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Journal Issue: Childhood Obesity Volume 16 Number 1 Spring 2006

The Role of Parents in Preventing Childhood Obesity
Ana C. Lindsay Katarina M. Sussner Juhee Kim Steven Gortmaker

Family-Based Obesity-Prevention Programs

Although a great deal of research has been done on how parents shape their children's eating and physical activity habits, surprisingly few high-quality data exist on the effectiveness of obesity-prevention programs for children that center on parental involvement. One reason for the paucity of data is that, despite some studies that indicate promising results, few programs are solely parent-based. Most efforts to involve parents are components of more comprehensive interventions. For example, many school-based programs aimed at preventing childhood obesity are targeted at children within school settings but include parental components that help parents set limits on TV viewing and provide electronic “lock-out” devices.66 Likewise, health care– based interventions may add a parenting focus. Meanwhile, a WIC-sponsored nutrition intervention will take place within the context of WIC, but it might add a parental component aimed at reducing TV time.67

As yet little to no information is available on the cost-effectiveness of obesity-prevention interventions that have a parenting component. One middle-school program called Planet Health was found to be highly cost-effective— in fact, more cost-effective even than commonly accepted preventive interventions such as screening and treatment for hypertension.68 Precisely what influence the program's parental component specifically generated, however, is unclear. Nevertheless, creating more programs to improve parenting behaviors relevant to childhood overweight is a highly promising strategy. Such programs would be most effective if they were targeted at children of various ages based on research that shows how parents can best help children at different developmental stages. Researchers should carefully evaluate the programs' effectiveness.

Solely Parent-Based Interventions
One solely parent-based intervention consisted of twenty-eight families of seven- to twelve-year-old African American children who received primary care at an urban community clinic serving a low-income population. Families were randomly selected to receive counseling alone or counseling plus a behavioral intervention that included an electronic television time manager. Both groups reported similar decreases in their children's use of television, videotapes, and video games. The behavioral intervention group reported significantly greater increases in organized physical activity and somewhat greater increases in playing outside. Changes in overall household television use and in meals eaten while watching television also appeared to favor the behavioral intervention, with small to medium effect sizes, but these differences were not statistically significant.69

Another recent solely family-based intervention tested two versions of a culturally relevant program to prevent excess weight gain in pre-adolescent African American girls. The girls, aged eight to ten years, were divided into two groups, both of which participated in highly interactive weekly group sessions. In one group, the sessions targeted the girls; in the other, the sessions were geared toward their parents or caregivers. Girls in both groups demonstrated a trend toward reduced body mass index and waist circumference. In addition, girls in both groups reduced their consumption of sugar-sweetened beverages, increased their level of moderate to vigorous activity, and increased their daily serving of water.70

Comprehensive Interventions with a Parenting Component
Most interventions aimed at preventing overweight and obesity have been school-based, and all have improved health knowledge and health-related behaviors to some extent.71 Some of the most successful school-based interventions, however, have included a parenting component. These interventions have resulted in dramatic changes in health behaviors associated with child obesity and overweight as well as in changes in body mass index or obesity.

School-based interventions at the preschool level are scarce, but one study's findings provide strong support for establishing such programs. The Hip-Hop to Health Jr. program targeted three- to five-year-old minority children enrolled in Head Start programs in Chicago, with the aim of reducing the tendency toward overweight and obesity in African American and Latino preschool children. The intervention presented a developmentally, culturally, and linguistically appropriate dietary and physical activity curriculum for preschoolers, and a parent component addressed the families' dietary and physical activity patterns. Each week of the intervention covered a particular topic, such as the importance of “Go and Grow” foods, eating fruit, and reducing TV viewing. Parents received weekly newsletters with information that mirrored the children's curriculum on healthful eating and exercise as well as a five- to fifteen-minute homework assignment that reinforced concepts presented in the weekly newsletters. During the fourteen-week intervention, children in a control group attended a twenty-minute class once a week in which they learned about various general health concepts, such as dental health, immunization, seat belt safety, and 911 procedures. Their parents' weekly newsletters mirrored these sessions. A recent two-year follow-up study found that the intervention group's children had significantly smaller increases in body mass index than did those in the control group.72

Another recent study assessed the impact of the school-based Child and Adolescent Trial for Cardiovascular Health (CATCH) intervention among primarily Hispanic, low-income elementary school children. The intervention tested the effectiveness of changes in school food service, physical education, classroom curricula, and family activities. The family component consisted primarily of skill-building activity packets that students took home to complete with their parents. Third and fourth graders and their families were also invited to participate in Family Fun Nights at the school. The family component supplemented the classroom curriculum, which focused on improving the children's dietary and physical activity knowledge, attitudes, and self-reported behaviors, and reinforced the concepts, activities, and skills of the curriculum. Among both boys and girls, the intervention reduced overweight or the risk of overweight.73

Another successful elementary school–based health behavior intervention on diet and physical activity was the Eat Well and Keep Moving program. Classroom teachers in math, science, language arts, and social studies classes taught the quasi-experimental, two-year field trial among children in grades four and five, with six intervention and eight matched control schools. The intervention provided links to school food services and families and provided training and wellness programs for teachers and other staff members. Its aim was to decrease the consumption of foods high in total and saturated fat, to increase fruit and vegetable intake, to reduce television viewing, and to increase physical activity. Compared with students in the control schools, students in the intervention schools reduced their share of total energy from fat and saturated fat. They also increased their fruit and vegetable intake, vitamin C intake, and fiber consumption. They reduced their television viewing marginally.74

Recently, a pilot study divided children in four elementary schools into an intervention group and a control group and evaluated how a school-based health report card affected family awareness of and concerns about child weight status, plans for weight control, and preventive behaviors. Parents of overweight children (including those at risk of overweight) in the intervention group had greater awareness of their children's weight status and initiated more activities to control weight than did the parents of children in the control group.75

Planet Health was a two-year, school-based health behavior intervention targeting middle school–aged boys and girls in sixth through eighth grades. Students participated in a school-based interdisciplinary program that used existing classroom teachers and took place in four major subjects and physical education classes. Sessions focused on decreasing both television viewing and the consumption of high-fat foods and on increasing both fruit and vegetable intake and physical activity, with no explicit discussion of obesity. Compared with girls in the control group, girls in the intervention group reduced their prevalence of obesity; no differences were found among boys. The intervention reduced television hours among both girls and boys, increased fruit and vegetable consumption among both girls and boys, and reduced total energy intake among girls in the intervention group compared with girls in the control group. Among girls, obesity prevalence was reduced for each hour that television viewing was reduced. Although not primarily a parent-focused program, Planet Health had several family components, including an activity called “Power Down,” where the household together engaged in a TV charting exercise to reduce TV time.76 Further analysis of Planet Health found a reduced risk of disordered, or unhealthy, weight control behaviors in girls. An economic analysis found the program substantially cost-effective.77

Obesity-related interventions have also focused on limiting television viewing.78 A recent randomized control trial called “Switch- Play” aimed to replace TV viewing time with more physical activities. More than half the children reported reducing their TV viewing while less than half increased physical activity. Most of the children enjoyed alternative activity programs, and only 7 to 17 percent had difficulty turning off their favorite TV shows.79

An after-school intervention known as the GEMS pilot study tested the feasibility, acceptability, and potential efficacy of after-school dance classes and a family-based intervention to reduce television viewing and weight gain among African American girls in Stanford, California. At the follow-up, girls in the intervention group exhibited trends toward lower body mass index and waist circumference, increased after-school physical activity, and reduced television, videotape, and video game use, as compared with the control group. The treatment group also reported significantly reduced household television viewing and fewer dinners eaten while watching TV.80

Although intervention studies show the benefit of cutting TV hours, such practical barriers as long hours of parental work and inadequate child care options make it difficult for families to implement these changes. For many families, particularly in low-income, urban areas without safe places to play outdoors, TV is a substitute babysitter. Mothers are often more concerned with the types of TV programs their children watch than with how much time their children spend watching TV. These mothers raise the issue of affordable and accessible recreation facilities and programs and say the lack of such options contributes to their children's watching more TV at home.81

A systematic review of research on family involvement in weight control recently found that relatively few intervention studies exist, but those few suggest that parental involvement helps children lose weight.82 The studies also indicate that results, in terms of weight loss and behavioral changes, are better when children are treated together with their parents.83 Involving at least one parent in a weight-loss process improves overall short- and long-term weight regulation, as does overall support from family and friends.84 For families with several members battling overweight, family treatment can substantially reduce the per-person costs of obesity treatment, and children and their parents can achieve similar percentages of overweight change.85