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doi:10.1111/jpc.12500
ORIGINAL ARTICLE
Parental readiness to implement life-style behaviour changes in relation to children’s excess weight Filippina Giannisi,1 Panagiota Pervanidou,2 Eri Michalaki,1 Katerina Papanikolaou,3 George Chrousos2 and Mary Yannakoulia1 1
Department of Nutrition and Dietetics, Harokopio University, and 2First Department of Pediatrics, and 3Department of Child Psychiatry, Agia Sophia Children’s Hospital, University of Athens Medical School, Athens, Greece
Aim: The aim if this study is to evaluate parental readiness to implement changes in specific life-style behaviours for preventing or reducing obesity in children. Methods: Eighty-seven parents of overweight or obese children participated in this cross-sectional study. Parents completed a questionnaire for the assessment of their perceptions about their children’s weight and their readiness to take action in general, as well as in relation to ten obesogenic life-style behaviours. The transtheoretical model with the five stages of change (precontemplation, contemplation, preparation, action and maintenance) was used for this assessment. A total readiness score was calculated for the 10 behaviours. Results: A total of 4.6% of parents were in the precontemplation–contemplation stage for overall weight management. However, this percentage was greater for particular behaviours, such as allowing children to self-regulate their food intake, having family meals, reducing screen time and increasing physical activity. Child’s body mass index, paternal education level and parental perception about child’s excessive weight being attributed to over-consumption of sweets and salty snacks were significantly associated with total readiness score. Conclusions: The results of the present study indicate that the high readiness for general action reported by parents of overweight/obese children does not necessarily imply their readiness to engage in changes in specific life-style behaviours. Key words:
diet; family; life-style; physical activity; readiness.
What is already known on this topic
What this paper adds
1 Parents influence their children’s eating and physical activity habits. 2 They underestimate their children’s degree of overweight and report low levels of readiness to make changes in general. 3 The impact of family involvement on the success of childhood obesity treatments is important.
1 The general readiness for action reported by the parents of overweight/obese children in several health-care settings does not necessarily imply their readiness to engage in specific lifestyle behaviours requiring dietary and physical activity habits changes. 2 Assessment of readiness to implement these life-style changes as well as of factors associated with high readiness level may help health professionals to offer families tailored interventions addressing their individual perceptions and barriers. 3 Parents’ work schedules and time constraints limit their engagement in behaviours important for child’s weight management, increasing physical activity or family dinner.
Parents influence their children’s eating and physical activity habits and, therefore, the development of diseases related to them, like obesity. Apart from transmitting their genetic predispositions, parents provide the environment in which these predispositions are expressed.1 In childhood obesity, parents and family are an important etiologic factor, affecting also treatment success.2,3 Correspondence: Dr Mary Yannakoulia, Department of Nutrition and Dietetics, Harokopio University, El. Venizelou 70, Athens 17671, Greece; Fax: + 30 210 9549141; email: [email protected] Conflict of interest: None declared. Accepted for publication 30 November 2013.
476
Despite their key role, a great percentage of parents, one-third to just over three-quarters according to different studies, encounter difficulties in accepting their contribution; they underestimate their children’s degree of overweight,4–6 and they report low levels of readiness and confidence for implementing changes.7,8 Factors associated with the overall readiness of parents include older age of the child and beliefs that their child’s weight is a health problem as well as whether they perceive themselves to be overweight.7 In relation to confidence for executing specific actions, Taveras et al. reported that parents were least confident in their ability to remove the television from their children’s room, limiting television and encouraging physical activity.8 However, no study has evaluated parental
Journal of Paediatrics and Child Health 50 (2014) 476–481 © 2014 The Authors Journal of Paediatrics and Child Health © 2014 Paediatrics and Child Health Division (Royal Australasian College of Physicians)
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Parental readiness to life-style changes
readiness for taking action and changing obesity-related diet and physical activity behaviours. The Expert Committee that was convened in 2005 by the American Medical Association in collaboration with the Health Resources and Service Administration and the Centres for Disease Control and Prevention published specific life-style recommendations for primary care physicians and any other allied health-care providers involved in paediatric weight management.9 The aim of the present study was to evaluate parental perception of their child’s weight status, as well as their readiness to implement these life-style changes. We hypothesised that parents might report to be willing to help their children to manage overweight but not be motivated to engage in specific diet and physical activity actions.
Methods Study population and design Between September 2009 and May 2010, 93 children and their parents presented to the obesity clinic of a major public paediatric hospital for the first time and approached for study participation. Three children were excluded (mother illiterate, parent living away from home, child with Down syndrome), and three parents refused to take part, leaving 87 parent–child dyads participating in the study (Fig. 1). Parents completed an anonymous, self-administered questionnaire for the assessment of their perceptions about their children’s weight, obesity etiology and consequences, as well as their readiness to implement specific life-style changes. The questionnaires were distributed by one of the paediatricians of the study team during the scheduled visits of the family in the obesity clinic. The paediatrician was available for questions and clarifications during questionnaire completion. The majority of questionnaires were completed by mothers (95.4%); for convenience reasons, all participants are referred to as ‘parents’.
396 scheduled appointments
275 parents – children presented to the clinic
93 of them were first visit
3 refused participation 1 mother was illiterate 1 parent wasliving away from home 1 child had Down syndrome
87 ‘parents’ – children enrolled Fig. 1
Flow chart of participants in the study.
Study measures and analysis Questionnaire The questionnaire was designed to collect general sociodemographic information and disease history of the family, as well as information on parental attitudes and behaviours. Parents were asked to report their age, ethnic origin, marital status, years of schooling and occupation, number of people permanently living at home and family living space. Self-reports of parental height and weight were recorded in order to calculate the body mass index (BMI) values as weight/height2 (kg/m2). Overweight was defined as BMI between 25.0 and 29.9 kg/m2, whereas obesity as BMI ≥ 30.0 kg/.10 Perception of child’s weight. A 10-cm visual analogue scale was used to assess parental perceptions of their child’s weight, from ‘normal weight’ to ‘extremely obese’, as in a previous report.7 In addition, a multiple-choice question was used with potential responses ‘my child is . . .’ (i) ‘underweight’, (ii) ‘normal weight’, (iii) ‘overweight’ and (iv) ‘obese’. Multiple-choice questions assessed parental beliefs on their child’s obesity etiology, its consequences, possible solutions and their paediatricians’ obesity concerns. Parental readiness. The transtheoretical model with the five stages of change (precontemplation, contemplation, preparation, action and maintenance)11 was used to assess the readiness of parents to take action in general for their child’s overweight as well as to implement changes in specific lifestyles and/or behaviours. The behaviours were the ones recommended by the Expert Committee,9 that is (i) consumption of greater than or equal to five servings of fruits and vegetables per day; (ii) minimisation or elimination of sugar-sweetened beverages; (iii) limits of ≤2 h of screen time per day and no television in the room where the child sleeps; (iv) ≥1 h of physical activity per day; (v) eating breakfast daily; (vi) limiting meals out of home, including fast food venues and other restaurants; (vii) eating family meals at least five or six times per week; and (viii) allowing the child to self-regulate his or her meals and avoiding overly restrictive behaviours. Two more behaviours were added, namely reduction of sweets and improvement in the quality of snacks, on the basis that sweet/ salty snacks are very popular among Greek children,12–14 and they may play an unfavorable role in the management of energy balance. Thus, stages of change (i.e. parental readiness) were assessed for 10 life-style behaviours. Parents had to choose one of the following responses for each behaviour in order to be classified to a specific stage of change: (i) ‘I do not think about changing the behaviour’: precontemplation; (ii) ‘I think about changing this behaviour, but I am not sure’: contemplation; (iii) ‘I will change this behaviour in the next month’: preparation; (iv) ‘I am already making this behavioural change’: action; and (v) ‘I have already implemented changes regarding this behaviour for more than 6 months’: maintenance. For the statistical analysis, precontemplation and contemplation stages were merged into one ‘contemplation’ stage because of the small number of parents in each of them; similarly, action and maintenance were combined to one ‘action’ stage. These assumptions did not violate the original
Journal of Paediatrics and Child Health 50 (2014) 476–481 © 2014 The Authors Journal of Paediatrics and Child Health © 2014 Paediatrics and Child Health Division (Royal Australasian College of Physicians)
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characteristics of each of the stages, and they have been previously applied in a similar manner.7 To calculate the ‘total readiness score’, a value from 0 to 4 was assigned to each stage, from precontemplation to maintenance, respectively, for each of the 10 life-style behaviours. Therefore, the total score may range from 0 to 40.
Anthropometry Physical measurements of body weight and height were obtained from all children (light clothing, no shoes). BMI was used for participants’ classification as normal weight, overweight or obese.15
Statistical analysis Continuous variables are presented as mean ± standard deviation, whereas categorical variables as absolute and relative frequencies. Associations between continuous variables were tested by Pearson or Spearman coefficients and categorical variables by use of χ2 test. Multiple regression analysis was applied to evaluate the explanatory ability of various characteristics of the participants in relation to the investigated outcome, the total readiness score, after adjusting for potential confounders. The results from the regression models are presented as standardised beta (β) coefficients. SPSS software, version 13.0 (SPSS Inc., Chicago, IL, USA) was used for all the statistical calculations.
Results Of the total cohort, 86% were obese (the rest of them were overweight), and 61% were female (Table 1). Their mean age was 9.7 ± 2.9 years, and half of them were the first child of the family. Nearly one-third of the parents were obese, and 25.0% of them had a college or university degree. A weak positive association was found between child’s BMI and maternal (r = 0.223, P = 0.040), but not paternal, BMI (r = 0.095, P = 0.387). Of all parents, 65.0% described their child as overweight and 33.0% as obese; on the other hand, 75.0% of parents of overweight children and 35.0% of parents of obese children classified their offspring’s weight status correctly (Table 2). Weight status misclassification was greater in parents of boys than in those of girls (69.7% vs. 42.7%, P = 0.047). About two-thirds of parents reported that they visited the obesity clinic because of concerns about the increasing weight of their child and its health consequences. Most of the parents (85.1%) reported that their paediatrician was concerned about their child’s weight; however, only 42.5% of them were referred to a childhood obesity management group by the health professional. The most frequently stated parental beliefs on the etiology of excess body weight were consumption of big food portions (57.5%) and having a sedentary life-style (49.4%). Nearly all parents believed that obesity is a major health problem for their child, whereas two-thirds of them considered that excess weight had an effect on their child’s emotions and general mood. About one-third of parents reported feeling exclusively responsible for implementing lifestyle changes, whereas 40% of them stated that the changes should be accomplished in co-operation with the child. 478
Table 1 Demographic and weight-related characteristics of the study participants (children and their parents) Characteristics
n = 87
Ethnicity, Greek (%) Children Age (years) BMI (kg/m2) Weight status (%) Overweight Obese Mothers Age (years) Weight status (%) Overweight Obese Education: ≥13 years (%) Fathers Age (years) Weight status (%) Overweight Obese Education: ≥13 years (%)
87.4† 9.7 ± 2.9 28.48 ± 4.19 13.8 86.2 39.3 ± 4.8 33.3 32.1 30.2 42.5 ± 5.2 56.0 35.7 27.6
Data are presented as means ± standard deviation or relative frequencies. †The rest of them were of Albanian and Russian ethnicity.
Regarding their readiness, more than half of parents (57.5%) were in the preparation stage for taking action in general for their child’s weight, 37.9% in the action stage and only 4.6% in the contemplation stage (Fig. 2). However, the contemplation group was larger for specific behaviours, such as allowing children to self-regulate their food intake (36.0%), having family meals (29.9%), reducing screen time (27.6%) and increasing physical activity (26.4%). More than half of parents were in the action stage for reducing consumption of sodas, sweets, and eating out and having breakfast on a daily basis. The ‘total readiness score’ was 25.4 ± 6.7. Parental demographic and children’s characteristics, as well as parental perception, were explored in relation to readiness using multiple regression analysis. Child’s BMI (standardised β = −0.23, P = 0.05), paternal education level (standardised β = 0.25, P = 0.03) and parental perception about child’s excessive weight being attributed to over-consumption of sweets and salty snacks (standardised β = −0.30, P = 0.01) were statistically associated with ‘total readiness score’ (Table 3). Similar results were found when maternal, instead of paternal, education was used as an independent variable in the model.
Discussion We investigated the readiness of parents to change specific lifestyle behaviours in order to help their child to manage excess weight. Interestingly, more than 95% of parents were at least in the preparation stage for the overall weight management, but this percentage was much lower when they were questioned about specific diet and physical activity actions. In particular,
Journal of Paediatrics and Child Health 50 (2014) 476–481 © 2014 The Authors Journal of Paediatrics and Child Health © 2014 Paediatrics and Child Health Division (Royal Australasian College of Physicians)
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Table 2
Parental readiness to life-style changes
Classification of children based on actual weight or parental report Classification based on parental report
Classification based on actual weight
Overweight Obese
Normal-weight
Overweight
Obese
1 (8.3) 1 (1.4)
9 (75.0) 47 (63.5)
2 (16.7) 26 (35.1)
Actual numbers are reported, and percentages are in parentheses. One parent did not classify his/her child’s weight status.
Fig. 2 Parental readiness for suggested lifestyle changes.
Table 3 Logistic regression model for parents’ ‘total readiness’ score
Child’s BMI Parental belief that over-consumption of sweet and salty snacks was responsible for children’s excess weight Paternal education ≥13 years Perception of child’s weight (10-point visual analogue scale) Child’s sex Child’s age
Standardised coefficient β
P
–0.288 –0.298
0.050 0.008
0.247 0.241
0.029 0.057
0.003 0.021
0.981 0.863
BMI, body mass index.
our parent subjects reported low levels of readiness for all physical activity-related behaviours as well as for those behaviours calling for complex actions, such as organising family dinners and helping or educating children to self-control their diet, rather than imposing rules and restrictions. Reducing screen time and ensuring enough time for exercise each day require active personal involvement of parents. Parents are aware of the benefits of physical activity, but several barriers prevent them from investing time on it.16 Their attitudes may be
related to broader cultural concerns and beliefs which may give priority to other issues regarding their children. Low readiness levels reported in this study may, thus, reflect parents’ distress about neighbourhood safety and their over-protectiveness,17,18 their demanding work schedules and time constraints,19,20 as well as their preference for academic rather than other pursuits.21 Parents may also encounter difficulties in scheduling creative activities16 and allowing time for free, child-driven, inventive play,21 which offers several physical and developmental benefits for young people.22 Whatever the reason, low parental readiness for a more healthful life-style may explain the ineffectiveness of several obesity prevention and management programmes in increasing children’s physical activity levels.23,24 Family dinner is a dietary behaviour that has recently received scientific attention. Cross-sectional and longitudinal studies reported that children who regularly eat dinner with other family members are less likely to be overweight.25–27 However, in the present study, 30% of parents of overweight children stated that they were in the precontemplation/contemplation stage for having family meals frequently. Again, work schedules and time constraints may explain this finding, as serving a family meal requires a lot of scheduling and food preparation. For many parents, cooking may be just another task, viewed as an impediment to other activities, that should be completed as quickly as possible, being neither pleasurable nor expressing creativity.28 Furthermore, meal times of obese youth are frequently perceived by their parents as distressing, behaviourally challenging and less positive in terms of family interactions.20
Journal of Paediatrics and Child Health 50 (2014) 476–481 © 2014 The Authors Journal of Paediatrics and Child Health © 2014 Paediatrics and Child Health Division (Royal Australasian College of Physicians)
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A demanding obesity-related change to be implemented by the parents is to allow their child to self-regulate his/her food intake and to avoid restrictive practices. Parents use several types of restrictions, for example, they limit foods high in sugar, but their efforts have opposite effects. Parental feeding restriction has been consistently associated with increased child’s energy intake and body weight.29,30 Imposing restrictions predict an authoritarian parental style,31 and this may provide an explanation why parents have difficulties in changing this behaviour as it demands more profound changes in their parenting practices. On the other hand, as parents use less restrictive feeding practices when they believe that their children are able to selfregulate,32 health professionals should focus on early interventions to teach parents about children’s abilities in this domain. Interestingly, in our sample, although most of the paediatricians were concerned about children’s excess weight, only half of the children were referred to a specialised management group. This is in accordance to a finding from a U.S. study reporting delayed referral to a specialist,33 and again, it underscores the importance of early intervention, importantly, at the screening stage. In relation to the ‘total readiness score’, parental education was positively associated with it, whereas child’s BMI and parental beliefs regarding the effect of sweet and salty snacks on child’s weight were negatively related. Higher education level may reflect greater knowledge on childhood obesity and potential solutions, but it may also indicate higher socio-economic status and better access to health services. Indeed, several studies so far have indicated that parental perceptions about child’s body weight are related to maternal educational level.4,34 Besides, as child’s body weight increases, parents may feel less confident and thus less motivated and ready to proceed to changes. Rhee et al. reported for the parents of obese children that the odds of being in the precontemplation as well as those of being in the preparation/action stages of change were significantly increased when child’s BMI was ≥95th percentile.7 The present study assessed parental readiness about children’s obesity beyond taking general corrective actions; thus, it provides insight into specific life-style behaviours that need better assessment and targeting in terms of parental motivation. There are, however, some study limitations. The cross-sectional design and the limited information on the socio-economic factors that operate within each family did not allow us to explore etiological mechanisms. We only formulated hypotheses that need to be tested in future research, and although we attempted to account for variables that were likely associated with parental readiness, the potential for residual confounding by uncontrolled covariates may be possible. Most of the information collected was based on self-reports by the parents. The validity of parental reports has been previously questioned,35 and it is a known limitation of this type of research. However, we used an anonymous self-completed questionnaire, instead of an interview, and this method, providing less personal communication, was found to limit responders’ tendency to give socially desirable answers.35,36 Finally, the study population consisted of a convenience sample of parents seeking advice for their children’s excess weight in a major public paediatric hospital, and the results may not be generalised to parents of overweight children not interested in finding support or looking for treatment in private health-care settings. 480
Conclusion In conclusion, the increased readiness for general action reported by the parents of overweight/obese children in several medical settings does not necessarily imply their readiness to engage in specific life-style behaviour changes. Knowledge of factors associated with high readiness levels may help healthcare professionals to offer families more tailored interventions that address these factors and perceptions.
Acknowledgements The authors have no financial relationships relevant to this article to disclose. The study was funded in part by the Department of Nutrition and Dietetics Graduate Program, Harokopio University.
References 1 Maffeis C. Aetiology of overweight and obesity in children and adolescents. Eur. J. Pediatr. 2000; 159 (Suppl. 1): S35–44. 2 Golan M. Parents as agents of change in childhood obesity–from research to practice. Int. J. Pediatr. Obes. 2006; 1: 66–76. 3 Faith MS, Van Horn L, Appel LJ et al. Evaluating parents and adult caregivers as ‘agents of change’ for treating obese children: evidence for parent behavior change strategies and research gaps: a scientific statement from the American Heart Association. Circulation 2012; 125: 1186–207. 4 Baughcum AE, Chamberlin LA, Deeks CM, Powers SW, Whitaker RC. Maternal perceptions of overweight preschool children. Pediatrics 2000; 106: 1380–6. 5 Boutelle K, Fulkerson JA, Neumark-Sztainer D, Story M. Mothers’ perceptions of their adolescents’ weight status: are they accurate? Obes. Res. 2004; 12: 1754–7. 6 Maynard LM, Galuska DA, Blanck HM, Serdula MK. Maternal perceptions of weight status of children. Pediatrics 2003; 111: 1226–31. 7 Rhee KE, De Lago CW, Arscott-Mills T, Mehta SD, Davis RK. Factors associated with parental readiness to make changes for overweight children. Pediatrics 2005; 116: e94–101. 8 Taveras EM, Mitchell K, Gortmaker SL. Parental confidence in making overweight-related behavior changes. Pediatrics 2009; 124: 151–8. 9 Barlow SE. Expert committee recommendations regarding the prevention, assessment, and treatment of child and adolescent overweight and obesity: summary report. Pediatrics 2007; 120: S164–92. 10 World OH. Obesity: preventing and managing the global epidemic. Geneva, Switzerland: World Health Organization, 1997. 11 Prochaska JO, Velicer WF. The transtheoretical model of health behavior change. Am. J. Health Promot. 1997; 12: 38–48. 12 Yannakoulia M, Karayiannis D, Terzidou M, Kokkevi A, Sidossis LS. Nutrition-related habits of Greek adolescents. Eur. J. Clin. Nutr. 2004; 58: 580–6. 13 Kosti RI, Panagiotakos DB, Mihas CC et al. Dietary habits, physical activity and prevalence of overweight/obesity among adolescents in Greece: the Vyronas study. Med. Sci. Monit. 2007; 13: CR437–44. 14 Hassapidou M, Fotiadou E, Maglara E, Papadopoulou SK. Energy intake, diet composition, energy expenditure, and body fatness of adolescents in northern Greece. Obesity (Silver Spring) 2006; 14: 855–62. 15 Cole TJ, Bellizzi MC, Flegal KM, Dietz WH. Establishing a standard definition for child overweight and obesity worldwide: international survey. BMJ 2000; 320: 1240–3.
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16 Dwyer GM, Higgs J, Hardy LL, Baur LA. What do parents and preschool staff tell us about young children’s physical activity: a qualitative study. Int. J. Behav. Nutr. Phys. Act. 2008; 5: 66. 17 Burdette HL, Whitaker RC. A national study of neighborhood safety, outdoor play, television viewing, and obesity in preschool children. Pediatrics 2005; 116: 657–62. 18 Sonneville KR, La Pelle N, Taveras EM, Gillman MW, Prosser LA. Economic and other barriers to adopting recommendations to prevent childhood obesity: results of a focus group study with parents. BMC Pediatr. 2009; 9: 81. 19 Hawkins SS, Cole TJ, Law C. Examining the relationship between maternal employment and health behaviours in 5-year-old British children. J. Epidemiol. Community Health 2009; 63: 999–1004. 20 Zeller MH, Reiter-Purtill J, Modi AC, Gutzwiller J, Vannatta K, Davies WH. Controlled study of critical parent and family factors in the obesigenic environment. Obesity (Silver Spring) 2007; 15: 126–36. 21 Ginsburg KR. The importance of play in promoting healthy child development and maintaining strong parent-child bonds. Pediatrics 2007; 119: 182–91. 22 Burdette HL, Whitaker RC. Resurrecting free play in young children: looking beyond fitness and fatness to attention, affiliation, and affect. Arch. Pediatr. Adolesc. Med. 2005; 159: 46–50. 23 Marcus C, Nyberg G, Nordenfelt A, Karpmyr M, Kowalski J, Ekelund U. A 4-year, cluster-randomized, controlled childhood obesity prevention study: STOPP. Int. J. Obes. (Lond) 2009; 33: 408–17. 24 Francis M, Nichols SS, Dalrymple N. The effects of a school-based intervention programme on dietary intakes and physical activity among primary-school children in Trinidad and Tobago. Public Health Nutr. 2010; 13: 738–47. 25 Sen B. Frequency of family dinner and adolescent body weight status: evidence from the national longitudinal survey of youth, 1997. Obesity (Silver Spring) 2006; 14: 2266–76.
26 Gillman MW, Rifas-Shiman SL, Frazier AL et al. Family dinner and diet quality among older children and adolescents. Arch. Fam. Med. 2000; 9: 235–40. 27 Yannakoulia M, Ntalla I, Papoutsakis C, Farmaki AE, Dedoussis GV. Consumption of vegetables, cooked meals, and eating dinner is negatively associated with overweight status in children. J. Pediatr. 2010; 157: 815–20. 28 Jabs J, Devine CM, Bisogni CA, Farrell TJ, Jastran M, Wethington E. Trying to find the quickest way: employed mothers’ constructions of time for food. J. Nutr. Educ. Behav. 2007; 39: 18–25. 29 Faith MS, Scanlon KS, Birch LL, Francis LA, Sherry B. Parent-child feeding strategies and their relationships to child eating and weight status. Obes. Res. 2004; 12: 1711–22. 30 Clark HR, Goyder E, Bissell P, Blank L, Peters J. How do parents’ child-feeding behaviours influence child weight? Implications for childhood obesity policy. J. Public Health (Oxf.) 2007; 29: 132–41. 31 Hubbs-Tait L, Kennedy TS, Page MC, Topham GL, Harrist AW. Parental feeding practices predict authoritative, authoritarian, and permissive parenting styles. J. Am. Diet. Assoc. 2008; 108: 1154–61, discussion 1161–1152. 32 Tan CC, Holub SC. Children’s self-regulation in eating: associations with inhibitory control and parents’ feeding behavior. J. Pediatr. Psychol. 2011; 36: 340–5. 33 Quattrin T, Liu E, Shaw N, Shine B, Chiang E. Obese children who are referred to the pediatric endocrinologist: characteristics and outcome. Pediatrics 2005; 115: 348–51. 34 Genovesi S, Giussani M, Faini A et al. Maternal perception of excess weight in children: a survey conducted by paediatricians in the province of Milan. Acta Paediatr. 2005; 94: 747–52. 35 Morsbach SK, Prinz RJ. Understanding and improving the validity of self-report of parenting. Clin. Child Fam. Psychol. Rev. 2006; 9: 1–21. 36 Pless IB, Miller JR. Apparent validity of alternative survey methods. J. Community Health 1979; 5: 22–7.
The Narran Lake, by Hayley Claringbold (10) from Operation Art 2011.
Journal of Paediatrics and Child Health 50 (2014) 476–481 © 2014 The Authors Journal of Paediatrics and Child Health © 2014 Paediatrics and Child Health Division (Royal Australasian College of Physicians)
481
doi:10.1111/jpc.12500
ORIGINAL ARTICLE
Parental readiness to implement life-style behaviour changes in relation to children’s excess weight Filippina Giannisi,1 Panagiota Pervanidou,2 Eri Michalaki,1 Katerina Papanikolaou,3 George Chrousos2 and Mary Yannakoulia1 1
Department of Nutrition and Dietetics, Harokopio University, and 2First Department of Pediatrics, and 3Department of Child Psychiatry, Agia Sophia Children’s Hospital, University of Athens Medical School, Athens, Greece
Aim: The aim if this study is to evaluate parental readiness to implement changes in specific life-style behaviours for preventing or reducing obesity in children. Methods: Eighty-seven parents of overweight or obese children participated in this cross-sectional study. Parents completed a questionnaire for the assessment of their perceptions about their children’s weight and their readiness to take action in general, as well as in relation to ten obesogenic life-style behaviours. The transtheoretical model with the five stages of change (precontemplation, contemplation, preparation, action and maintenance) was used for this assessment. A total readiness score was calculated for the 10 behaviours. Results: A total of 4.6% of parents were in the precontemplation–contemplation stage for overall weight management. However, this percentage was greater for particular behaviours, such as allowing children to self-regulate their food intake, having family meals, reducing screen time and increasing physical activity. Child’s body mass index, paternal education level and parental perception about child’s excessive weight being attributed to over-consumption of sweets and salty snacks were significantly associated with total readiness score. Conclusions: The results of the present study indicate that the high readiness for general action reported by parents of overweight/obese children does not necessarily imply their readiness to engage in changes in specific life-style behaviours. Key words:
diet; family; life-style; physical activity; readiness.
What is already known on this topic
What this paper adds
1 Parents influence their children’s eating and physical activity habits. 2 They underestimate their children’s degree of overweight and report low levels of readiness to make changes in general. 3 The impact of family involvement on the success of childhood obesity treatments is important.
1 The general readiness for action reported by the parents of overweight/obese children in several health-care settings does not necessarily imply their readiness to engage in specific lifestyle behaviours requiring dietary and physical activity habits changes. 2 Assessment of readiness to implement these life-style changes as well as of factors associated with high readiness level may help health professionals to offer families tailored interventions addressing their individual perceptions and barriers. 3 Parents’ work schedules and time constraints limit their engagement in behaviours important for child’s weight management, increasing physical activity or family dinner.
Parents influence their children’s eating and physical activity habits and, therefore, the development of diseases related to them, like obesity. Apart from transmitting their genetic predispositions, parents provide the environment in which these predispositions are expressed.1 In childhood obesity, parents and family are an important etiologic factor, affecting also treatment success.2,3 Correspondence: Dr Mary Yannakoulia, Department of Nutrition and Dietetics, Harokopio University, El. Venizelou 70, Athens 17671, Greece; Fax: + 30 210 9549141; email: [email protected] Conflict of interest: None declared. Accepted for publication 30 November 2013.
476
Despite their key role, a great percentage of parents, one-third to just over three-quarters according to different studies, encounter difficulties in accepting their contribution; they underestimate their children’s degree of overweight,4–6 and they report low levels of readiness and confidence for implementing changes.7,8 Factors associated with the overall readiness of parents include older age of the child and beliefs that their child’s weight is a health problem as well as whether they perceive themselves to be overweight.7 In relation to confidence for executing specific actions, Taveras et al. reported that parents were least confident in their ability to remove the television from their children’s room, limiting television and encouraging physical activity.8 However, no study has evaluated parental
Journal of Paediatrics and Child Health 50 (2014) 476–481 © 2014 The Authors Journal of Paediatrics and Child Health © 2014 Paediatrics and Child Health Division (Royal Australasian College of Physicians)
F Giannisi et al.
Parental readiness to life-style changes
readiness for taking action and changing obesity-related diet and physical activity behaviours. The Expert Committee that was convened in 2005 by the American Medical Association in collaboration with the Health Resources and Service Administration and the Centres for Disease Control and Prevention published specific life-style recommendations for primary care physicians and any other allied health-care providers involved in paediatric weight management.9 The aim of the present study was to evaluate parental perception of their child’s weight status, as well as their readiness to implement these life-style changes. We hypothesised that parents might report to be willing to help their children to manage overweight but not be motivated to engage in specific diet and physical activity actions.
Methods Study population and design Between September 2009 and May 2010, 93 children and their parents presented to the obesity clinic of a major public paediatric hospital for the first time and approached for study participation. Three children were excluded (mother illiterate, parent living away from home, child with Down syndrome), and three parents refused to take part, leaving 87 parent–child dyads participating in the study (Fig. 1). Parents completed an anonymous, self-administered questionnaire for the assessment of their perceptions about their children’s weight, obesity etiology and consequences, as well as their readiness to implement specific life-style changes. The questionnaires were distributed by one of the paediatricians of the study team during the scheduled visits of the family in the obesity clinic. The paediatrician was available for questions and clarifications during questionnaire completion. The majority of questionnaires were completed by mothers (95.4%); for convenience reasons, all participants are referred to as ‘parents’.
396 scheduled appointments
275 parents – children presented to the clinic
93 of them were first visit
3 refused participation 1 mother was illiterate 1 parent wasliving away from home 1 child had Down syndrome
87 ‘parents’ – children enrolled Fig. 1
Flow chart of participants in the study.
Study measures and analysis Questionnaire The questionnaire was designed to collect general sociodemographic information and disease history of the family, as well as information on parental attitudes and behaviours. Parents were asked to report their age, ethnic origin, marital status, years of schooling and occupation, number of people permanently living at home and family living space. Self-reports of parental height and weight were recorded in order to calculate the body mass index (BMI) values as weight/height2 (kg/m2). Overweight was defined as BMI between 25.0 and 29.9 kg/m2, whereas obesity as BMI ≥ 30.0 kg/.10 Perception of child’s weight. A 10-cm visual analogue scale was used to assess parental perceptions of their child’s weight, from ‘normal weight’ to ‘extremely obese’, as in a previous report.7 In addition, a multiple-choice question was used with potential responses ‘my child is . . .’ (i) ‘underweight’, (ii) ‘normal weight’, (iii) ‘overweight’ and (iv) ‘obese’. Multiple-choice questions assessed parental beliefs on their child’s obesity etiology, its consequences, possible solutions and their paediatricians’ obesity concerns. Parental readiness. The transtheoretical model with the five stages of change (precontemplation, contemplation, preparation, action and maintenance)11 was used to assess the readiness of parents to take action in general for their child’s overweight as well as to implement changes in specific lifestyles and/or behaviours. The behaviours were the ones recommended by the Expert Committee,9 that is (i) consumption of greater than or equal to five servings of fruits and vegetables per day; (ii) minimisation or elimination of sugar-sweetened beverages; (iii) limits of ≤2 h of screen time per day and no television in the room where the child sleeps; (iv) ≥1 h of physical activity per day; (v) eating breakfast daily; (vi) limiting meals out of home, including fast food venues and other restaurants; (vii) eating family meals at least five or six times per week; and (viii) allowing the child to self-regulate his or her meals and avoiding overly restrictive behaviours. Two more behaviours were added, namely reduction of sweets and improvement in the quality of snacks, on the basis that sweet/ salty snacks are very popular among Greek children,12–14 and they may play an unfavorable role in the management of energy balance. Thus, stages of change (i.e. parental readiness) were assessed for 10 life-style behaviours. Parents had to choose one of the following responses for each behaviour in order to be classified to a specific stage of change: (i) ‘I do not think about changing the behaviour’: precontemplation; (ii) ‘I think about changing this behaviour, but I am not sure’: contemplation; (iii) ‘I will change this behaviour in the next month’: preparation; (iv) ‘I am already making this behavioural change’: action; and (v) ‘I have already implemented changes regarding this behaviour for more than 6 months’: maintenance. For the statistical analysis, precontemplation and contemplation stages were merged into one ‘contemplation’ stage because of the small number of parents in each of them; similarly, action and maintenance were combined to one ‘action’ stage. These assumptions did not violate the original
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characteristics of each of the stages, and they have been previously applied in a similar manner.7 To calculate the ‘total readiness score’, a value from 0 to 4 was assigned to each stage, from precontemplation to maintenance, respectively, for each of the 10 life-style behaviours. Therefore, the total score may range from 0 to 40.
Anthropometry Physical measurements of body weight and height were obtained from all children (light clothing, no shoes). BMI was used for participants’ classification as normal weight, overweight or obese.15
Statistical analysis Continuous variables are presented as mean ± standard deviation, whereas categorical variables as absolute and relative frequencies. Associations between continuous variables were tested by Pearson or Spearman coefficients and categorical variables by use of χ2 test. Multiple regression analysis was applied to evaluate the explanatory ability of various characteristics of the participants in relation to the investigated outcome, the total readiness score, after adjusting for potential confounders. The results from the regression models are presented as standardised beta (β) coefficients. SPSS software, version 13.0 (SPSS Inc., Chicago, IL, USA) was used for all the statistical calculations.
Results Of the total cohort, 86% were obese (the rest of them were overweight), and 61% were female (Table 1). Their mean age was 9.7 ± 2.9 years, and half of them were the first child of the family. Nearly one-third of the parents were obese, and 25.0% of them had a college or university degree. A weak positive association was found between child’s BMI and maternal (r = 0.223, P = 0.040), but not paternal, BMI (r = 0.095, P = 0.387). Of all parents, 65.0% described their child as overweight and 33.0% as obese; on the other hand, 75.0% of parents of overweight children and 35.0% of parents of obese children classified their offspring’s weight status correctly (Table 2). Weight status misclassification was greater in parents of boys than in those of girls (69.7% vs. 42.7%, P = 0.047). About two-thirds of parents reported that they visited the obesity clinic because of concerns about the increasing weight of their child and its health consequences. Most of the parents (85.1%) reported that their paediatrician was concerned about their child’s weight; however, only 42.5% of them were referred to a childhood obesity management group by the health professional. The most frequently stated parental beliefs on the etiology of excess body weight were consumption of big food portions (57.5%) and having a sedentary life-style (49.4%). Nearly all parents believed that obesity is a major health problem for their child, whereas two-thirds of them considered that excess weight had an effect on their child’s emotions and general mood. About one-third of parents reported feeling exclusively responsible for implementing lifestyle changes, whereas 40% of them stated that the changes should be accomplished in co-operation with the child. 478
Table 1 Demographic and weight-related characteristics of the study participants (children and their parents) Characteristics
n = 87
Ethnicity, Greek (%) Children Age (years) BMI (kg/m2) Weight status (%) Overweight Obese Mothers Age (years) Weight status (%) Overweight Obese Education: ≥13 years (%) Fathers Age (years) Weight status (%) Overweight Obese Education: ≥13 years (%)
87.4† 9.7 ± 2.9 28.48 ± 4.19 13.8 86.2 39.3 ± 4.8 33.3 32.1 30.2 42.5 ± 5.2 56.0 35.7 27.6
Data are presented as means ± standard deviation or relative frequencies. †The rest of them were of Albanian and Russian ethnicity.
Regarding their readiness, more than half of parents (57.5%) were in the preparation stage for taking action in general for their child’s weight, 37.9% in the action stage and only 4.6% in the contemplation stage (Fig. 2). However, the contemplation group was larger for specific behaviours, such as allowing children to self-regulate their food intake (36.0%), having family meals (29.9%), reducing screen time (27.6%) and increasing physical activity (26.4%). More than half of parents were in the action stage for reducing consumption of sodas, sweets, and eating out and having breakfast on a daily basis. The ‘total readiness score’ was 25.4 ± 6.7. Parental demographic and children’s characteristics, as well as parental perception, were explored in relation to readiness using multiple regression analysis. Child’s BMI (standardised β = −0.23, P = 0.05), paternal education level (standardised β = 0.25, P = 0.03) and parental perception about child’s excessive weight being attributed to over-consumption of sweets and salty snacks (standardised β = −0.30, P = 0.01) were statistically associated with ‘total readiness score’ (Table 3). Similar results were found when maternal, instead of paternal, education was used as an independent variable in the model.
Discussion We investigated the readiness of parents to change specific lifestyle behaviours in order to help their child to manage excess weight. Interestingly, more than 95% of parents were at least in the preparation stage for the overall weight management, but this percentage was much lower when they were questioned about specific diet and physical activity actions. In particular,
Journal of Paediatrics and Child Health 50 (2014) 476–481 © 2014 The Authors Journal of Paediatrics and Child Health © 2014 Paediatrics and Child Health Division (Royal Australasian College of Physicians)
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Table 2
Parental readiness to life-style changes
Classification of children based on actual weight or parental report Classification based on parental report
Classification based on actual weight
Overweight Obese
Normal-weight
Overweight
Obese
1 (8.3) 1 (1.4)
9 (75.0) 47 (63.5)
2 (16.7) 26 (35.1)
Actual numbers are reported, and percentages are in parentheses. One parent did not classify his/her child’s weight status.
Fig. 2 Parental readiness for suggested lifestyle changes.
Table 3 Logistic regression model for parents’ ‘total readiness’ score
Child’s BMI Parental belief that over-consumption of sweet and salty snacks was responsible for children’s excess weight Paternal education ≥13 years Perception of child’s weight (10-point visual analogue scale) Child’s sex Child’s age
Standardised coefficient β
P
–0.288 –0.298
0.050 0.008
0.247 0.241
0.029 0.057
0.003 0.021
0.981 0.863
BMI, body mass index.
our parent subjects reported low levels of readiness for all physical activity-related behaviours as well as for those behaviours calling for complex actions, such as organising family dinners and helping or educating children to self-control their diet, rather than imposing rules and restrictions. Reducing screen time and ensuring enough time for exercise each day require active personal involvement of parents. Parents are aware of the benefits of physical activity, but several barriers prevent them from investing time on it.16 Their attitudes may be
related to broader cultural concerns and beliefs which may give priority to other issues regarding their children. Low readiness levels reported in this study may, thus, reflect parents’ distress about neighbourhood safety and their over-protectiveness,17,18 their demanding work schedules and time constraints,19,20 as well as their preference for academic rather than other pursuits.21 Parents may also encounter difficulties in scheduling creative activities16 and allowing time for free, child-driven, inventive play,21 which offers several physical and developmental benefits for young people.22 Whatever the reason, low parental readiness for a more healthful life-style may explain the ineffectiveness of several obesity prevention and management programmes in increasing children’s physical activity levels.23,24 Family dinner is a dietary behaviour that has recently received scientific attention. Cross-sectional and longitudinal studies reported that children who regularly eat dinner with other family members are less likely to be overweight.25–27 However, in the present study, 30% of parents of overweight children stated that they were in the precontemplation/contemplation stage for having family meals frequently. Again, work schedules and time constraints may explain this finding, as serving a family meal requires a lot of scheduling and food preparation. For many parents, cooking may be just another task, viewed as an impediment to other activities, that should be completed as quickly as possible, being neither pleasurable nor expressing creativity.28 Furthermore, meal times of obese youth are frequently perceived by their parents as distressing, behaviourally challenging and less positive in terms of family interactions.20
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A demanding obesity-related change to be implemented by the parents is to allow their child to self-regulate his/her food intake and to avoid restrictive practices. Parents use several types of restrictions, for example, they limit foods high in sugar, but their efforts have opposite effects. Parental feeding restriction has been consistently associated with increased child’s energy intake and body weight.29,30 Imposing restrictions predict an authoritarian parental style,31 and this may provide an explanation why parents have difficulties in changing this behaviour as it demands more profound changes in their parenting practices. On the other hand, as parents use less restrictive feeding practices when they believe that their children are able to selfregulate,32 health professionals should focus on early interventions to teach parents about children’s abilities in this domain. Interestingly, in our sample, although most of the paediatricians were concerned about children’s excess weight, only half of the children were referred to a specialised management group. This is in accordance to a finding from a U.S. study reporting delayed referral to a specialist,33 and again, it underscores the importance of early intervention, importantly, at the screening stage. In relation to the ‘total readiness score’, parental education was positively associated with it, whereas child’s BMI and parental beliefs regarding the effect of sweet and salty snacks on child’s weight were negatively related. Higher education level may reflect greater knowledge on childhood obesity and potential solutions, but it may also indicate higher socio-economic status and better access to health services. Indeed, several studies so far have indicated that parental perceptions about child’s body weight are related to maternal educational level.4,34 Besides, as child’s body weight increases, parents may feel less confident and thus less motivated and ready to proceed to changes. Rhee et al. reported for the parents of obese children that the odds of being in the precontemplation as well as those of being in the preparation/action stages of change were significantly increased when child’s BMI was ≥95th percentile.7 The present study assessed parental readiness about children’s obesity beyond taking general corrective actions; thus, it provides insight into specific life-style behaviours that need better assessment and targeting in terms of parental motivation. There are, however, some study limitations. The cross-sectional design and the limited information on the socio-economic factors that operate within each family did not allow us to explore etiological mechanisms. We only formulated hypotheses that need to be tested in future research, and although we attempted to account for variables that were likely associated with parental readiness, the potential for residual confounding by uncontrolled covariates may be possible. Most of the information collected was based on self-reports by the parents. The validity of parental reports has been previously questioned,35 and it is a known limitation of this type of research. However, we used an anonymous self-completed questionnaire, instead of an interview, and this method, providing less personal communication, was found to limit responders’ tendency to give socially desirable answers.35,36 Finally, the study population consisted of a convenience sample of parents seeking advice for their children’s excess weight in a major public paediatric hospital, and the results may not be generalised to parents of overweight children not interested in finding support or looking for treatment in private health-care settings. 480
Conclusion In conclusion, the increased readiness for general action reported by the parents of overweight/obese children in several medical settings does not necessarily imply their readiness to engage in specific life-style behaviour changes. Knowledge of factors associated with high readiness levels may help healthcare professionals to offer families more tailored interventions that address these factors and perceptions.
Acknowledgements The authors have no financial relationships relevant to this article to disclose. The study was funded in part by the Department of Nutrition and Dietetics Graduate Program, Harokopio University.
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The Narran Lake, by Hayley Claringbold (10) from Operation Art 2011.
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