Childhood Overweight And Obesity

O ver the past three decades,childhood overweight andobesity rates have risen atalarming rates. Since 1980, the obesity rate for children ages 6 to 11 years has more than doubled (now at 18%), and the rate for ages 12 to 19 years has quadrupled (now at 21%) (Ogden, Carroll, Kit, & Flegal, 2014). In addition, 6% of children ages 6 to 11 years and 8% of children ages 12 to 19 years fall in the category of extreme obesity, meaning their body mass index (BMI) scores are at or above 120% of the 95th percentile according to the Centers for Disease Control and Prevention’s (CDC) (2015) BMI-for-age growth chart. Children are now suffering from seri- ous diseases previously seen only in adults, such as heart disease, diabetes type 2, liver disease, and cardiovascu- lar problems. The World Health Organization (WHO) (n.d.) considers childhood obesity one of the most serious health challenges of the 21st century. Childhood Overweight And Obesity

Aside from metabolic disorders, the main cause of obesity is the com- bination of excess caloric intake and decreased energy expenditure over time (WHO, 2016). To combat and prevent obesity, it is important to look at the underlying causes for the excess intake and decreased expendi- ture. Past research has identified a multitude of contributors, such as easy access to fast food, increased por- tion sizes, less time and fewer oppor- tunities for physical activity, and sedentary lifestyles (Sabin, Kao, Juonala, Baur, & Wake, 2015). When looking specifically at obesity in childhood, it is important to consider the sociocultural context. The respon-

available in the home are determined by parents. Some parents are under the impression that children will only eat until they are full; however, inap- propriate portion control can affect satiety responses in children (Fisher & Kral, 2008). If children are regularly given large portions or asked to finish everything on their plate, their satiety signals may be altered, and they become unable to reliably detect when they are full. Childhood Overweight And Obesity

ORDER A PLAGIARISM – FREE PAPER NOW

In early years, parents also control the child’s environment, including activities they encourage and allow their children to participate in, and whether they are physically active or more sedentary. Children who spend a lot of time watching television or playing with computers and video games tend to be more sedentary overall, and several studies have found a link between screen time and obesity (Bai et al., 2016; Dennison, Erb, & Jenkins, 2002). On the other hand, children who are encouraged to play outside and are provided with toys that require more active play are less likely to be obese.

Interestingly, in a study by Myers and Vargas (2000), only 5% of parents mentioned they would increase their child’s daily activity level to control the child’s weight, and even fewer

sibility for the socialization of young children lies mainly with parents (Holden, Vittrup, & Rosen, 2011). In addition to feeding their children, and thus, deciding what their chil- dren eat, parents also model eating behaviors, exercise habits, and atti- tudes toward food and exercise, and they make decisions about their chil- dren’s activities. Given the intergener- ational transmission of obesity (Cole, Power, & Moore, 2008), parents are a key link to discovering effective pre- vention strategies. To combat the problem as a society, it is essential to understand how parents think and feel about obesity and diet-related issues. Assessing the knowledge and opinions of parents may reveal dispar- ities and create opportunities for future prevention plans.

Parents as Providers, Environmental Gatekeepers, and Role Models

In early and middle childhood, parents control most food options available to their children, so even when children’s taste preferences and general disposition influence what they will actually eat, types of food

The purpose of this study was to investigate eating and exercise habits of fami- lies with young children, their knowledge of health and obesity risks, and their attitudes toward prevention and intervention efforts. Parents and caregivers (N=205) of children aged 3 to 10 years completed a survey online or on paper. Participants were recruited from preschools and Head Start centers in the Southwestern United States. Results indicated that many parents and children were overweight, but most parents incorrectly labeled their overweight and obese children as being of healthy weight. Parents showed uncertainty and lack of knowledge regarding healthy eating, portion sizes, physical activity recom- mendations, obesity trends, and health risks. They rated themselves as most responsible for addressing childhood obesity, but support for various intervention efforts varied. Based on parent responses, the main barriers toward healthy weight status were food cost, lack of knowledge, and lack of time. Researchers and medical professionals should be mindful of these barriers when designing obesity prevention efforts and advising families on healthy lifestyles. Childhood Overweight And Obesity

Brigitte Vittrup, PhD, is an Associate Professor, Department of Family Sciences, Texas Woman’s University, Denton, TX. Danielle McClure, MS, RD/LD, is a Dietitian, Texas Woman’s University, Denton, TX.

Barriers to Childhood Obesity Prevention: Parental Knowledge and Attitudes

Brigitte Vittrup and Danielle McClure

 

 

82 PEDIATRIC NURSING/March-April 2018/Vol. 44/No. 2

mentioned cutting down on sugary beverages. Thus, if parents provide an environment conducive to their child’s weight gain, the challenge to remain within a healthy weight range will be present from very early in the child’s life.

Parents’ own food and exercise habits influence their children’s habits as well, such as the types of food they eat, where and when they eat, and their overall relationship with food. Whereas infants and toddlers are fairly good at regulating their energy intake, they quickly become attuned to exter- nal signals about food consumption (Mela, 2001), and parents provide a lot of these signals through their own food habits and their “food parenting practices” (Larsen et al., 2015, p. 247). In addition, parents who are physical- ly active in their daily lives are more likely to have physically active chil- dren compared to parents who live sedentary lifestyles (Hesketh et al., 2014; Spurrier, Magarey, Golley, Curnow, & Sawyer, 2008).

Parental Knowledge And Attitudes

Parents may not be aware of the rec- ommended caloric intake for their children, which foods are considered healthy, or even whether their child is considered overweight or obese (Nelson, Lytle, & Pasch, 2009; Parkinson, Drewett, Jones, & Adamson, 2013). Even if they possess this knowledge, to what extent are they concerned about it and are will- ing to intervene. Lampard, Byrne, Zubrick, and Davis (2008) found that most parents of overweight children showed little to no concern about their children’s weight. In addition, parents sometimes question their efficacy to limit non-core foods and promote healthy eating (Campbell, Hesketh, Silverii, & Abbott, 2010), and some blame children’s picky eating habits, the cost of food, and insufficient time to prepare healthy meals (Akhtar- Danesh, Dehghan, Morrison, & Fonseka, 2011; Berge, Arikian, Doherty, & Neumark-Sztainer, 2012). It is important to further investigate the background of parents’ food choices for their children and their attitudes toward various prevention options to better inform intervention programs. Thus, the present study was designed to investigate actual eating and exer- cise habits of families with young chil- dren, parental knowledge about health

preschool age (3 to 5 years). Most par- ents (54%) were married, their educa- tional attainment ranged from less than high school to completion of a doctoral degree, and most (80%) had an annual income of less than $40,000. About half of the partici- pants (49%) were Hispanic, 8% were White, and 8% were Black. The remainder (35%) chose not to indi- cate their race or ethnicity. Participant characteristics can be seen in Table 1.

Instruments All participants completed a ques-

tionnaire titled Knowledge, Attitudes, and Barriers Related to Childhood Obesity. The questionnaire consisted of 178 items related to exercise, food, and lifestyle choices (50 questions);

and obesity risks, and parental atti- tudes toward intervention efforts.

Method

Participants A total of 205 parents and primary

caregivers in the United States partic- ipated. They ranged in age from 19 to 64 years (M=32.69, SD=8.47). Most (87%) were mothers, 8% were fathers, and 5% were other family members. Parents with more than one child were asked to answer all survey ques- tions about one focal child who was between 3 and 10 years of age. Focal children for this study ranged in age from 3 to 10 years (M=4.37, SD=1.66), with most children (n=177) being of

Table 1. Parent and Child Characteristics (N=205)

Parent n (%)

Child n (%)

Sex Male 17 (8) 96 (47) Female 188 (92) 109 (53)

Weight Status Underweight 2 (1) 4 (2) Healthy weight 53 (30) 99 (58) Overweight 51 (29) 29 (17) Obese 71 (40) 40 (23)

Race/Ethnicity White 17 (8) Black 16 (8) Hispanic 100 (49) No answer provided 72 (35)

Marital Status Married/Cohabitating 111 (54) Single 51 (25) Divorced/Separated 43 (21)

Education Less than high school 23 (11) High school 66 (32) Some college 76 (37) Bachelor’s degree 34 (17) Post-graduate degree 6 (3)

Income Less than $20,000 98 (48) $20,000 to $39,000 66 (32) $40,000 to $59,000 15 (7) $60,000 to $79,000 8 (4) $80,000 or above 18 (9) Childhood Overweight And Obesity

PEDIATRIC NURSING/March-April 2018/Vol. 44/No. 2 83

perceptions of causes, responsibilities, and barriers linked to childhood obe- sity (48 questions); attitudes towards prevention and intervention (20 questions); knowledge about health and obesity (20 questions); percep- tions of own and child’s health (25 questions); and demographic infor- mation, including height and weight of both parent and child (15 ques- tions). The questionnaire was con- structed specifically for this study, with some questions inspired by sim- ilar question groups in a survey on childhood obesity conducted by San Jose Mercury News and the Kaiser Family Foundation (2004). Most questions (112) were Likert-type items where participants indicated their agreement or disagreement with vari- ous statements, indicated perceived levels of contribution of risk factors and support for various prevention options. An additional 32 questions were multiple choice items, and the remainder were free-response items. Participants were given the option of completing the survey online or in paper-pencil format. Thirty-five per- cent chose the online option. The average time for survey completion was 25 minutes. The short comple- tion time was due to most questions being quick-response Likert-type or multiple choice items.

Procedure Upon approval from the universi-

ty’s Institutional Review Board, par- ticipants were recruited from preschools and Head Start centers in and around three major metropolitan areas in the Southwestern United States. At some locations, we handed out flyers directly to parents during drop-off or pick-up time, and at other centers, classroom teachers were given a stack of flyers to distribute in the children’s cubbies. Flyers con- tained information about the study, a link to the online survey, and infor- mation about who to contact for a paper survey (usually the center director). The first page of the survey (both online and paper version) was a consent form with detailed informa- tion about the study, and participants were informed that completion of the survey indicated their informed consent to participate. After complet- ing the survey, participants were given the option to sign up to receive a $10 gift card as a thank you for their participation. Data collection occurred over three months. Childhood Overweight And Obesity

those of overweight (14%) and healthy weight (13%) children.

When asked how often they buy a fast food meal for their children, responses ranged from “Never” to “Almost every day,” with 46% indi- cating it happens at least once per week. The most common reasons for buying fast food for their children were convenience (60%) or the child specifically asks for it (17%).

Parental Knowledge about Health and Obesity

Key findings related to parental knowledge about health and obesity are shown in Table 2. When asked how they define “a healthy diet,” many (40%) gave vague answers that did not provide a specific definition. Of those who provided more detailed answers, many (43%) defined it as eating more fruits and vegetables. When asked how they determine potion sizes for their children, the majority indicated they either do not know how to determine appropriate portions or they simply gauge it by how much they think their children will eat. Some said they use spoons or measuring cups, but the sizes of por- tions varied widely, anywhere from a tablespoon to a full cup measure. Only 10% mentioned using specific portion size charts or serving size information on food labels. Parents also appeared to be unsure of physical activity recommendations for chil- dren. When asked what they believed was an adequate amount, they report- ed anywhere from 1 to 28 hours per week (M=5.92, SD=3.68).

Parents’ estimates of childhood obesity prevalence in the United States ranged from 2% to 90% (M=39.22, SD=23.39). Only 19% gave estimates that fell within a 5% margin of the correct rate. When asked to define the difference between over- weight and obese, only 6% mentioned BMI, whereas the rest made vague comparisons based on weight in pounds, the presence of health risks, or simply that obese is more than overweight.

When asked to identify which health risks are associated with obesi- ty, the majority (71%) mentioned dia- betes, and a good number also men- tioned heart disease and hyperten- sion. Less than 20% mentioned respi- ratory problems, cholesterol, or men- tal health issues. On average, partici- pants correctly identified 2 risk factors (M=2.12, SD=1.45, Range=0 to 6). Childhood Overweight And Obesity

Results

Weight Status and Health Concerns

Of the 177 parents who reported both their height and weight, 69% were deemed to be overweight or obese, and of the 172 children whose parents reported their height and weight, 40% were overweight or obese. Parent BMI scores were calculated based on their self-reported height and weight measurements. Scores ranged from 15.25 to 58.57 (M=28.81, SD=6.95). Only 30% were of healthy weight (BMI=18.5 to 24.9), whereas 29% were overweight (BMI=25 to 29.9), and 40% were obese (BMI≥30). Child BMI scores were calculated based on parent reports of the children’s height and weight, and scores were converted into percentiles for age according to the CDC’s (2015) BMI- for-age growth charts. Their percentile scores ranged from 2 to 99 (M=70.06, SD=26.01). Most (58%) were of healthy weight (5th to 84th percentile), 17% were overweight (85th to 94th per- centile), and 23% were obese (95th to 100th percentile). These characteristics are included in Table 1. Parent BMI scores were positively correlated with child weight percentiles (r[177]=0.23, p=0.004).

Almost all (98%) parents of chil- dren who were of healthy weight cor- rectly assumed their child was not overweight. However, all parents of overweight children and 75% of par- ents of obese children incorrectly assumed their child was not over- weight. This may be because only 6% of children were diagnosed as over- weight by a doctor, according to par- ents’ own reports. In comparison, 45% of parents were diagnosed as such.

Most (83%) parents in this sample indicated they tried to control their own weight, but only 18% tried to control their child’s weight. Of those, the majority (75%) mentioned chang- ing types of foods their children ate, such as less sugary and fatty foods, and more fruits and vegetables. Thirty-one percent mentioned por- tion control and eating less, and only 22% tried to increase their children’s physical activity levels. Child weight status was significantly related to whether parents tried to control their children’s weight (X2[2, n=176]=8.73, p=0.01). More parents of obese chil- dren (33%) had done so compared to Childhood Overweight And Obesity

 

 

84 PEDIATRIC NURSING/March-April 2018/Vol. 44/No. 2

When asked what burden childhood obesity causes for society as a whole, 26% mentioned financial burdens, such as increased healthcare costs, higher insurance premiums, and higher taxes. Twenty-two percent were unable to think of any burden to society or simply stated that the bur- den would be on the individual, not society. The remainder mentioned loss of productivity and various answers related to individuals, such as bullying, self-esteem problems, and health risks.

Parental Perceptions of Responsibility and Barriers

On a scale of 1 to 5, parents rated

(M=4.45, SD=1.09) and healthy weight parents (M=4.74, SD=0.69, F[2, 170]=3.28, p=0.04, h2p=0.04). Simil arly, obese parents also assigned more responsibility to their children (M=3.73, SD=1.15) compared to over- weight (M=3.07, SD=0.30) and healthy weight parents (M=3.35, SD=1.45, F[2, 170]=3.72, p=0.02, h2p=0.05).

When asked what they saw as major barriers for prevention of child- hood obesity, the two areas men- tioned most frequently were the cost of healthy foods and parents setting bad examples in terms of eating and exercise. The lack of nutritional knowledge and education; parents’ busy schedules, making it difficult to

themselves as having the greatest responsibility in addressing the prob- lem of childhood obesity (M=4.64, SD=0.86), followed by the food indus- try (M=3.80, SD=1.26) and schools (M=3.72, SD=1.19). Government (M=3.07, SD=1.43) and genetic predis- position (M=3.33, SD=1.23) were rated as least responsible (see Figure 1).

A multivariate analysis of variance (MANOVA) revealed significant differ- ences in the pattern of these ratings based on parent weight status (V=0.21, F[16, 270]=2.03, p=0.01, h2p=0.07) but not based on child weight status (p=0.26). Obese parents assigned more responsibility to themselves (M=4.84, SD=0.48) compared to overweight

Table 2. Parents’ Knowledge about Health and Obesity

How do you define a healthy diet? % Vague/non-specific answers: “Eating sensibly,” “Eating a balanced diet,” “Eating good foods.” 40 Eating more fruits and vegetables. 43 Limiting high-fat foods and fast food. 16 Reducing sugar intake. 12 Eating lean meats. 10 Eating natural or unprocessed foods. 8 How do you determine portion sizes for your child? % Don’t know. 34 As much as child will eat. 19 Spoons or measuring cups: “Tablespoon,” “Cooking spoon,” “1/4 cup,” “1/2 cup,” “1 cup.” 14 Size of child’s fist/palm. 12 Food labels/portion size charts. 10 What is the difference between overweight and obese? % Obese is more than overweight. 30 Pounds over ideal weight: “10 pounds over,” “30 pounds over,” “100 pounds over.” 28 Obese has health risks, overweight does not. 22 Based on body mass index. 6 What are some health risks associated with childhood obesity? % Diabetes. 71 Heart disease. 41 Hypertension. 29 Respiratory problems. 17 Elevated cholesterol. 15 Depression/low self-esteem. 12 What burden does childhood obesity cause for society in general? % Financial (healthcare costs, taxes, insurance premiums). 26 Don’t know. 15 Loss of productivity. 10 No societal burden. 7 Childhood Overweight And Obesity

 

 

PEDIATRIC NURSING/March-April 2018/Vol. 44/No. 2 85

find time to prepare healthy meal options; and schools serving unhealthy lunches and cutting physi- cal education courses were also men- tioned (see Figure 2).

Parental Support for Intervention Options

Parents were queried on their will- ingness to support 12 prevention efforts on a scale of 1 (Definitely would NOT support) to 5 (Definitely WOULD

report card (M=2.88, SD=1.51), an additional 5% tax on high-fat/high- sugar foods (M=2.90, SD=1.43), and more expensive school lunches in exchange for healthier meals (M=2.92, SD=1.50).

A principal components analysis with Varimax rotation was conducted to reduce the 12 items to related fac- tors. The sample was adequate (KMO=0.81). Three factors were derived, and they explained 56% of the variance. Items were grouped together as school and healthcare provider responsibility, increased access to health programs and facili- ties, and higher cost efforts. All sub- scales had high reliability (a=0.73 to 0.81). Therefore, factor scores were saved and used for further analysis. Items related to school and healthcare provider responsibilities were support- ed the most (M=3.69, SD=0.90), fol- lowed by items related to increased access (M=3.55, SD=1.00) and items related to higher cost efforts (M=3.07, SD=1.01). Factor loadings for the three factors are found in Table 3.

A MANOVA revealed parent weight status did not influence support rat- ings; however, socioeconomic status (SES) did (V=0.10, F[6, 328]=2.80, p=0.011, h2p=0.05). Low-SES parents were more supportive of the factor related to healthcare provider respon- sibilities (M=3.81, SD=0.87) compared to middle (M=3.60, SD=0.99) and high-SES parents (M=3.27, SD=0.80, F[2, 165]=5.01, p=0.008, h2p=0.06). Childhood Overweight And Obesity

Discussion Most parents in this sample were of

unhealthy weight according to their reported height and weight measures, and a sizeable number of children were of unhealthy weight as well. Higher parent BMI scores were associ- ated with higher child weight per- centiles, indicating the risk of obesity runs within families. Interestingly, while 69% of parents were overweight or obese, only 45% were diagnosed as such by a doctor. Similarly, 40% of children were overweight or obese, but only 6% children were diagnosed as such by a doctor. It is important to note these numbers are based on self- reports, and thus, could be influenced by their own perceptions of their health status.

Of most concern was that most parents with overweight and obese children did not consider their chil- dren to be overweight. Thus, it

support). Overall, parents expressed the most support for requiring schools to teach students healthy eating and exercise habits (M=4.20, SD=1.00), increased access to tax funded recre- ational facilities in the community (M=4.04, SD=1.10), and more time set aside for well-child visits without addi- tional cost for the patient (M=4.00, SD=1.18). They expressed the least support for requiring schools to weigh students and send parents a health

Figure 1. Parental Perceptions of Who Is Most Responsible for Addressing

Childhood Obesity Problems (0 = Not Responsible; 5 = Very Responsible) Childhood Overweight And Obesity