CD012547. doi: 10.1002/14651858.CD012547.pub2. PMID: 31902132; PMCID: PMC6956675. Abstract available from: https://pubmed.ncbi.nlm.nih.gov/31902132/ 
6. Chai LK, Collins C, May C, Brain K, Wong See D, Burrows T. Effectiveness of family-based weight management interventions for children with overweight and obesity: an umbrella review. JBI Database System Rev Implement Rep. 2019 Jun 18. doi: 10.11124/JBISRIR-2017-003695. [Epub ahead of print]. Abstract available from: https://www.ncbi.nlm.nih.gov/pubmed/31021970
7. Ball GDC, Merdad R, Birken CS, Cohen TR, Goodman B, Hadjiyannakis S, et al. Managing obesity in children: a clinical practice guideline. CMAJ. 2025 Apr 13;197(14):E372-E389. doi: 10.1503/cmaj.241456. PMID: 40228835; PMCID: PMC12007946. Abstract available from: https://pubmed.ncbi.nlm.nih.gov/40228835/
8. Australian Government, Department of Health and Aged Care. Clinical Practice Guidelines for the Management of Overweight and Obesity for Adults, Adolescents and Children in Australia. Draft Guidelines, September 2024. Available from: https://www.deakin.edu.au/__data/assets/pdf_file/0004/2856298/Draft-Guidelines-Full-Guidelines.pdf 
9. National Institute for Health and Care Excellence. Overweight and obesity management. 2025. Available from: https://www.nice.org.uk/guidance/ng246 
10. Lundahl A, Kidwell KM, Nelson TD. Parental underestimates of child weight: a meta-analysis. Pediatrics. 2014 Mar;133(3):e689-703. doi: 10.1542/peds.2013-2690. Epub 2014 Feb 2. Abstract available from: https://www.ncbi.nlm.nih.gov/pubmed/24488736/
11. Heerman WJ, JaKa MM, Berge JM, Trapl ES, Sommer EC, Samuels LR, et al. The dose of behavioral interventions to prevent and treat childhood obesity: a systematic review and meta-regression. Int J Behav Nutr Phys Act. 2017 Nov 15;14(1):157. doi: 10.1186/s12966-017-0615-7. Abstract available from: https://www.ncbi.nlm.nih.gov/pubmed/29141651
12. Schlechter CR, Rosenkranz RR, Guagliano JM, Dzewaltowski DA. A systematic review of children's dietary interventions with parents as change agents: application of the RE-AIM framework. Prev Med. 2016 Oct;91:233-43. doi: 10.1016/j.ypmed.2016.08.030. Abstract available from: https://www.ncbi.nlm.nih.gov/pubmed/27569830