care, health and development Child: Review Article

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doi:10.1111/cch.12241

Impact of social norms and social support on diet, physical activity and sedentary behaviour of adolescents: a scoping review C. E. Draper,*† L. Grobler,‡ L. K. Micklesfield* and S. A. Norris* *MRC/Wits Developmental Pathways for Health Research Unit, University of the Witwatersrand, Johannesburg, South Africa †Division of Exercise Science and Sports Medicine, University of Cape Town, Cape Town, South Africa, and ‡Centre for Evidence-based Health Care, Stellenbosch University, Stellenbosch, South Africa Accepted for publication 8 February 2015

Abstract

Keywords adolescents, diet, physical activity, sedentary behaviour Correspondence: Catherine E. Draper, MA, PhD, MRC/Wits Developmental Pathways for Health Research Unit, University of the Witwatersrand, Johannesburg 2050, South Africa E-mail: [email protected]

The prevalence of non-communicable diseases (NCDs) in adulthood is rapidly increasing, and it is essential that risk factors for NCDs be addressed in adolescence, both for the health of individuals during adolescence and for their health in later life. These risk factors include diet, physical activity and sedentary behaviour. No literature has been published that comprehensively summarizes the impact of social norms and social support on these behaviours among adolescents. Therefore, a scoping review was conducted to determine the extent of recent (since 2000) literature available on this topic. A comprehensive search strategy was used to search PubMed and EMBASE for eligible reviews. Review papers (narrative reviews, systematic and non-systematic reviews) published in English in peer-reviewed journals from 2000 to February 2013 were included in the overview. Two of the authors screened the titles and abstracts of the search results independently. Thirty reviews were included in the scoping review. This scoping review has shown sufficient evidence for parental influences, and especially the positive impact of an authoritative parenting style, on healthy behaviours of adolescents, although the evidence is somewhat more compelling for diet than for physical activity and sedentary behaviour. More research is needed to investigate parental and family influences on physical activity and sedentary behaviour. And the effect of peer influences on diet, physical activity and sedentary behaviour of adolescents requires further investigation. The evidence presented affirms the consideration of social norms and social support in the development of interventions to address these behaviours in adolescents. The evidence regarding parenting style provides some concrete guidance for such interventions.

Introduction A global increase in the burden of non-communicable diseases (NCDs) has been reported (Murray et al. 2012), along with the rise in the number of deaths from NCDs, particularly from diabetes, which almost doubled in the last 20 years (Lozano et al. 2012). Among adolescents, risks for NCDs in adulthood are rapidly increasing (Patton et al. 2012), and the prevalence of

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type 2 diabetes mellitus is rising in adolescents as well (Pinhas-Hamiel & Zeitler 2005; Reinehr 2013). Considering that adolescence is a key phase of development for establishing future adult health patterns and behaviours (Sawyer et al. 2012), it is essential that risk factors for NCDs be addressed in this age group, both for the health of the adolescent and for their health in later life. These risk factors include physical inactivity, unhealthy diet and obesity (World Health

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Organization 2013), the latter having become a global concern among children and adolescents (Kosti & Panagiotakos 2006; Larson & Story 2008). Children and adolescents between the ages of 5 and 17 years old should be accumulating at least 60 min of moderate-to-vigorous physical activity daily (World Health Organization 2010). However, in a comparison of data from 85 countries, the percentage of adolescents achieving this recommended level was 50% or less in almost all countries, with girls being less likely to achieve this recommendation (Patton et al. 2012). There is evidence to indicate that adolescents in high-income countries are spending 40–60% of their waking hours engaging in sedentary behaviour (Saunders et al. 2014). This suggests that many adolescents may not be meeting the recommendation of 2 h or less of recreational screen time per day (Saunders et al. 2014). The impact of income status on these risk behaviours has been noted, with the lowest rates of physical activity and highest rates of overweight being found among adolescents from low- and middle-income countries (LMICs) (Patton et al. 2012). Adolescents from low socioeconomic status (SES) groups are more likely to engage in unhealthy behaviours, such as physical inactivity, increased sedentary behaviour and poor diet, and have a higher body mass index (BMI) (Hanson & Gluckman 2011; Hanson et al. 2012). While the influence of gender on overweight and obesity is variable across LMICs and high-income countries (Patton et al. 2012), it does appear to influence physical activity and sedentary behaviour (independent from physical inactivity) with male adolescents being more physically active than female adolescents (Patton et al. 2012). Physical activity has been shown to decline in adolescent girls (Nader et al. 2008; Olds et al. 2009; Dumith et al. 2012), and sedentary behaviour has been shown to increase significantly between early- and mid-adolescence among girls (Hardy et al. 2007). These findings highlight the need for a focus on health behaviour change among adolescents, especially girls, in order to curb the rise of NCDs among adolescents, and to reduce the risk for NCDs in adulthood. In this regard, adolescence has been proposed as a ‘second sensitive developmental period in which puberty and rapid brain maturation lead to new sets of behaviours and capacities that trigger or enable transitions in family, peer, and educational domains, and in health behaviours. These transitions modify childhood trajectories towards health and wellbeing’ (Viner et al. 2012). Blum et al. (2012) has argued that the key to understanding these trajectories is an ecological or life-course framework, which includes macro-level factors (such as political events and economic forces), neighbourhood factors (e.g. cultural beliefs, economic resources and gender norms) and school factors (such as opportunities, safety and support).

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This framework also includes family and peer influences within the social environment. From this ecological perspective, family and peer influences relate to social support, which has been defined as ‘aid and assistance exchanged through social relationships and interpersonal transactions’ (Heaney & Israel 2002). Family and peer influences could also influence social norms, which can be defined as a social group’s expectations of behaviour, and indicate what is considered appropriate or inappropriate in certain circumstances (Bartholomew et al. 2006). From a theoretical perspective, social norms and social support align with theories of behaviour change, which are relevant for addressing behaviours associated with NCD risk. In the theory of planned behaviour (Ajzen 1991), subjective social norms are seen to influence behavioural intention, which can lead to behaviour change. Similarly, according to social cognitive theory (Bandura 1986), perceptions of others’ behaviour can influence individual behaviour change. Furthermore, social cognitive theory acknowledges the influence of the environment, which could include the social environment, on behaviour change. Social influences can also impact on individual self-efficacy for behaviour change (Bandura 1986). Considering that no literature had been published that comprehensively summarizes the impact of social norms and social support on behaviours associated with NCD risk among adolescents, a scoping review was conducted to determine the extent of recent (since 2000) literature available on this topic. The purpose of a scoping review is to map and summarize the evidence available within a particular area of interest in order to establish the breadth of literature on the subject (Arksey & O’Malley 2005; Rumrill et al. 2010). As scoping reviews are more exploratory in comparison with systematic reviews, they do not necessarily evaluate the quality of studies (Rumrill et al. 2010), but can be helpful in determining the usefulness of conducting a full systematic review and in identifying gaps in research on a particular topic (Arksey & O’Malley 2005).

Methods This scoping review was originally conducted as part of an intervention development process for an intervention targeting adolescent girls (Draper et al. 2014). For this reason, the scoping review was limited to information on adolescent girls, a particularly vulnerable group in terms of health behaviour and body composition. It should however be noted that all papers included in this review pertained to both male and female adolescents (no reviews specifically addressed female adolescents). The authors therefore believe that the findings of the review are applicable to both male and female adolescents. Because of time

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and funding constraints, a decision was made to limit the search to the most recent literature. Despite the limitations associated with this decision, the authors felt that sufficient information could be retrieved to inform the intervention development process. A comprehensive search strategy was developed using the keywords and related MeSH terms for social norms, social support, physical activity, sedentary behaviour, dietary intake and eating behaviour. The search strategy was run in both PubMed and EMBASE using the following limits: date (2000– February 2013), females, adolescent, review, humans. Only review papers (narrative reviews, systematic and non-systematic reviews) published in English in peer-reviewed journals from 2000 to February 2013 were included in the scoping review (see Supporting Information Table S1 for further details). Two of the authors screened the titles and abstracts of the search results independently. When uncertain of a paper’s eligibility the full text of the paper was retrieved. Relevant data were extracted from all eligible papers. The following information was extracted from all of the eligible reviews by one author (LG): • Administrative details: review author(s); published or unpublished; year of publication; details of other relevant papers cited. • Review methods: aim/objective of the review; date of most recent search; databases searched; search limitations; types of studies included in the review; type of participants assessed in

Figure 1. Flow diagram of search results.

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the studies included in the review; type of intervention(s) assessed in the studies included in the review; type of outcomes assessed in the studies included in the review. • Review results: number of studies included in review; location and setting of the included studies (e.g. higher-income vs. lower-income country); main findings of the review.

Results The results of the search are described in Fig. 1 (see Fig. 1: flow diagram of the search results). The full text papers of 42 potentially eligible reviews were screened for eligibility. The characteristics of the 30 reviews that met the inclusion criteria of this scoping review are outlined in Table 1. Twelve reviews were excluded from this scoping review. Table 2 lists the excluded reviews together with the reasons for their exclusion (see Table 2).

Overview of the results of the included reviews The collated results of the included reviews are described according to behaviour: diet, physical activity and sedentary behaviour. The resulting impacts of family and peer influences are presented under each of these behaviour subheadings. Based on a post hoc decision, an additional subsection on obesity was included, independent of the behaviour subsections, as some reviews that met the inclusion criteria of the scoping review

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Table 1. Characteristics of included reviews Physical Sedentary Family Peer Diet activity behaviour Obesity influences influences

Author/s

Title

Aims/objectives

Allender et al. (2006)

Understanding participation in sport and physical activity among children and adults: a review of qualitative studies

Biddle et al. (2011)

Sedentary behaviour interventions in young people: a meta-analysis

Cislak et al. (2011)

Family-related predictors of body weight and weight-related behaviours among children and adolescents: a systematic umbrella review

Eisenberg et al. (2008)

Peer harassment and disordered eating

Fletcher et al. (2011)

You are what your friends eat: systematic review of social network analyses of young people’s eating behaviours and bodyweight

Gerards et al. (2011)

Interventions addressing general parenting to prevent or treat childhood obesity

Hill (2002)

Developmental issues in attitudes to food and diet

Hingle et al. (2010)

Parental involvement in interventions to improve child dietary intake: a systematic review

Khambalia et al. (2012

A synthesis of existing systematic reviews and meta-analyses of school-based behavioural interventions for controlling and preventing obesity The integration of a family systems approach for understanding youth obesity, physical activity, and dietary programs

Systematically examine published and unpublished qualitative research studies that have examined UK children’s and adults’ reasons for participation and non-participation in sport and physical activity To ascertain through meta-analysis whether interventions targeted at reducing sedentary behaviours in young people are successful Integrate evidence for relationships between family variables, weight-related behaviours and body weight indices of children and adolescents Review literature on the association between peer harassment and a range of weight-related attitudes and behaviours (i) Association between measures of individual social position or measure of overall structure of social networks and young people’s eating behaviours, caloric intake and or body weight. (ii) How does setting and participants’ sociodemographic characteristics affect these associations? Provide an overview of interventions which address general parenting in order to prevent or treat obesity in youth (0–18 years) Describe and discuss competing influences on food choice and eating behaviour. Conduct systematic review of randomized controlled trials designed to prevent obesity, prevent disease and/or promote health in children and adolescents through dietary behaviour changes that involved parents Summarize and critically appraise evidence from existing meta-analyses and systematic reviews examining school-based programmes to prevent and control obesity Explore the effectiveness of including parenting and family factors in obesity, physical activity, and dietary programmes in youth from elementary school through adolescence Present a systematic review of qualitative studies of 6–18-year-olds’ views and experiences regarding determinants of their intake of fruit and vegetables Conduct a descriptive systematic review into the nature and effectiveness of family involvement in weight control, weight maintenance and weight-loss interventions Present research findings and recommendations on the role of families in preventing weight-related problems in adolescents

Kitzman-Ulrich et al. (2010)

Krølner et al. (2011)

Determinants of fruit and vegetable consumption among children and adolescents: a review of the literature. Part II: qualitative studies

McLean et al. (2003)

Family involvement in weight control, weight maintenance and weight-loss interventions: a systematic review of randomized trials

Neumark-Sztainer Preventing the broad spectrum of (2005) weight-related problems: working with parents to help teens achieve a healthy weight and a positive body image Neumark-Sztainer Eating among teens: do family (2006) mealtimes make a difference for adolescents’ nutrition?

✓

✓

✓

✓

✓

✓

✓

✓

✓

✓

✓

✓

✓

✓

✓ ✓

✓

✓

✓

✓

✓

✓

✓

✓

✓

Summarize some of key findings from ✓ studies that have examined associations between family mealtime patterns and eating among teens

✓

✓

✓

✓

✓

✓

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Table 1. Continued Author/s

Title

Aims/objectives

Review child and adolescent weight-related health intervention characteristics, with a particular focus on parental participation Pearson et al. Update the evidence for fruit and (2008) vegetable consumption, focusing specifically on family correlates and by reporting the results and findings for fruit and vegetables separately Power & Nutritional and other influences in Determine the role of factors such as Parsons childhood as predictors of adult nutrition, physical activity and other (2000) obesity behavioural factors during childhood in the development of adult obesity Regber et al. Parenting styles and treatment of Describe different parenting styles, and (2007) adolescents with obesity to present a set of typical case situations and treatment strategies for nurses working with adolescents with obesity Salmon & Prevalence, trends and environmental Describe prevalence and trends in Timperio influences on child and youth physical children’s physical activity (PA) and (2007) activity overview the evidence of relationships between the broader neighbourhood social and physical environment and child and youth PA Savage et al. Parental influence on eating behavior: Describe factors shaping the (2007) conception to adolescence development of children’s food preferences and eating behaviours during the first years of life Seo & Sa (2010) A meta-analysis of obesity interventions Evaluate the efficacy of interventions among U.S. minority children designed to prevent or treat obesity in US minority children Skelton et al. Where are family theories in Advance the study of family theories in (2012) family-based obesity treatment? obesity treatment and to bring a Conceptualizing the study of families better understanding of family in pediatric weight management complexities to family-based treatment Sleddens et al. General parenting, childhood Synthesize evidence regarding the (2011) overweight and obesity-inducing influence of general parenting on behaviors: a review children’s diet and activity behaviours, and weight status Sleddens et al. Physical activity parenting: a systematic Provide overview of the physical activity (2012) review of questionnaires and their parenting questionnaires available associations with child activity levels and report on the validation of these measures Stevens (2010) Obesity prevention interventions for Describe current literature on middle school-age children of ethnic interventions to reduce obesity in minority: a review of the literature middle school-age children of ethnic minority Summarize obesity prevention Stice et al. A meta-analytic review of obesity prevention programs for children and programmes and their effects, and (2006) adolescents: the skinny on investigate participant, intervention, interventions that work delivery, and design features associated with larger effects Stockmyer 2001 Remember when mom wanted you To determine which factors influence home for dinner? adolescents’ diets and to improve eating habits Van der Horst A brief review on correlates of physical Present a systematic update of et al. (2007) activity and sedentariness in youth correlates of children’s and adolescent’s physical activity, insufficient physical activity and sedentariness van Grieken Primary prevention of overweight in Review evidence regarding the effects of et al. (2012) children and adolescents: a interventions aiming to prevent meta-analysis of the effectiveness of excessive sedentary behaviour in interventions aiming to decrease children and adolescents on sedentary behaviour sedentary behaviour and BMI Wang et al. Do children and their parents eat a Systematically review and assess the (2011) similar diet? Resemblance in child and degree of association and similarity parental dietary intake: systematic between children’s and their parents’ review and meta-analysis dietary intake

Niemeier et al. (2012)

Parent participation in weight-related health interventions for children and adolescents: a systematic review and meta-analysis Family correlates of fruit and vegetable consumption in children and adolescents: a systematic review

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Physical Sedentary Family Peer Diet activity behaviour Obesity influences influences ✓

✓

✓

✓

✓

✓

✓

✓

✓

✓

✓

✓

✓

✓

✓

✓

✓

✓

✓

✓

✓

✓

✓

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✓

✓

✓ ✓

✓

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✓

✓

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✓

✓

Social influences on adolescent health behaviour

Author/s

Title

Reason for exclusion

Baheiraei et al. (2011)

Health-promoting behaviors and social support of women of reproductive age, and strategies for advancing their health: protocol for a mixed methods study

Not relevant/not a review

Burke et al. (2011)

The impact of adverse childhood experiences on an urban pediatric population Healthy Families America effectiveness: a comprehensive review of outcomes Changing gendered norms about women and girls at the level of household and community: a review of the evidence Factors that affect the young female athlete Supportive non-parental adults and adolescent psychosocial functioning: using social support as a theoretical framework Relationships among body mass index, parental perceptions, birthweight and parental weight after referral to a weight clinic

Harding et al. (2007) Keleher & Franklin (2007) Lal & Hoch (2007) Sterret et al. (2011)

Watkins et al. (2007)

Bowen & Beresford (2002)

Dietary interventions to prevent disease

Not adolescents

Hernán et al. (2004) Niclasen (2005)

Health among teenagers and young adults Overweight and obesity. Social consequences, self-esteem and quality of life, with focus on children and teenagers Obesity and adolescence: psychological factors and family relationships Health issues and preventive health strategies for adolescent girls

Paper not in English

Trombini (2007) Ma et al. (2009)

investigated the influence of social norms and social support on obesity prevention and treatment without specifically referring to obesity-related behaviours.

Diet Family influences Parent intake of fruit and vegetables and healthy eating behaviours have been positively associated with adolescent’s fruit and vegetable intake, and healthful eating behaviours (Neumark-Sztainer 2005; Pearson et al. 2008; Cislak et al. 2011; Krølner et al. 2011). However, the association between the diets of parents and children has been found to be moderate or weak by some, with average correlations of approximately 0.2 (Wang et al. 2011), possibly because of difficulty in assessing child and parents’ dietary intake. A stronger association has been found between children and parents’ dietary intake in LMICs compared with high-income countries, for example parent–child correlations for key dietary measures in the United States were 0.20–0.33, compared with mother–child correlations of 0.41– 0.49 for the consumption of food groups in Brazil (Wang et al. 2011).

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Table 2. Characteristics of excluded reviews

Parenting style has been associated with dietary behaviour of adolescents. Authoritative parents are those who are both responsive to their children’s needs, as well as controlling of their children’s behaviours (Maccoby & Martin 1983). An authoritative parenting style has been positively related to fruit and vegetable intake, and healthful eating behaviours of young adolescents (Neumark-Sztainer 2005; Savage et al. 2007; Cislak et al. 2011; Sleddens et al. 2011), as well as the frequency of family meals (Stockmyer 2001; Neumark-Sztainer 2005, 2006). One review, however, did not find the same associations, and also found that parental monitoring and family size was unrelated to adolescent fruit and vegetable intake (Pearson et al. 2008). A high degree of maternal control has been associated with less frequent snacking in adolescents (Sleddens et al. 2011). However, ‘over control’ of children’s eating behaviours, which is associated with an authoritarian parenting style (highly demanding and less responsive), has been shown to be counter productive (Hill 2002) in terms of healthy eating behaviours. Positive associations have been identified between parent occupation status (high status being associated with a higher income and higher levels of skills required) and fruit consumption, and between parent education and fruit, juice and vegetable consumption (Pearson et al. 2008). The availability of fruit

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and vegetables in the home has been positively related (Stockmyer 2001; Hill 2002; Neumark-Sztainer 2005; Savage et al. 2007; Krølner et al. 2011) to adolescent fruit and vegetable consumption, although one review found no relationship (Pearson et al. 2008).

Peer influences Compared with the evidence on family and parental influences, there is far less evidence on the influence of peers on diet, although peer influences, such as through peer pressure to eat unhealthy food, or social norms that discourage eating healthy food, have been negatively associated with healthful eating behaviour (Krølner et al. 2011). Studies on peer influences and eating disorders have shown that these influences appear to be greatest in early adolescence (12–14 years), diminishing later in high school (Fletcher et al. 2011). Bulimic symptoms (dieting, extreme weight-loss behaviours and binge eating) have been shown to be strongly predicted by having female high school friends who also reported bulimic symptoms (odds ratio 1.29, P < 0.0001); however, the relationship between binge eating and social networks was not significant when individual-level sociodemographic and physical factors were included in the analysis (Fletcher et al. 2011). In a review of social network analyses of young people’s eating behaviours, it was found that youth who have obese friends are more likely to become obese themselves (increased odds of 51%), and that young people select friends that have a similar BMI to themselves, a concept known as homophily. School friends therefore tend to be similar in terms of their BMI, with the association being strongest in overweight youth who are twice as likely to have overweight friends (Fletcher et al. 2011). In terms of other social factors influencing eating disorders, peer harassment and weight teasing caused by the social pressure to be thin, lead to eating disorders (Eisenberg & Neumark-Sztainer 2008). The desire to be thin is seen to be greater in adolescent girls from higher-income families, and adolescent girls who equate thinness with attractiveness. Furthermore, it has been found that women from higher-SES groups restrict their food intake more than those from lowerSES groups (Power & Parsons 2000).

Physical activity Family influences Similar to diet, authoritative parenting has been shown to be a positive predictor of physical activity (Sleddens et al. 2011), and

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positive associations have been shown between family influences (such as parents’ encouragement and support for adolescent’s physical activity, and parents’ attitudes about physical activity) and physical activity (Van der Horst et al. 2007). The relationship between parental physical activity and adolescent physical activity is equivocal, with some finding no relationship (Van der Horst et al. 2007), and others finding a positive relationship between parental modelling of physical activity and adolescent physical activity (Neumark-Sztainer 2005). Physical activity parenting, defined as parental behaviours intended to influence children’s physical activity, may positively influence children’s physical activity, although the conceptualization and measurement of the construct of physical activity parenting have been criticized (Sleddens et al. 2012). Parental support has been associated with increased physical activity in adolescents (Neumark-Sztainer 2005; Allender et al. 2006; Cislak et al. 2011), along with higher household income and higher levels of parental education (Cislak et al. 2011). Sibling physical activity has also been found to increase adolescent physical activity (Neumark-Sztainer 2005; Cislak et al. 2011).

Peer influences In terms of peer influences on physical activity, positive associations have been shown between friend support and physical activity of adolescents (Van der Horst et al. 2007), and that positive social interactions at a neighbourhood level may be conducive to adolescents’ physical activity levels (Salmon & Timperio 2007). In adolescent girls, physical activity may be facilitated by the development of new social networks, and peer support has been found to be very important in maintaining physical participation (Allender et al. 2006). Barriers to physical activity in adolescent girls include negative experiences during school physical education (PE) classes and appearing too muscular (Allender et al. 2006). Negative PE class experiences could relate to social interactions, and concerns around appearing too muscular could be linked to social norms regarding the appropriate feminine body shape.

Sedentary behaviour Family influences Far less evidence is available on family and peer influences on sedentary behaviour. Adolescents who have authoritative parents (who are both responsive to their children’s needs, as well as controlling of their children’s behaviours) have been

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shown to spend less of their leisure time engaging in sedentary behaviour (Sleddens et al. 2011). It has also been found that adolescents who are Caucasian, have a higher SES, and have parents who are better educated are less likely to be sedentary (Van der Horst et al. 2007). While interventions to change sedentary behaviour in adolescents have had limited effectiveness, interventions in a community setting, such as schools, and those involving families have shown more promising results (Biddle et al. 2011; van Grieken et al. 2012). This could suggest that social norms and social support may play a role in the effectiveness of interventions to reduce sedentary behaviour among adolescents. Meta-analyses have shown a significant effect of interventions aiming designed to reduce sedentary behaviour in young people (younger than 18 years) found a small, but significant effect [Hedges’ g effect size index = −0.192; standard error (SE) = 0.056; 95% confidence interval (CI) = −0.303 to −0.082; P = 0.001 (Biddle et al. 2011); post-intervention mean difference: −17.95 min/day (95% CI: −26.61; –9.28); change-from-baseline mean difference: −20.44 min/day (95% CI: −30.69; –10.20) (van Grieken et al. 2012)].

Peer influences No reviews were found that investigated peer influences on sedentary behaviour among adolescents.

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requesting parents’ attendance and participation at a workshop) used to engage parents in interventions have been shown to be more successful than indirect methods (such as providing information to parents, but not requiring their response; Hingle et al. 2010), and general parenting programmes combined with lifestyle components (physical activity and nutrition) have proved more effective than general parenting programmes alone (Gerards et al. 2011). Similar to what was mentioned earlier regarding interventions to reduce sedentary behaviour, community-based obesity prevention programmes have been recommended, particularly the inclusion of culturally tailored strategies (effect size −0.93–3.28, mean effect size 0.30; Seo & Sa 2010; Stevens 2010), and these may draw on the concepts of social norms and social support. Not surprisingly, authoritative parenting has been associated with lower BMI (Gerards et al. 2011), and this parenting style has been promoted as an effective strategy for the prevention and management of obesity in adolescence (Regber et al. 2007; Kitzman-Ulrich et al. 2010; Sleddens et al. 2011). Although parental involvement in obesity prevention and treatment for adolescents is recommended, the complexity of families must be acknowledged, and family-focused theories, such as family systems theory, provide some insight into these complexities (Skelton et al. 2012).

Peer influence No reviews were found that investigated peer influences on obesity prevention and treatment for adolescents.

Family influences Behavioural interventions aimed at obesity prevention and treatment in adolescents incorporating family involvement and parent participation are recommended (McLean et al. 2003; Seo & Sa 2010; Stevens 2010), and have been shown to be more effective than interventions that do not include the family [for example, standard mean difference (in body weight) = −0.20, 95% CI: −0.41–0.00] (Khambalia et al. 2012; Niemeier et al. 2012). A meta-analysis has shown that weight-related health interventions for children and adolescents that required parent participation had greater success than interventions with no parent participation (P = 0.027, weighted average differences in effect sizes = 0.30, SE = 0.11; Niemeier et al. 2012). However, an earlier review (Stice et al. 2006), published in 2006, indicated that parental involvement was not significantly related to larger treatment effect sizes for obesity prevention interventions (Stice et al. 2006). Direct methods (for example,

Discussion Thirty reviews were included in this scoping review. In terms of family influences, 10 reviews assessed the impact of these on diet, six assessed their impact on physical activity, four assessed their impact on sedentary behaviour and 12 assessed their impact on obesity. Only eight reviews investigated the effect of peer influences on adolescent diet (four reviews), physical activity (three reviews) and sedentary behaviour (one review). There were no reviews found that evaluated peer influences on obesity. Based on the findings of the scoping review there appears to be sufficient evidence for parental influences on healthy behaviours of adolescents, although the evidence is somewhat more compelling for diet than for physical activity and sedentary behaviour. More research needs to be done to investigate family influences on sedentary behaviour. A key finding from this review is that an authoritative parenting style (parents who are

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both responsive to their children’s needs, as well as controlling of their children’s behaviours) can have a positive impact on diet, physical activity and sedentary behaviour, and also on weight status. Higher parental education and income status have also been shown to positively influence these behaviours. However, these factors relate to more fundamental social determinants of health and issues of equity. Intervention at the individual and/or interpersonal levels may be insufficient to address factors such as income and education, and the ecological framework mentioned previously highlights the need for intervention at community and macro-levels, which would include social policy. Education level and income status could relate to the availability of healthy foods, which has been associated with certain healthier eating behaviours, and possibly access to opportunities for physical activity. While these factors may not specifically indicate social support for healthy adolescent behaviour, they may contribute to what is considered appropriate or inappropriate in a particular social context, and therefore influence social norms, according to the definition provided earlier (Bartholomew et al. 2006). While the case for parental influences on healthy behaviours of adolescents is strong, additional research is required to clarify the influence of peers on diet, physical activity and sedentary behaviour of adolescents, as well as on obesity prevention and treatment for adolescents. In addition to this, further research needs to be conducted to better understand differences in family and peer influences between LMICs and high-income countries. Although some differences have been identified with regard to dietary behaviour, little is known about how these differ for physical activity and sedentary behaviour. The evidence mentioned earlier regarding parental education level, occupation and income status suggest that these differences would be worth exploring. Considering the documented difficulties regarding the assessment of dietary intake and the conceptualization and measurement of the construct of ‘physical activity parenting’, further methodological work to address these difficulties would also be beneficial. In terms of the implications of these findings for interventions, the evidence presented affirms the consideration of social norms and social support in the development of interventions to address diet, physical activity and sedentary behaviour among adolescents. However, further research is required on the effectiveness of interventions targeting peer social support and social norms to increase physical activity, decrease sedentary behaviour and/or improve diet among adolescents. For those involved in the development and implementation of interventions targeting adolescent behaviour, the evidence regarding

© 2015 John Wiley & Sons Ltd, Child: care, health and development, 41, 5, 654–667

parenting style can provide some concrete guidance. This evidence suggests that such interventions, when targeting parents, should acknowledge that it may not be sufficient for parents to just model healthy behaviour, provide healthy food and opportunities for physical activity, and restrict sedentary behaviours. It may be necessary, and perhaps more important, to address the way in which parents manage or control these behaviours with their adolescent, which essentially refers to their parenting style. Workshops or training focussing on general parenting could be included in interventions in order to address parenting styles, and the impact of these on diet, physical activity and sedentary behaviour in adolescents. Furthermore, interventions should aim to directly involve parents, by specifically requesting their attendance at training, education or counselling sessions, etc., as opposed to using less direct methods such as sending them information, inviting them to events or suggesting their participation in activities with their child (Hingle et al. 2010). Other evidence suggests that interventions to promote healthy behaviours among adolescents should at the very least take parental education status, occupational and income status into consideration. It could be argued, however, that such interventions should target families with parents of lower education and income status. For parents, the evidence reviewed indicates that changes in their own health behaviours and attitudes and beliefs about parenting may be necessary, and that their direct involvement in efforts to improve their adolescent’s health is required. Parents may also be in a position to influence social norms in their communities, and they should be encouraged to critically reflect on the way in which they may be reinforcing unhealthy eating habits and inactivity among adolescents. This may be particularly relevant in societies where a large body size is encouraged, especially among women, as well as the high intake of carbohydrate-rich staple foods. Peer influences are a serious consideration when trying to address social norms, especially in settings where certain unhealthy choices may be aspirational in some settings, such as eating fast food, or having the latest electronic device, which could contribute to an increase in screen and sedentary time. The task of trying to change these social norms may be further complicated by the fact that these social norms and aspirations may to some extent be different among boys and girls, and that a range of intervention strategies may be necessary to address these norms in a way that is acceptable and appropriate for all groups. Working with parents and peers alone may not be sufficient to alter social norms, particularly those relating to entrenched social behaviours and cultural beliefs, as these may need to be

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addressed at a wider community level, in line with an ecological approach, in order for any shift to be seen. Interventions to address social norms and social support should therefore include community mobilization and engagement with key community stakeholders, as intervention strategies. These align with an ecological approach, as well as with social cognitive theory (Bandura 1986), which highlights the importance of an environment that facilitates behaviour change, although its acknowledgement of broader social and environmental factors is limited. For adolescents, this also includes the school environment and teachers. Engagement with communities and schools may not only be necessary for an impact on the social environment, but could also be essential for any changes to the physical environment that are required as part of making healthier lifestyle choices easier for adolescents. Furthermore, a facilitating environment would include policy relevant to adolescent health behaviour, such as physical education policy in schools, food served or sold in the school environment, and facilities that would promote physical activity in schools and communities. For researchers, the implications of the findings of this review, and of the recommendations outlined earlier, are that more research needs to be conducted to address the research gaps that have been identified in order to effectively address adolescent health behaviours. Further insight into family influences on sedentary behaviour and physical activity, and the influence of peers on diet, physical activity and sedentary behaviour would be useful for those developing and implementing interventions to address these behaviours in adolescents. There is also a need for additional research focusing on the effectiveness of interventions that include family, peer and/or community mobilization components. Studies that look at the relative effectiveness or combinations of these approaches could be valuable, as this could help to identify the ‘key ingredients’ of successful interventions for adolescents. In addition to evidence on effectiveness, further evidence is also required regarding the optimal implementation of family, peer and/or community mobilization components within future interventions. Such implementation research should consider cost implications, appropriate settings (and feasibility of interventions in various settings), theoretical approaches and delivery strategies, as well as the required intensity of interventions for effectiveness. In conclusion, this scoping review has helped to provide a summary of the impact of social norms and social support on diet, physical activity and sedentary behaviour of adolescents. In particular, it has highlighted a number of gaps in the literature, and we would recommend that these gaps first be addressed before conducting a full systematic review on the topic.

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Key messages • Further research on parental influences on physical activity, and even more so on sedentary behaviour, is required. • Additional research is needed to examine peer influences on diet, physical activity and sedentary behaviour of adolescents. • An authoritative parenting style appears to have a positive impact on adolescents’ diet, physical activity and sedentary behaviour, and also on weight status, and this should be considered when designing adolescent interventions. • Interventions to address diet, physical activity and sedentary behaviour of adolescents should address social norms and social support in the research population.

Acknowledgements The authors wish to acknowledge that this work was conducted when CE Draper was employed within the UCT/MRC Research Unit for Exercise Science and Sports Medicine.

Funding This review was funded through the MRC/DfID Africa Research Leader Scheme (UK).

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Supporting information Additional Supporting Information may be found in the online version of this article at the publisher’s web-site: Table S1. Search strategy.

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