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Thursday 8 May 2008

“It's Not an Issue at the Moment”: A Qualitative Study of Mothers About Childhood Obesity

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MCN, The American Journal of Maternal/Child Nursing
“It's Not an Issue at the Moment”: A Qualitative Study of Mothers About Childhood Obesity
ISSN: 0361-929X
Accession: 00005721-200701000-00008
Author(s):

Zehle, Katharina MPH; Wen, Li Ming MD; Orr, Neil PhD; Rissel, Chris PhD

Issue:
Volume 32(1), January/February 2007, p 36–41
Publication Type:
[feature article]
Publisher:
© 2007 Lippincott Williams & Wilkins, Inc.
Institution(s):
Katharina Zehle is a Project Officer, Health Promotion Unit, Sydney South West Area Health Service, NSW Australia.
Li Ming Wen is a Senior Research and Evaluation Officer, Health Promotion Unit, Sydney South West Area Health Service, NSW Australia. He can be contacted via e-mail at lmwen@email.cs.nsw.gov.au.
Neil Orr is a Research Officer, Health Promotion Unit, Sydney South West Area Health Service, NSW Australia.
Chris Rissel is a Director of Health Promotion Services, Health Promotion Unit, Sydney South West Area Health Service, NSW Australia.
All authors declare that there is no any conflict of interest. There was no external funding for this study. The study was approved by the Ethics Review Committee of Sydney South West Area Health Service.
Keywords: Children, Overweight and obesity, Health promotion
ABSTRACT

Purpose: To explore childhood obesity through mothers' perceptions, attitudes, beliefs, and behaviors.

Study Design and Methods: Descriptive qualitative study using in-depth interviews. Sixteen in-depth interviews were conducted with primiparous mothers of children aged 0–2 years. The questions focused on nutrition, the context of eating in the family, physical activity, television viewing, and the responsibility of parents as role models. Thematic analysis was used to identify regular patterns of meaning regarding the major issues pertaining to childhood obesity, nutrition, and physical activity.

Results: Five themes were identified: (1) developing eating habits, (2) developing active and sedentary habits, (3) differences between age groups, (4) sources of information, and (5) response to information. Although awareness about the need to provide a nutritious diet and opportunities for children to be active was high among the mothers, this was not always reflected in their behaviors. For many mothers, obesity became a concern only if excessive weight gain occurred. Prevention through establishing good habits early, although considered, was not always actively pursued.

Clinical Implications: Interventions to prevent overweight and obesity need to focus on equipping parents with the skills to translate their knowledge into behavior and lay the foundations early for their children to develop healthy habits.




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Childhood obesity has reached epidemic proportions in developed countries and is expected to continue to rise. According to the International Obesity Task Force (IOTF), approximately 155 million school-aged children and 22 million preschool-aged children are overweight or obese globally (IOTF, 2004). The U.S. National Center for Health Statistics shows that the percentage of young people who are overweight has more than tripled since 1980. Among children and teens aged 6–19 years, 16% (more than 9 million young people) are considered overweight (Centers for Disease Control and Prevention [CDC], 2005). In Australia, with levels of overweight and obesity increasing at approximately 1% per year, the prevalence of overweight and obesity in children is predicted to rise to 50% by 2025 (Australasian Society for the Study of Obesity, 2004). Approximately 25–50% of these children can progress to obesity in adulthood, with a consequent high risk of cardiovascular disease, diabetes, and cancer. If the current trend continues, morbidity in adulthood originating from obesity in childhood can become a significant component of the total burden of disease.

Although underlying genetic factors may predispose children to overweight and obesity, the overarching cause is energy imbalance: excessive energy intake and inadequate energy expenditure (Gable & Lutz, 2000; Hodges, 2003). However, focusing on these factors alone may not be sufficient to explain the development of overweight in early childhood. The context of the parent-child feeding and play interaction needs to be considered for obesity prevention to be maximally effective (Baughcum et al., 2001).


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During infancy and early childhood, a child's energy intake and output depend almost exclusively on the behavior of parents. The protective effect of breastfeeding against later childhood obesity has been cited often (Arenz, R_cklerl, Koletzko, & von Kries, 2004). However, for various reasons many women do not breastfeed for 6 months, nor do they delay the introduction of solids until 6 months.

Eating, physical activity, play, and television viewing are important parent-child interactions (Benton, 2004; Wardle, Guthrie, Sanderson, Birch, & Plomin, 2001; Westenhoefer, 2002), and the patterns established in regard to these factors in the early childhood period have the potential to significantly impact the children's likelihood of becoming obese.

Physical activity during childhood prevents obesity because it is the principal means by which energy is expended (Moore et al., 2003). The major factors that determine the level of physical activity in children are determined by parental factors, such as their own level of physical activity, lifestyle habits, positive or negative attitudes to physical activity, and whether they encourage each other and their children through social support (Moore et al., 1991). In addition, the level of physical inactivity in the community generally may contribute to physical inactivity in children. There is also strong evidence that regular long-duration television viewing is associated with overweight and obesity (Marshall, Biddle, Gorely, Cameron, & Murdey, 2004). This relationship appears to work in two ways: junk food advertising on television encourages unhealthy eating, and the time spent watching television reduces participation in physical activity (Robinson, 1999). The amount of television that children view is largely determined by the home environment, and by encouraging television viewing (or more likely not actively discouraging it), parents or caregivers may inadvertently be contributing to their child's physical inactivity.

Pediatric nurses, through their knowledge of and experience with child and family interactions, can make a significant contribution to the prevention of childhood obesity by addressing nutrition and physical activity issues for infants, children, and parents (Kemp, Anderson, Travaglia, & Harris, 2005). As part of the development of a program to address childhood obesity to be delivered by early childhood nurses during home visits, this study team explored the views of primiparous mothers with young children on nutrition and physical activity for their infants.

Methods

This descriptive qualitative study used in-depth interviews with first-time mothers about obesity prevention. The study protocol was approved by the Ethics Review Committee (RPAH Zone) of Sydney South West Area Health Service, NSW, Australia.

Study Participants

The participants in this study were 16 first-time mothers with children below the age of 2 years (Table 1) who lived in the Central Sydney Area Health Service region (CSAHS), which is an inner urban district of Sydney. In addition, women needed to be fluent in English to participate in the study. The study participants were between 25 and 36 years old and were from a range of socioeconomic and cultural backgrounds. Nine ethic groups were represented, and three women spoke a language other than English at home. The most common level of education was a university degree, and five had paid employment at the time of the interview (Table 2).


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Table 1. Themes Identified in Qualitative Interviews

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Table 2. Characteristics of Study Participants

The participants were recruited from one of two sources: from mother groups based at a number of early childhood centers run by the Area Health Service or from playgroups in the same area that are facilitated by the NSW Playgroup Association. Women were invited to participate by the project officer (K. Z.) during an information session, and those who expressed an interest in participating were subsequently approached for an interview.

The Interview

Based on the current literature and in consultation with a nutritionist and early childhood nurses, a series of open-ended questions about the key determinants of childhood obesity was developed. The questions were aimed at eliciting women's attitudes and knowledge regarding childhood nutrition and physical activity. With regard to these issues, four topics were explored:

1. Infant nutrition and breastfeeding and the introduction of solid foods.
2. Physical activity of the child and the mother, including the role of TV viewing.
3. The role of health services in providing information and support to new parents.
4. The role of broader social and family networks as sources of support.

The sociodemographic characteristics of women and children were also collected.

For the purpose of investigating nutrition and physical activity during child development, mothers were allocated to one of the three groups depending on the age of their child (0–4 months, 5–12 months, or 13–24 months). Sixteen interviews were conducted, which mainly took place in the child's home and took approximately 1 hour. The interviews were audiotaped and transcribed; notes were also taken.

Data Analysis

The data used in the analysis were transcriptions of the taped interviews. In addition, as a quality-control measure, the transcriptions were compared to the hand-written notes to determine their accuracy and consistency. The analysis of the data involved a three-stage process, which was adapted from the approach to thematic analysis described by Boyatzis (1998). First, each interview was read and organized into broad topic codes within the four topic areas referred to earlier. Thematic analysis of these topic codes was used to identify and describe the major issues in each of the topic areas. The themes were identified on the basis of key words and phrases and were modified as each interview was examined with the aim of keeping the themes to a manageable number. Topics not of immediate interest to the research objectives of the study were discarded. The themes were then merged across the cases. In consultation with the research team, the identified themes were interpreted with respect to the five topics (Table 1).

Results

Five themes were identified: (1) developing eating habits, (2) developing active and sedentary habits, (3) differences between age groups, (4) sources of information, and (5) response to information. Direct quotes from the parents are used to more fully describe each theme.

Developing Eating Habits

During the early months of childhood, despite uncertainty about the appropriate amount of milk to be given to children, few women were concerned about overfeeding. In these women/mothers, weight gain was viewed as a positive development, and they expected that early childhood nurses, during routine visits, would identify if overweight had become a problem. “He had big, round cheeks - that's why you continue to breastfeed, cause you see your child growing.” “Was told by the clinic I was overfeeding…disagree with that theory…isn't it supply by demand …”

Once children had started eating solid food, nutrition-conscious women spoke of the importance of the early childhood period for laying the foundations for good nutrition throughout their lifetime. These women reported that they did not allow their children to eat unhealthy food and hoped that this would stop their child from developing poor nutrition habits in later life. For example, one woman said: “The more she doesn't have it now the more she won't want it later.” Other women were less concerned about their child's diet and did not want to deny their children anything: “He wants everything he's not supposed to have.”

A number of women believed that unhealthy food only needed to be restricted once overweight became an issue: “It's not an issue at the moment … I don't know why I'd have to keep him away from fries or milkshakes … my parents didn't do it and I'm skinny.”

The use of food as a reward was also discussed in the interview, because it can have a major bearing on the child's diet. Although women believed that it was undesirable to reward children in this way, they often failed to see how it could be avoided. Nutrition-conscious women reported that they only used healthy foods to reward their children; those who were less nutrition conscious were less discriminating about what they used.

Developing Active and Sedentary Habits

The findings with regard to the level of physical activity in children are somewhat difficult to interpret because there appeared to be a difference in how researchers and participants defined physical activity. For researchers, physical activity generally included all bodily movements, such as walking or swimming. However, participants had a narrower definition of physical activity that predominantly referred to physical exercise. This meant that the participants did not include play in their definition, and thus the level of physical activity reported was low.

With regard to the modeling of physical activity, more active women believed that they provided a good example to their children. Those who reported being less physically active spoke more of encouragement through words than participating themselves: “Not sure to what extent I have to be active as long as you support the child.”

All participants identified benefits of TV watching to children. This is related to the educational value of TV, as well as its use as a childminder. Although most women were aware of the dangers of watching too much of TV, most felt that this did not apply to their child as they were unlikely to sit passively for an extended period. In addition, few women were concerned that TV viewing in infancy would lead to excessive viewing later on. Although aware of the potential harmfulness of TV viewing, few women could offer an alternative that could play the same role. “I know she is quiet, amused, stimulated and safe … I fear that it may become a learned behavior … but at this point it's the best we can do.” “It helps him concentrate … he takes time out (in front of TV) and focuses on something.”

Differences Between Age Groups

There were major differences between the age groups with regard to feeding practices and expectations. All of the women with a child in the 0–4 months age group breastfed their child, as was expected, and breastfeeding became much less common as the children aged. Women who were currently breastfeeding appeared to be highly committed to the practice and expected to continue until the child became at least 6 months older in age.

There were also age-based differences on whether children were fed on demand. This was very common in the younger group but became less so as the children aged. However, many women expressed concerns about the adequacy of feeding once they had made this change. “The GP [general practitioner] says she's fine … she'll eat more the next meal, but I can't do that … I worry about her not getting enough.”

In this category of findings regarding the difference between ages, the time spent watching TV was a concern to some parents, for it became longer as the children aged: “I'm sure I'll succumb to the ease of it.”

Sources of Information

Overall, women appeared to be well informed about breastfeeding and infant nutrition. The women said they used a range of sources to get information about parenting, with a number of reputable Australian children's health books commonly used. Antenatal classes, nurses, midwives, and lactation consultants were also identified as important sources of information and support. However, once their child had passed through the early infant period and women became more knowledgeable, they were more discerning in the type of information they sought. Early childhood nurses were commonly identified as the source of information when child development or parenting issues arose.

The women also appeared to have a good grasp of the importance of physical activity for a child's physical and emotional development, and some recognized that they were role models for their children and understood that their own behaviors could influence their child's.

Although the women's knowledge about infant nutrition was often from official childhood nutrition recommendations, their source of the information about physical activity was much more diffuse. Most of the women understood the importance of physical activity to their child's development, but only a few had sought out the information about the issue.

Response to Information

Particularly during the early months, women greatly appreciated advice from early childhood nurses. However, once the children were a bit older, nurses were less appreciated and were sometimes seen as hindrances. Some mothers expressed their feeling that nurses sometimes had a prescriptive approach that often left women feeling inadequate if they could not follow the nurse's advice. This meant that they became less likely to consult nurses even though they had been valuable sources of support and advice previously: “I'd heard about the 4–6 month recommendation, that's why I didn't tell the clinic…I knew they wouldn't agree with me.” “…Started with Farex [editor's note: Farex is a brand of infant rice cereal sold in Australia] at 2.5 months.”

Most of the women had recent experience of their child's transition from breast (or bottle) feeding to solid food. With regard to breastfeeding, most women who had breastfed ceased prior to 6 months, the recommendation promoted by Australian infant nutrition authorities. The major reasons given were that the child was no longer satiated by the milk that was available and they were still hungry after they had been fed.

During this transition period, women often reported that at the time they had stopped breastfeeding, they had been very willing to listen to expert advice. However, they did not feel compelled to follow recommendations and reserved the right to decide for themselves as to whether they continued to breastfeed. The women reported that a factor that had contributed to their decision to stop breastfeeding was that they felt overloaded by conflicting and impractical information. This had made them less likely to follow the advice of experts once they had reached the point of information overload. For example, two women said: “We do what works for us … how it fits in with our ideas.” “You take what's right for you and use it.”

With regard to parenting advice, older family members were often viewed as being out of touch and intrusive with their advice and how they offered it. For women from non–English-speaking backgrounds, many of the criticisms related to the advice being culturally loaded and inappropriate for the Australian context: “I'm worried about the amount he eats, but mum always tells me to give him more … we are Italian and we always focus on food.”

Women appreciated mothers/play groups, which provided them with much needed social and moral support. In addition, their exposure to fellow mothers gave them a sense of the diversity of experiences of motherhood and parenting. Many women found this affirming because they learned that there was not one exclusively “right” way to bring up a child and that they were doing okay. Consequently, so long as their child appeared to be healthy and contented, most women felt comfortable with their parenting abilities.

Discussion

The findings suggest that although these women were often well informed about the importance of healthy nutrition and physical activity for young children, they were not particularly well informed about prevention of obesity. Actual parenting practices were often determined by more immediate concerns related to the child's diet and general health, however, and complying with recommendations was often difficult to sustain.

There was evidence that because of the large quantity of information provided during the early childhood period, women were unsure about the soundness of all of the advice. This meant that many parenting behaviors could have been guided by misconceptions about nutrition and physical activity during the early childhood period. In addition, the low level of compliance with many guidelines regarding childhood nutrition (such as breastfeeding) raises questions about the salience of the guidelines and how effectively they had been communicated.

Another issue that may impact childhood nutrition was the practice by some parents of limiting the child's access to unhealthy foods. There is evidence that this practice may increase rather than decrease a child's' preference for unhealthy foods (Benton, 2004). It has been shown that when a particular food is used to promote good behavior, it becomes associated with parental attention, thus creating a linkage between food and behavior that can undermine healthy eating. As unhealthy foods are often used, this behavior can lead to a preference for unhealthy foods (Benton, 2004).

With regard to physical activity, less active mothers often failed to see how their child's physical activity was modeled on their own behavior, or how their sedentary behavior promoted sedentariness in their child (Fogelholm, Nuutinen, Pasanen, My_hänen, & Säätelä, 1999). This adds complexity to childhood obesity programs, as programs aimed at reducing childhood obesity may need to focus on preventing obesity in parents.

Most of the women spoke of the value of early childhood nurses during the first years of childhood. They were generally seen as trustworthy professionals who played an important supportive role in infant parenting. However, in Australia, nurses have not spent much time addressing childhood obesity issues with parents. As trusted health professionals, they appear to have a significant role to play in childhood obesity prevention interventions.

The ineffectiveness of information alone in achieving behavior change has been well documented in the health promotion literature. With regard to addressing childhood obesity, a more interventionist approach is advocated. For example, Benton (2004) advocates long-term involvement with parents through the various stages of early childhood in order to promote healthy nutrition and physical activity (Benton). In addition, a more problem-solving approach is recommended. This could perhaps be achieved by more actively involving childhood nurses in childhood obesity interventions (Hedges, Simmes, Martinez, Linder, & Brown, 2005).

Clinical Implications

This study has a number of important implications for the development of childhood obesity prevention programs. Early childhood nurses have the potential to influence appropriate nutrition and physical activity for infants and can address these issues among parents within the social context of infants. When promoting suitable nutrition and physical activity to parents, nurses should communicate effectively with the whole family on key behaviors that are associated with later overweight and obesity. These key behavior areas are increased duration of breastfeeding, a later introduction of solids, increased intake of fruit and vegetables, decreased intake of sweetened drinks, decreased amount of television viewing, and an increased range of opportunities for physical activity. In addition, interventions to prevent overweight and obesity need to focus on equipping parents with the skills to translate knowledge into behavior and lay the foundations early for their children to develop healthy eating and physical activity habits.

Acknowledgments

This study would not have been possible without the help and cooperation of the participating mothers, all of whom were from various mothers groups in the Central Sydney area. We also would like to thank Angela Balafas for her advice on early development of the study and Ms. Suzanne Gleeson and Ms. Beverley Lloyd for their advice on data analysis.

References

Arenz, S., R_cklerl, R., Koletzko, B., & von Kries, R. (2004). Breast-feeding and childhood obesity—A systematic review. International Journal of Obesity, 28, 1247–1256. [Context Link]

Australasian Society for the Study of Obesity. (2004). Obesity in Australian children: Definition and prevalence [Online]. Retrieved June 9, 2006, from www.asso.org.au/home/obesityinfo/generalinfo . [Context Link]

Baughcum, A., Powers, S. W., Johnson, S. B., Chamberlin, L., Deeks, C. M., Jain, A., et al. (2001). Maternal feeding practices and beliefs and their relationships to overweight in early childhood. Journal of Development and Behavioral Pediatrics, 22, 391–408. [Context Link]

Benton, D. (2004). Role of parents in the determination of the food preferences of children in the development of obesity. International Journal of Obesity, 28, 858–869. [Context Link]

Boyatzis, R. E. (1998). Transforming qualitative information: Thematic analysis and code development. Thousand Oaks, CA: Sage. [Context Link]

Centers for Disease Control and Prevention. (2005). Overweight and obesity. Retrieved August 16, 2006, from www.cdc.gov/nccdphp/dnpa/obesity/ . [Context Link]

Fogelholm, M., Nuutinen, O., Pasanen, M., My_hänen, E., & Säätelä, T. (1999). Parent-child relationship of physical activity patterns and obesity. International Journal of Obesity, 23, 1262–1268. Bibliographic Links [Context Link]

Gable, S., & Lutz, S. (2000). Household, parent, and child contributions to childhood obesity. Family Relations, 49, 293–300. [Context Link]

Hedges, S., Simmes, D., Martinez, A., Linder, C., & Brown, S., (2005). A home visitation program welcomes home first-time moms and their infants. Home Health Care Nurse, 23(5), 286–289. [Context Link]

Hodges, E. (2003). A primer on early childhood obesity and parental influence. Pediatric Nursing, 29, 13–19. Bibliographic Links [Context Link]

International Obesity Task Force. (2004). Childhood obesity [Online]. Retrieved June 9, 2006, from www.iotf.org/ . [Context Link]

Kemp, L., Anderson, T., Travaglia, J., & Harris, E. (2005). Sustained nurse home visiting in early childhood: Exploring Australian nursing competencies. Public Health Nursing, 22(3), 254–259. Ovid Full Text Bibliographic Links [Context Link]

Marshall, S. J., Biddle, S. J. H., Gorely, T., Cameron, N., & Murdey, I. (2004). Relationships between media use, body fatness and physical activity in children and youth: A meta-analysis. International Journal of Obesity, 28, 1238–1246. [Context Link]

Moore, L., Gao, D., Bradlee, L., Cupples, A., Sundarajan-Rumamurti, A., Proctor, M., et al. (2003). Does early physical activity predict body fat change throughout childhood? Preventive Medicine, 37, 10–17. [Context Link]

Moore, L., Lombari, D., White, J., Campbell, J., Oliveria, S., & Ellison, R. (1991). Influence of parent's physical activity levels on activity levels of young children. The Journal of Pediatrics, 118, 215–219. Bibliographic Links [Context Link]

Robinson, T. N. (1999). Reducing children's television viewing to prevent obesity: A randomised controlled trial. Journal of the American Medical Association, 282, 1561–1567. Bibliographic Links [Context Link]

Wardle, J., Guthrie, C., Sanderson, S., Birch, L., & Plomin, R. (2001). Food and activity preferences in children of lean and obese parents. International Journal of Obesity, 25, 971–977. Bibliographic Links [Context Link]

Westenhoefer, J. (2002). Establishing dietary habits during childhood for long-term weight control. Annals of Nutrition and Metabolism, 46(Suppl. 1), 18–23. [Context Link]

Key Words: Children; Overweight and obesity; Health promotion



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