(p. 156) A Population Approach to Parenting Support for Childhood Obesity
Childhood obesity presents a major public health dilemma. The dramatic increase in the prevalence of overweight and obesity among children has created concern among government agencies, policymakers, and health professionals. Obesity leads to considerable physical and psychological comorbidities, and estimates of the public health costs are staggering. Evidence-based, parent-centered interventions are a recommended pathway to prevent and treat childhood obesity (World Health Organization [WHO], 2012); however, recruitment remains a challenge. No parenting interventions to date have utilized a population health framework to reduce obesity at a population level. Emphasis must be placed on addressing this public health dilemma from both a preventive and a treatment perspective if improvements in obesity rates are to be achieved.
This chapter presents the argument for a population health model to prevent and treat childhood obesity. The increased prevalence rates and significant health risks associated with obesity are presented, along with the evidence supporting a parent-centered approach. The Lifestyle Triple P multilevel parenting and family support strategy is outlined. The existing research evidence for components of this suite are presented, along with the clinical and research-related needs associated with applying a public health framework.
(p. 157) The Rationale for a Population Approach to Parenting Support for Obesity
The Global Epidemic of Obesity
The WHO (2012) defines obesity as an excess of body fat that may significantly impair health. Obesity is commonly defined using body mass index (BMI), which is weight (in kilograms) divided by height (in meters) squared. In the pediatric population, large variations in BMI due to pubertal status, age, and gender mean that age- and sex-specific BMI centile charts based on a large set of reference data are used. Height and weight can be plotted on a growth chart, and the corresponding centile can be used to classify weight, such as WHO Child Growth Standards (WHO, 2006) or the US Centers for Disease Control and Prevention (CDC) 2000 growth charts (Kuczmarski et al., 2000).
Childhood obesity has reached epidemic proportions worldwide, with 24% of males and 23% of females classified as overweight or obese in 2013 (Ng et al., 2014). The highest prevalence rates are in the upper-middle-income countries; however, there is also a rising trend in developing regions (Kelishadi, 2007). Although prevalence remains high, emerging evidence suggests that the rapid rise in obesity prevalence may be plateauing in some countries (e.g., Australia and the United States; Olds et al., 2011). Obesity rates in the adolescent population and the proportion of severely obese children are still worsening at a dramatic rate (Garnett, Baur, Jones, & Hardy, 2016; Kelly et al., 2013). The risk of obesity is higher for children from socioeconomically disadvantaged groups, with around 30% of children in these groups overweight or obese, compared with around 20% in those with higher socioeconomic status (Hardy, King, Espinel, Cosgrove, & Bauman, 2011).
A Major Public Health Burden
Excess body fat has serious health consequences. Obese children have higher risks of cardiovascular disease (Park, Falconer, Viner, & Kinra, 2012); type 2 diabetes mellitus and fatty liver disease (Cruz et al., 2005); sleep apnea (Narang & Mathew, 2012); and bone and joint problems (Napolitano, Walsh, Mahoney, & McCrea, 2000). Emerging evidence suggests that even very young children who are overweight exhibit signs of adverse health effects, including elevated blood pressure and impaired blood glucose metabolism (Gardner et al., 2009). Children with excess body fat are exposed to psychosocial comorbidity, emotional and physical bullying, and social exclusion (Griffiths, Wolke, Page, Horwood, & ALSPAC Study Team, 2006).
Overweight and obese children are more likely to carry their excess weight into adulthood, with 75% of obese children remaining obese as adults (James, 2004). The adverse effects of adult obesity have been well substantiated, including higher rates of type 2 diabetes mellitus, cardiovascular disease, hypertension, osteoarthritis, gout, cancers, and polycystic ovarian syndrome (Guh et al., 2009). Obesity is one of the leading factors contributing to premature mortality (Prospective Studies Collaboration, 2007). It is likely that the public health problems associated with obesity will be amplified as the current generation of overweight children grows into adulthood.
(p. 158) The public health burden of obesity is enormous. In 2008, the total cost of death and disability arising from obesity in Australia was estimated to be $58.2 billion per year, representing a three-fold increase from 2005 (Crowle & Turner, 2010). A recent meta-analysis estimated that medical spending attributable to obesity in the United States was $149 billion in 2014 US dollars at the national level (Kim & Basu, 2016). These data suggest that obesity has progressed from being a problem of the individual to a worldwide challenge, which must be addressed at a population level. Policymakers are becoming increasingly aware of the statistics, and many are calling for evidence-based interventions.
Parents as the Agents of Lifestyle Change
Parents can have a large impact on their children’s health and well-being, particularly in relation to eating behaviors and physical activity levels. Parents who are active and eat well tend to have children who adopt similar habits (Cullen et al., 2003). There is a strong association between the dietary intake of children and that of their parents. Parental intake of fruit and vegetables and high-fat foods has been positively associated with child intake (van der Horst et al., 2007). A similar association has also been found between parent and child activity levels. Active parents tend to raise active children, with children of active parents up to five times more active than those with inactive parents (Moore et al., 1991).
Parents are in a prime position to promote a healthy home environment. When healthy foods, such as fruits and vegetables, are available and accessible to children in the home, child intake of these foods subsequently increases (Rasmussen et al., 2006). Children exhibit increased activity levels when their parents engage in active games with them (Sallis et al., 1992), support physical activity behaviors (Gustafson & Rhodes, 2006), and provide transportation to locations where physical activity is held (Sallis, Alcaraz, McKenzie, & Hovell, 1999).
Parenting style has also been associated with children’s lifestyle patterns and obesity risk (Gerards, Dagnelie, Jansen, De Vries, & Kremers, 2012). An authoritative parenting style is associated with a lower risk of obesity in children (Sleddens, Gerards, Thijs, De Vries, & Kremers, 2011). Inadequate monitoring of the child’s food intake can result in decreased vegetable intake and increased consumption of unhealthy foods and beverages (De Bourdeaudhuij et al., 2006). Failure to set reasonable screen time limits can result in more television viewing and lower physical activity levels (Arredondo et al., 2006; Gentile & Walsh, 2002). Conversely, stringent controls of food intake can compromise the child’s ability to learn how to self-regulate eating and may lead to overeating (Faith, Scanlon, Birch, Francis, & Sherry, 2004). The child’s preference for and consumption of palatable foods has been found to increase when parents restrict access to these foods (Clark, Goyder, Bissell, Blank, & Peters, 2007). Poor family functioning (characterized by poor communication and high levels of conflict) is also correlated with an increased risk of excess body fat (Halliday, Palma, Mellor, Green, & Renzaho, 2014).
Parents influence their child’s early lifestyle behaviors and health habits carried into adulthood (Mamun, Lawlor, O’Callaghan, Williams, & Najman, 2005). Maternal food preferences, timing of eating, and where food is consumed in the home is correlated with children’s eating behaviors when they are adults (Benton, 2004). The benefits of an active child who eats healthily include an enhanced health status, better academic performance, and improved social and emotional outcomes (Bauman, 2004; Rampersaud, Pereira, Girard, Adams, & Metzi, 2005). (p. 159) Parenting interventions delivered at a young age before lifestyle habits have become established are likely to be an effective and sustainable approach.
Evidence of Effectiveness of Parent-Centered Obesity Programs
There is general consensus that obesity initiatives should target parents (Golan, 2006). Systematic reviews highlight the importance of targeting parents as agents for change in the treatment and prevention of obesity (e.g., Loveman et al., 2015; Waters et al., 2011). Greater body size reductions are associated with interventions that combine parenting, nutrition and physical activity elements, as opposed to programs that focus on diet or physical activity alone (Reinehr, 2013). Furthermore, parent-only interventions have shown maintenance of treatment gains 7 years post-intervention (Golan & Crow, 2004). A family-based approach shifts the focus from child weight control to promoting parenting skills and confidence in establishing a home environment conducive to healthy living. This approach reduces the likelihood that the child feels targeted, which is likely to reduce the risk of inappropriate dietary restriction, weight preoccupation, and distorted body image in children (Davison & Birch, 2001).
Limitations of Current Parent-Centered Obesity Programs
Although parenting interventions are an important tool for obesity management and prevention, there continue to be significant barriers with implementation and engagement. Many programs suffer from recruitment and retention issues and have little or no emphasis on improving parenting skills (Lindsay, Sussner, Kim, & Gortmaker, 2006). The length of existing obesity-specific parenting interventions may be another barrier to attendance, with an average of 10 sessions per intervention ranging from 9 weeks to 6 months (Gerards, Sleddens, Dagnelie, De Vries, & Kremers, 2011). Parents have identified program length as one of the major barriers to attendance (Nguyen et al., 2012).
Parents may fail to identify the relevance of obesity-specific interventions to their child. There is a clear disconnect in parental perceptions of child weight status and the child’s actual weight, with only 17% of parents correctly identifying their child as overweight (Carnell, Edwards, Croker, Boniface, & Wardle, 2005). Furthermore, when parents are able to correctly identify their child’s weight status as a problem, they may fail to identify weight as a significant health issue for the child (Jones et al., 2011). Obesity stigma may further hinder parents from self-selecting into interventions where weight is the target for change (Puhl & Heuer, 2010). Research suggests that parents resist attendance for fear of creating an adverse emotional impact on their child’s self-esteem (Haynos & O’Donohue, 2012). Currently, there is little information in the literature identifying effective ways to engage parents in lifestyle interventions.
The Case for a Population Approach to Childhood Obesity
In the past, reactive management of childhood obesity has shaped management programs, resulting in delivery to families in which the child is already overweight or obese. According to WHO (2012), the key platform in the management of the obesity epidemic should be a population (p. 160) health approach. Such an approach may achieve population-level behavior change through a blend of universal and targeted parenting interventions, with differing levels of intervention intensity and breadth of reach. A universally accessible program that promotes the health of all children, whether at risk of obesity or not, is more likely to engage parents and enhance parental recruitment. It could potentially serve as a platform for referrals into more targeted programs for children with significant weight issues. A media campaign designed to raise public awareness in relation to lifestyle choices and destigmatize parenting support would complement prevention and treatment initiatives.
Lifestyle Triple P—Parenting as a Population Health Priority
The Lifestyle Triple P Multilevel System
Lifestyle Triple P is a variant of the Triple P—Positive Parenting Program developed specifically to prevent and treat childhood obesity through empowering parents with strategies and confidence to manage both lifestyle-specific and general child behavior. To our knowledge, it is currently the only evidence-based parenting program designed specifically as a comprehensive population health model for childhood obesity. There are currently three levels of the model: (a) a universal media campaign for all parents (Level 1); (b) a low-intensity, seminar series for all parents regardless of child weight status (Level 2); and (c) a targeted intensive program for children who are already overweight or obese (Level 5). Table 12.1 provides a description of each intervention.
Table 12.1: The Lifestyle Triple P Multilevel System of Parenting and Family Support for Childhood Obesity
Very low intensity
All parents and community members interested in healthy lifestyle information
Aimed at improving awareness of healthy options and normalizing parenting support. The campaign may involve school newsletters, newspaper advertisements, radio spots, and a website.
Parents of children from all weight status categories
3-session seminar series delivered over 3 weeks
Aimed at improving practical parenting skills to encourage healthy living. Topics include positive parenting, fussy eating, reading food labels, modifying recipes, and nutrition and activity guidelines.
Parents of overweight or obese children
14-session group program (including 10 group sessions and 4 telephone consultations) delivered over 17 weeks
Content includes understanding nutrition, understanding physical activity, modifying recipes, limiting sedentary activity and playing active games, reading food labels, managing problem behavior, and planning ahead.
The Lifestyle Triple P Evidence Base
The Triple P system has a strong evidence base (Sanders, Kirby, Tellegen, & Day, 2014) and is one of the only parenting interventions to demonstrate reductions in population-level indices of child maltreatment and behavioral problems (Chapter 44, this volume). The Lifestyle Triple P system has not yet been evaluated at a population level. Three randomized controlled trials (RCTs) and a number of pilot studies have evaluated the efficacy of the intensive Group Lifestyle Triple P (Level 5) intervention. More recently, the brief Lifestyle Triple P Seminar Series (Level 2) has also been evaluated in an RCT.
Group Lifestyle Triple P Research
West, Sanders, Cleghorn, and Davies (2010) evaluated Group Lifestyle Triple P with 101 parents of overweight or obese children aged 4 to 11 years in Brisbane, Australia. Parents were randomly allocated to the intervention or wait-list control groups. Results demonstrated a significant decrease in child BMI z scores following the intervention, with additional BMI improvements at 12-month follow-up. A significant decrease was also observed for child weight-related problem behavior and dysfunctional parenting styles, and parental confidence in managing child behavior improved. These intervention effects were medium to large and were maintained at (p. 161) (p. 162) 12-month follow-up. These results support the efficacy of this intervention as a treatment tool for children who are already overweight or obese.
Data from two pilot trials conducted in community health settings in Western Australia further supported the efficacy of the intervention (Child & Adolescent Community Health Service, 2011a, 2011b). Both trials found a significant reduction in child BMI z score, child lifestyle problem behavior, child emotional difficulties, and dysfunctional parenting. Improvements in parental functioning and confidence were also observed. Although the trials had small sample sizes and no control group comparison, the findings support the results from larger RCTs advocating the effectiveness of the program.
Further support for Group Lifestyle Triple P comes from research investigating its efficacy when combined with adjunct care. Bartlett, Desha, and colleagues (2017) evaluated Group Lifestyle Triple P combined with three overnight family camps and dietetic consultations in an RCT with a group of 97 parents of overweight and obese children aged 5 to 12 years. Parents were assessed on a range of child and parent outcomes at baseline and 6- and 12-month follow-ups. Significant improvements in child body size were found at 6 months, including significant reductions in BMI z scores and weight z scores. Dysfunctional parenting styles also improved following the intervention. Weight z-score improvements were maintained at 12-month follow-up. While these findings suggest that the intervention plus conventional care intervention was superior to conventional care alone at 6-month follow-up, future research should focus on evaluating the individual treatment components and their relative contribution to intervention effects.
A further promising finding for the efficacy and cross-cultural applicability of Group Lifestyle Triple P comes from an RCT conducted in the Netherlands with 86 parents of overweight and obese children aged 4 to 8 years (Gerards et al., 2015). Positive short-term intervention effects were found for children’s soft-drink consumption, parental responsibility regarding physical activity, encouragement to eat, psychological control, and parental confidence and satisfaction with parenting. At 12 months postintervention, effects were found on sedentary behavior, time spent playing outside, parental monitoring of food intake, and responsibility regarding nutrition. No significant intervention effects were found on child body size. This finding may be due to the degree of child adiposity in the sample. Children had a mean baseline BMI z score of 1.85, with only 63% classified as obese. Conversely, the Australian trial children had a mean baseline BMI z score of 2.11 (i.e., more overweight; West et al., 2010). Therefore, it may be that there was insufficient power to detect a statistically significant change in BMI z score. Another explanation for the lack of findings on child BMI could be due to baseline differences in parent weight. Parents in the intervention group had a higher BMI than the control parents. It may be that parents with weight issues may find it more difficult to make lifestyle changes in their family. It is recommended that future research should statistically control for differences in parental weight status at baseline to see if significant BMI z scores result.
Lifestyle Triple P Seminar Series Research
The first trial of the Lifestyle Triple P Seminar Series was conducted in Brisbane, Australia (Bartlett, Sanders, & Leong, 2017). One hundred and sixty parents were randomly allocated to either the intervention or the control condition and were assessed at preintervention, postintervention, and 6- and 12-month follow-up. Results revealed significant improvements on lifestyle-specific and general parental confidence, parenting styles, and child lifestyle problem behavior (p. 163) at the 12-month follow-up. Parents in the control condition showed an increase in the total time the child spent watching television over the 12 months, with no such worsening of screen time in the intervention condition. Child BMI z scores and weight z scores showed a trend in the intended direction, with a reduction in the intervention condition; however, this difference was not statistically significant. The positive benefits for families participating in a Lifestyle Triple P seminar are provided in Box 12.1.
The potential benefits of this program are substantial. No RCT to date has demonstrated that a brief lifestyle-specific parenting intervention produces success at 12-month follow-up (Reinehr, 2013). Evidence for maintenance of treatment change at 12 months following the intervention is important given the long-term health benefits associated with such changes. A successful short program delivered to all children at a young age could have meaningful implications for public health. Participation can be seen as being universal and health oriented. It has the capacity to effect a long-term change in attitudes toward healthy living in both child and parent. There is potential for this program to produce additional effects for public health problems beyond obesity, such as prevention of disordered eating. The health burden of obesity, diabetes, and other chronic lifestyle-related diseases could be significantly reduced.
(p. 164) Parameters for Service Delivery, Policy, and Research
Engagement of Multiple Settings
Community dissemination of evidence-based parenting programs for obesity should be augmented by engagement in multiple settings. Schools, early childhood centers, medical and health centers, sport/recreation clubs, and religious organizations are all potential targets for intervention, promotion, and implementation.
The general practitioner is generally considered the coordinator of primary care for families; however, most report that they are quite uncomfortable about discussing child weight issues with a parent (Wethington, Sherry, & Polhamus, 2011) and are not confident with subsequent management of childhood obesity (Gerards et al., 2012). General practice may be an environment for case ascertainment and to encourage parents to participate in interventions. A recent report in the American Academy of Pediatrics (2016) suggested that pediatricians and other pediatric health practitioners in a family-centered health context have the propensity to assess risk, link families to resources, and coordinate care with community partners. The role of the medical practitioner as a referral agent for the obese child can be greatly augmented by their support for a universal health education program for all families.
It would seem that the best strategy for implementation of a universal program would be to target schools and child care centers, rather than general medical practice alone. Nguyen and colleagues (2012) recommended schools as one of the most successful recruitment tools for obesity programs. A short program such as the seminar series could easily be offered to all parents and potentially be delivered to substantial numbers within an educational setting.
A Trained Local Workforce
One potential obstacle to the delivery of an evidence-based parenting program for childhood obesity can be a lack of an adequately trained workforce. Lifestyle Triple P, for example, does not require highly specialized training and accreditation. Professionals from multiple disciplines are able to receive training to deliver the intervention with fidelity. Increasing the capacity of the public health workforce to manage the obesity epidemic is key to population-level change.
A Monitoring and Feedback System
Few countries have established systems for regular monitoring of child height and weight. In Australia, there have only been two national surveys in the last decade, and they have not provided detailed data in relation to ethnicity, socioeconomic status, or parenting behavior. More regular monitoring of prevalence and trend data is required. Indicators should include not only body measurements but also individual risk factors, such as parenting practices and child lifestyle behaviors. A brief, reliable measure that is sensitive to population-level changes can be (p. 165) performed as part of national health surveys and could offer a means of assessing parental feedback regarding challenges faced with raising their children, the type of support needed, and the motivating factors for program participation.
A Cost-Effective Obesity Initiative
Cost-effectiveness of interventions in obesity initiatives is a central consideration for policymakers and service providers. This is particularly relevant in relation to population-level interventions. The assessment of cost-effectiveness is difficult to perform given the multifactorial nature of the societal cost of childhood obesity. Most of the costs manifest in adult life, such as disease comorbidities and work productivity, which makes it difficult to estimate the impact of childhood interventions. Few evaluation trials have conducted cost assessments, other than to investigate the costs of delivering the intervention (Lobstein et al., 2015). Conducting in-depth cost analysis research on obesity interventions may strengthen the argument for policymakers.
Father Involvement in Obesity Programs
There is emerging evidence for a relationship between the father’s parenting practices and child feeding styles with the child’s eating behavior and weight status (Fraser et al., 2011). The extent to which fathers show warmth and support also predicts better weight outcomes and maintenance of weight loss over time (Stein, Epstein, Raynor, Kilanowski, & Paluch, 2005). Father-only interventions targeting lifestyle habits demonstrate significant decreases in father BMI and improvements in child lifestyle behavior (e.g., Morgan et al., 2011). However, father data remain underrepresented in the obesity literature. Future research should aim to identify the differences between mother and father attendance motivators to allow formulation of appropriate recruitment and engagement strategies. Future studies should also assess father outcome data to evaluate intervention effectiveness and tailor interventions (if required).
Reaching At-Risk Groups
Given that obesity is associated with lower socioeconomic status and some ethnic minorities (Vereecken, Keukelier, & Maes, 2004), it is important from a public health perspective to engage these at-risk groups. Parent-centered interventions for childhood obesity should assess their effectiveness in relation to socioeconomic status and ethnicity. Disadvantaged families may require additional interventions beyond lifestyle-specific support (e.g., strengthening mother–child attachment or psychosocial support to vulnerable caregivers), and from a policy perspective, lifestyle programs, such as Lifestyle Triple P, may be delivered as part of a package alongside these other inputs. Cross-cultural delivery of programs may be challenging given the diversity in food items and nutritional guidelines in different countries. This may require tailoring the program through close consultation with the local workforce followed by independent evaluation.
(p. 166) Conclusions
Health authorities worldwide are calling for effective interventions to address childhood obesity. Parent-centered interventions have proven effective. The Lifestyle Triple P multilevel system applies a population health framework to childhood obesity prevention and management. The efficacy of Group Lifestyle Triple P (Level 5) and the Lifestyle Triple P Seminar Series (Level 2) has been validated in the literature. Future research should be conducted to establish the population-level effects of the entire Lifestyle Triple P system delivered at a community level. It is anticipated that the obesity epidemic will worsen into the future without appropriate preventive and treatment measures, and a population approach is likely to be a major part of the ultimate solution.
• Evidence-based parenting programs are a recommended pathway to prevent and treat childhood obesity.
• Despite their proven success, significant problems exist with parental recruitment and retention.
• A population health approach to parenting support for childhood obesity must be adopted to support parents and families.
• The Lifestyle Triple P multilevel system incorporates a suite of interventions, including (a) a media and communications campaign; (b) a light-touch, brief seminar series for all parents; and (c) an intensive intervention for parents of children who are overweight or obese.
• Taken together, these interventions provide a framework for policymakers and government representatives in the prevention and treatment of childhood obesity.
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