By Dr Leah Brennan MAPS, Senior Research Fellow, Centre for Obesity Research and Education, Monash University, and Associate Professor Jan Matthews MAPS, Associate Principal Research Fellow, Parenting Research Centre, Melbourne

It is estimated that 23 per cent of Australian children and adolescents are above their healthiest weight (Commonwealth Scientific Industrial Research Organisation, 2008) and rates of overweight are expected to rise to 35 per cent by 2025 (Haby & Markwick, 2008). Childhood overweight and obesity are higher in low-income families, Indigenous and specific ethnic and cultural groups (e.g., Pacific Islander, Middle Eastern and Mediterranean).

The increasing prevalence of overweight and obesity is largely attributed to our obesogenic environment, which encourages the consumption of dense foods and larger portion sizes, resulting in increased energy intake. It has also led to a reduction in both organised and incidental physical activity and an increase in sedentary time, resulting in reduced energy expenditure.

Overweight and obese children have a greater risk of becoming overweight and obese adolescents and adults. Childhood obesity also increases the risk of chronic diseases such as type 2 diabetes, heart disease and some cancers. Physical disorders that impact on quality of life such as respiratory, skin and musculoskeletal disorders are also associated with child and adolescent overweight and obesity (Lobstein, Buar, & Uauy, 2004).

The social and psychological consequences of child and adolescent obesity can be both immediate and long term. Overweight and obese children and adolescents are subjected to teasing, exclusion and discrimination. These negative experiences are associated with psychosocial difficulties, including low self-esteem, body dissatisfaction, disordered eating, depression and anxiety. Overweight and obese young people are also at increased risk of developing binge eating disorder, bulimia nervosa and depression in adulthood (Lobstein, Buar & Uauy, 2004).

Prevention and treatment

Obesity prevention efforts are typically based in the school/preschool setting and target dietary education and/or physical activity. Results of a recent review of high quality studies indicated that interventions targeting dietary education alone and those targeting dietary education and physical activity were largely ineffective in preventing obesity, although physical activity interventions may reduce overweight in the short term (Summerbell et al., 2009).

There is also a need for effective treatment of those children and adolescents who are already above their healthiest weight. Treatment approaches found to be effective can be broadly categorised as focusing on physical activity and sedentary behaviour, diet or behaviourally oriented treatment programs (Oude Luttikhuis et al., 2008). Behavioural lifestyle interventions have been found to be more effective than standard care, and the success of these interventions is largely attributed to the role of parents in supporting behaviour change (Epstein et al., 2007).

Available research suggests that these approaches do not have a negative impact on psychosocial wellbeing and may actually improve it (Carter & Bulik, 2008). There is a need for research examining the predictors of treatment success and strategies to improve clinician-family interactions (Oude Luttikhuis et al., 2008).

The role of parents

Parents can mediate the impact of the prevailing obesogenic environment on their own family environment. The role of parents has been studied extensively and they have been shown to have a powerful influence on their children’s eating and activity habits and level of body satisfaction in the following ways (for a review, see Golan & Crow, 2004).

Parental nutritional knowledge and concern for disease is associated with child diet quality.
Parents can control the food made available and food preparation methods in the home, thus influencing children’s food preferences. Children choose to eat foods served most often at home and prefer what has been available and acceptable at home.

Parents can control the frequency and selection of food purchased outside the home. More parental control of these decisions is associated with better child diet quality.
The presence of parents at family meals can promote a positive atmosphere and model appropriate food-related behaviours and healthy food choices. In combination, these factors are associated with improved child diet quality. Children and adolescents with more independence have unhealthier meal patterns and food choices.

Parents can influence their children’s eating habits and food choices via modelling. Children are more likely to eat foods eaten by their parents, and family members have similar food choices and attitudes towards food.

Parents who are physically active themselves or who encourage and facilitate their child being physically active have more physically active children.

Parents with unhealthy eating habits tend to use more controlling feeding strategies such as pressure to eat and overt restriction to encourage their children to develop healthy habits. These controlling feeding strategies seem to be counterproductive, interfering with children’s ability to self-regulate and adversely affecting children’s eating habits and weight.

Parents also influence their children’s body dissatisfaction and disordered eating behaviour. Daughters are at increased risk of body dissatisfaction and disordered eating when their mothers model these behaviours and their fathers’ attitudes to weight and shape are negative. Little is known about the impact of parents on their son’s body dissatisfaction and disordered eating.

Targeting parents in childhood weight management intervention

As demonstrated above, the family environment is the most important influence on children’s eating and physical activity habits. Multifaceted family-based intervention approaches that promote sustainable healthy eating and physical activity behaviours, and positive psychosocial wellbeing, can achieve long-lasting improvements in child weight and health (Epstein et al., 2007). Ideally, family-based interventions include parenting skills, behavioural modification, behavioural therapy, problem solving and strategies to assist children to manage the psychosocial consequences of excess weight.

While initially these interventions target both children and parents, more recently there has been a move towards use of parents as the sole agents of change. This approach was introduced to improve treatment retention and maintain behaviour change, and reduce stigmatisation, food obsession and disordered eating in children. Targeting parents as the sole agent of change results in better child weight loss and greater improvements in the home environment and health behaviours compared to targeting both parents and children, or children alone (Golan, Kaufman, & Shahar, 2006). There is growing evidence of this approach in obesity treatment and preliminary evidence of its effectiveness in obesity prevention.

This treatment approach is health rather than weight centered, and includes four key components: (1) improved nutritional knowledge and practice; (2) enhanced parenting skills; (3) provision of a healthy home environment; and (4) parental modelling of healthy behaviours. The nutritional component emphasises healthy eating patterns and decreased exposure to obesogenic foods, establishing regular family meals and modelling healthy food behaviours. The parenting skills component promotes an authoritative feeding style encompassing responsiveness (e.g., warmth, nurturing) and demandingness (e.g., setting limits, expecting age appropriate behaviour). Parents are encouraged to make all decisions about what food is purchased and provided, while children determine the amount they will eat.

This approach is consistent with the division of responsibility or ‘parent provide, child decide’ model of child feeding promoted by Satter (2011). Satter proposes that parents provide eating structure, support, and opportunities. They decide what food is provided. Children choose how much and whether to eat from what the parents provide. This means that parents are responsible for choosing and preparing food and providing regular meals and snacks. They are responsible for making mealtimes pleasant and modelling what they want their children to learn about food and mealtime behaviours. Parents are also responsible for not allowing their children to ‘graze’ between scheduled meals and snacks. This model proposes that “if parents do their jobs with respect to feeding, children do their jobs with respect to eating”. Thus, if parents follow the feeding guidelines children will eat, eat enough, eat a variety of food, and learn to behave at the table. Importantly, this model proposes that if parents allow their children to grow into the body that is right for them, then children will grow predictably.

PARENTING PROGRAM FOR CHILDHOOD OBESITY: LIFESTYLE TRIPLE P
(West et al., 2010)

Lifestyle Triple P is an Australian lifestyle intervention for childhood obesity that targets parents as the exclusive agents of change. It aims to reduce childhood overweight and obesity by increasing parenting skills and parental confidence to manage children’s weight-related behaviour. The 12 group sessions and three individual phone call sessions address nutrition, physical activity and positive parenting strategies.

A recently published trial of the program included 101 families of children 4-11 years old. Treatment resulted in significant reductions in child BMI for age and sex z-score following treatment and further improvements at six-month follow up. Parents also reported improvements in children’s weight-related problem behaviour, in addition to increased confidence and competence in using positive parenting strategies to manage this. These changes were maintained at six-month follow-up.

This is the first childhood obesity study to assess changes in children’s weight-related problem behaviour and the use of parenting practices. The authors suggest that treatment outcomes may be further improved if the program includes more sessions over a longer period of time.

Targeting parents as the sole agent of change in childhood overweight and obesity prevention and treatment may improve treatment outcomes and reduce risks of harm. This approach provides a practical way to assist parents to learn about both what to do and how to do it. It provides a positive and proactive way to help parents be part of the solution to childhood obesity.

The author can be contacted at drleahbrennan@gmail.com

References

  • Commonwealth Scientific Industrial Research Organisation. (2008). Australian National Children’s Nutrition and Physical Activity Survey. Canberra: Australian Government.
  • Carter, F.A.P., Bulik, C.M.P. (2008). Childhood obesity prevention programs: How do they affect eating pathology and other psychological measures? Psychosomatic Medicine. 2008, 70(3), 363-71.
  • Epstein, L.H., Paluch, R.A., Roemmich, J.N., Beecher, M.D. (2007). Family-based obesity treatment, then and now: Twenty-five years of pediatric obesity treatment. Health Psychology, 26(4), 381-91.
  • Golan, M., & Crow, S. (2004). Parents are key players in the prevention and treatment of weight-related problems. Nutrition Reviews, 62(1), 39-50.
  • Golan, M., Kaufman, V., Shahar, D.R. (2006).Childhood obesity treatment: Targeting parents exclusively v. parents and children. British Journal of Nutrition, 95, 1008-15.
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  • Satter, E. (2011). Ellen Satter's Division of Responsibility in Feeding. Retrieved 13 July 2011 from http://www.ellynsatter.com/ellyn-satters-division-of-responsibility-in-feeding-i-80.html
  • Summerbell, C.D., Waters, E., Edmunds, L., Kelly, S.A.M., Brown, T., Campbell, K.J. (2009). Interventions for preventing obesity in children (Review). Cochrane Database of Systematic
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  • West. F., Sanders, M., Cleghorn, G.J., & Davies, P.S.W. (2010). Randomised clinical trial of a family-based lifestyle intervention for childhood obesity involving parents as the exclusive agents of change. Behaviour Research and Therapy, 48, 1170-1179.