Emotion-Focused Behavioral Weight Loss Treatment for Adolescents: A Randomized Clinical Trial

Family-based behavioral treatment (FBT) efficacy decreases in adolescence, a developmental period of gradual maturation and increasing autonomy during which emotion regulation skills develop.

To evaluate the feasibility and efficacy of FBT alone compared with FBT plus emotion regulation across 6 months of treatment and 12 months of follow-up on adolescent weight change, emotion regulation, emotional eating, and parent weight change.

This parallel-group randomized clinical trial of adolescents 13 to 16 years of age with body mass index (BMI) in the 85th percentile or higher but less than the 99.9th percentile was conducted from August 29, 2019, to January 4, 2024, at 2 university clinics. Central randomization was completed by a statistician, and outcome assessors were blinded to treatment condition. The majority of treatments and assessments were delivered remotely via video conference due to the COVID-19 pandemic.

FBT plus emotion regulation vs traditional FBT skills alone for weight loss. FBT included nutrition and physical activity education, behavior change strategies, and parenting skills. Both treatments had 6 months of adolescent and parent groups and behavior coaching sessions. The combined group included FBT skills and added dialectical behavior therapy and emotion-focused therapy.

The main outcomes were adolescent weight (body mass index [BMI] z score (BMIz) and BMI as a percentage of the 95th BMI percentile [%BMIp95]), emotion regulation skills (measured by Difficulties in Emotion Regulation Scale [DERS] scores), emotional eating behaviors (measured by Emotional Eating Scale [EES] scores), parent weight, and feasibility and acceptability of treatment. Primary outcome analyses used an intention-to-treat approach.

A total of 166 (FBT plus emotion regulation = 84; FBT = 82) dyads (adolescents: mean [SD] age, 14.3 [1.2] years; 95 [57%] female; mean [SD] BMIz, 2.2 [0.6]; mean [SD] %BMIp95, 120.4 [21.4]; parents: mean [SD] age, 45.3 [6.5] years; 141 [85%] female; mean [SD] BMI, 32.6 [7.0]) were assessed at baseline, midtreatment, posttreatment, and 6- and 12-month follow-up visits. There were no statistically significant differences in posttreatment weight loss among adolescents receiving FBT plus emotion regulation compared with FBT (difference in BMIz, 0.03 [95% CI, -0.05 to 0.10]). However, adolescents in FBT plus emotion regulation did not regain as much weight at the 12-month follow-up (difference in BMIz, -0.09 [95% CI, -0.17 to -0.02]). At the 12-month follow-up, 4% (95% CI, 1%-12%) of adolescents in FBT and 22% (95% CI, 8%-48%) of adolescents in FBT plus emotion regulation lost a clinically significant amount of weight (≥0.20 BMIz). At 12 months' follow-up, parent weight (difference in BMI, 0.51 [95% CI, -0.03 to 1.05]) and adolescent emotion regulation (difference in DERS scores, -0.06 [95% CI, -0.25 to 0.50]) did not differ by treatment. By contrast, the FBT plus emotion regulation group had lower scores than the FBT group on emotional eating (difference in EES scores, -0.39 [95% CI, -0.63 to -0.15]).

In this randomized clinical trial of 166 parent-adolescent dyads, adding emotion regulation skills to FBT did not improve weight loss during treatment but was associated with less weight regain and lower emotional eating through the 12-month follow-up. These findings suggest that adding emotion regulation skills to an FBT program may attenuate weight regain and decrease emotional eating among adolescents.

ClinicalTrials.gov Identifier: NCT03674944.