There are no doubt rare cases of childhood obesity that occur due to genetic, psychological, or other biological factors that are specific to just the kid and do not apply to anyone else in the family.
In the vast majority of cases, however, familial or other factors resulting in childhood excess weight gain, affect more than just the kid.
An excellent review and Scientific Statement on the role of targeting parents as ‘agents of change’ for treating obese children was just released by the American Heart Association and published in CIRCULATION.
The paper evaluates the strength of evidence that particular parenting strategies can leverage behavior change and reduce positive energy balance in obese youth.
As may be expected, the evidence is inconsistent.
“For example, only 17% of the intervention studies reported differential improvements in child overweight as a function of parental involvement in treatment. On the other hand, greater parental adherence with core behavior change strategies predicted better child weight outcomes after 2 and 5 years in some studies.”
The authors identify a number of important research gaps, including the assessment of refined parenting phenotypes, cultural tailoring of interventions, examination of family relationships, and incorporation of new technologies.
Interestingly, the release of this statement coincides with the publication of a paper by Laurie Miller Brotman and colleagues from the New York University School of Medicine in the journal PEDIATRICS, suggesting that interventions aimed at generally improving parenting skills may reduce obesity risk in high-risk minority youth.
The study included 186 minority youth at risk for behavior problems who enrolled in long-term follow-up studies after random assignment to family intervention or control condition at age 4. Follow-up Study 1 included 40 girls at familial risk for behavior problems; Follow-up Study 2 included 146 boys and girls at risk for behavior problems based on teacher ratings.
Importantly, the family intervention aimed to promote effective parenting and prevent behavior problems during early childhood and did not not focus on physical health or attempt to specifically modify diets or physical activity.
After five years (Study 1) and 3 years (Study 2), the kids randomized to intervention had significantly lower BMI compared to controls with lower rates of obesity (BMI ≥95th percentile) among intervention girls and boys. These changes in body weight were associated with improvements in physical and sedentary activity, blood pressure, and diet.
Thus, as the authors point out, simply improving parenting skills without specifically focusing on messages pertaining to diet or activity may significantly reduce the risk of obesity him high-risk kids.
Obviously, these findings should not simply be used to promote a ‘blame the parents’ attitude or instigate a ‘witch hunt’ on parents of overweight or obese kids.
Rather, I believe that these data should serve as a reminder that many parents today face parenting challenges that may be unique to today’s family environment with fewer kids, working parents, ’empowered’ and ‘opinionated’ offspring, and lack of extended family support and role models.
Providing this support to parents may not only benefit weight management but also improve the emotional and physical health of our youth.
Remember, it takes a village to raise a child.
Faith MS, Van Horn L, Appel LJ, Burke LE, Carson JA, Franch HA, Jakicic JM, Kral TV, Odoms-Young A, Wansink B, Wylie-Rosett J, & on behalf of the American Heart Association Nutrition and Obesity Committees of the Council on Nutrition, Physical Activity and Metabolism, Council on Clinical Cardiology, Council on Cardiovascular Disease in the Young, Council on Cardiovascular Nursing (2012). 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 PMID: 22271754
Brotman, L., Dawson-McClure, S., Huang, K., Theise, R., Kamboukos, D., Wang, J., Petkova, E., & Ogedegbe, G. (2012). Early Childhood Family Intervention and Long-term Obesity Prevention Among High-risk Minority Youth PEDIATRICS DOI: 10.1542/peds.2011-1568
Many of these influences may result from parental response to infant temperament and parental perception of infant growth and appetite.
These issues were further explored by Sarah Redsell and colleagues from the University of Nottingham, UK, in a paper just published in BMC Public Health.
The researchers conducted six focus groups in 38 parents (36 female, 2 male), age range 19-45 years, of infants less than one year of age. Parents were selected from different demographic groups. Twelve parents were overweight and eight were obese.
Five main themes were identified:
a) parental concern about breast milk, infant contentment and growth;
b) the belief that the main cause of infant distress is hunger is widespread and drives inappropriate feeding;
c) rationalisation for infants’ larger size;
d) parental uncertainty about identifying and managing infants at risk of obesity;
e) intentions and behaviour in relation to a healthy lifestyle.
A common problem was that parents panicked or felt inadequate when the growth curves of their infants fell below the growth charts, even though the kids appeared otherwise healthy and content.
On the other hand, other parents expressed a sense of fulfillment when their infants gained large amounts of weight according to the centile charts. In particular, parents of premature infants had a strong desire for them to catch up to perceived norms, which was endorsed by others in the group.
Overweight or obese parents appeared biased towards larger babies and believed that having a bigger infant was healthier.
Mothers were quite defensive about any suggestion that their infant might be overweight or growing too quickly and found it easy to justify their infant’s size amongst themselves but feared criticism from others, such as health professionals, family or peers. Parents were not keen on the idea of restricting diet during infancy even for very large infants but thought that that dietary content and quality could be explored by health professionals.
Interestingly, several parents commented on the negative influence of grandparents (a topic I have previously blogged about). Although parents admitted it was grandparents’ prerogative to indulge their grandchild but when this extended to family mealtimes they reported feeling they had lost control of their infant’s diet. Overall, there was a stronger preference for larger infants amongst older family members.
This study clearly shows that there are a number of barriers to early intervention with parents of infants at risk of developing obesity but also that parents appear receptive to prevention prior to weaning.
Specifically, parents would likely benefit from better understanding the physiology of breast feeding, how to differentiate between infant distress caused by hunger and other causes, and the timing of weaning.
In addition some parents appear to need guidance to recognize and prepare healthy foods and facilitate physical activity for their infants.
Clearly, parenting support that focusses on raising healthy infants could play a major role in the prevention of subsequent childhood and adult obesity.
Redsell SA, Atkinson P, Nathan D, Siriwardena AN, Swift JA, & Glazebrook C (2010). Parents’ beliefs about appropriate infant size, growth and feeding behaviour: implications for the prevention of childhood obesity. BMC public health, 10 (1) PMID: 21087482
This issue was now examined by Jerica Berge and colleagues from the University of Minnesota in a paper published in the latest issue of OBESITY.
As described in the paper, the four classic parenting styles (known to be a characteric of the parent and to generally be stable over time) are:
Authoritative: high level of demandingness (on the child) with high level of responsiveness (to the child)
Authoritarian: high level of demandingness with low level of responsiveness
Permissive: low level of demandingness with high level of responsiveness
Neglectful: low level of demandingness with low low level of responsiveness
Furthermore, parenting practices can be divided into direct (e.g. encouraging) and indirect (e.g. modeling) patterns.
Data from Project EAT, a population-based study with over 2,500 adolescents from 31 Minnesota school with diverse ethnic and socioeconomic backgrounds, were used.
Maternal authoritative parenting style predicted lower BMI in adolescent sons and daughters, whereas maternal authoritarian style predicted higher BMI in sons (especially when combined with neglectful dads) but had no effect on daughters’ BMI.
In contrast fathers’ parenting styles alone, appeared to have no effect on sons or daughters’ BMI.
Sons of parents who encouraged but did not model healthy lifestyles had a higher BMI, but the effect of encouraging vs. modeling on daughters’ BMI was less clear.
Oddly, paternal permissive parenting style predicted more fruits and vegetables intake in daughters
Most surprisingly, no significant associations were found between parenting style and adolescent physical activity levels.
While there were no interactions between ethnicity and parenting styles, lower SES parents tended to be more authoritarian, while higher SES parents tended to be more authoritative.
The authors interpret their findings to suggest that authoritative parenting style may play a protective role related to adolescent overweight and that warmth and/or caring in the parent-adolescent relationship may be important in relation to female adolescent healthy dietary intake.
The biggest surprise however was the apparent importance of opposite sex parents’ influence on their offspring.
Based on their findings, the authors had two clinical tips:
1) Clinicians should perhaps promote authoritative parenting styles as high parental expectations and structure along with caring and emotional responsiveness, rather than rigidness, less structure and emotional unresponsiveness, may protect against overweight in sons.
2) Clinicians should promote congruency between parenting practices (in both words and actions), as this may be protective in both sons and daughters.
However, given the fact that parenting styles and behaviours have previously been shown to be stable over time, it may be doubtful as to how much influence clinicians can truly have on parenting.
Furthermore, although clearly an authoritarian parenting style appears worst, I am rather surprised that the influence of different parenting styles was not far greater or clearer than what was found in this study.
This may either be a reflection of how little influence parents actually have on adolescent behaviours and/or how little parenting actually has to do with kids’ risk for overweight or obesity in the first place.
Berge JM, Wall M, Bauer KW, & Neumark-Sztainer D (2010). Parenting characteristics in the home environment and adolescent overweight: a latent class analysis. Obesity (Silver Spring, Md.), 18 (4), 818-25 PMID: 19816417
While I am taking a brief break from clinics and other obligations (including daily blog posts), I will be reposting past articles, which I still believe to be relevant but may have escaped the attention of the 100s of new readers who have signed up in the past months.
The following was first posted on 11/12/07
Well, apparently it’s not just Mom’s “fault” – Dads matter too!
Melissa Wake and colleagues from the Royal Victoria Hospital in Victoria (AUS) studied the relationships between BMI status at ages 4 to 5 years and mothers’ and fathers’ parenting dimensions and parenting styles.
Participants were composed of all 4983 of the 4- to 5-year-old children in wave 1 of the nationally representative Longitudinal Study of Australian Children with complete BMI and maternal parenting data.
Mothers and fathers self-reported their parenting behaviors on 3 multi-item continuous scales (warmth, control, and irritability) and were each categorized as having 1 of 4 parenting styles (authoritative, authoritarian, permissive, and disengaged) using internal warmth and control tertile cut points.
They found that while mothers’ parenting behaviors and styles were not associated in any model with higher odds of children being in a heavier BMI category, higher father control scores were associated with lower odds of the child being in a higher BMI category.
Thus, compared with the reference authoritative style, children of fathers with permissive and disengaged parenting styles had higher odds of being in a higher BMI category (~30-50% greater risk depending on the statistical model).
Apparently these findings are consistent with a previous intervention study by Stein et al., which showed that fathers’ but not mothers’ parenting (warmth and support) predicted better maintenance of weight loss after a behavioral parenting intervention for pediatric obesity.
These authors suggest that fathers’ parenting may well be an important determinant of the extent to which the family environment as a whole is supportive of children’s attempts to lose weight.
Message to Dads: “Get involved – you count!”