Family-focused weight management program for five- to nine-year-olds incorporating parenting skills training with healthy lifestyle information to support behaviour modification.

Abstract

This case study aims to describe how general parenting principles can be used as part of parent-led, family-focused child weight management that is in line with current Australian Clinical Practice Guidelines. A parent-led, family-focused child weight management program was designed for use by dietitians with parents of young children (five- to nine-year-olds). The program utilises the cornerstones of overweight treatment: diet, activity, behaviour modification and family support delivered in an age-appropriate, family-focused manner. Parents participate in 16 sessions (4 parenting-focused, 8 lifestyle-focused and 4 individual telephone support calls) conducted weekly, fortnightly then monthly over six months. This case study illustrates how a family used the program, resulting in reduced degree of overweight and stabilised waist circumference in the child over 12 months. In conclusion, linking parenting skills to healthy family lifestyle education provides an innovative approach to family-focused child weight management. It addresses key Australian Clinical Practice Guidelines, works at the family level, and provides a means for dietitians to easily adopt age-appropriate behaviour modification as part of their practice.

Key words: behaviour modification, child, parenting, weight management.

INTRODUCTION

Childhood overweight is a major Australian public health issue affecting more than 20% of Australian children. (1) From an early age, overweight impacts negatively on psychosocial development and the cardiovascular, endocrine, orthopaedic and respiratory systems. (2) The most significant long-term consequence of childhood overweight is its persistence into adulthood. (2) Effective, age-appropriate treatment approaches are required to address the immediate consequences of childhood obesity and prevent persistence into adulthood.

The Australian National Health and Medical Research Council (NHMRC) has developed evidence-based 'Clinical Practice Guidelines for the Management of Overweight and Obesity in Children and Adolescents'. (2) The NHMRC recommends utilising all available treatment components: diet, activity, behaviour modification and family support; and highlights that treatment needs to be delivered in an age-appropriate manner. (2) For young children, this may be best focused on parent-led family-based, rather than child-centred, treatment.

An Israeli study of 50 children aged 6-11 years found that when parents, rather than the overweight child, were targeted as the 'agent of change' for managing child overweight, there were better child weight outcomes eight years later (10 [+ or -] 11% vs 19 [+ or -] 14% overweight, P < 0.05). (3) A parent-led, family-focused approach acknowledges that parents and families are the key food providers and influences on young children's eating behaviours. (2) Focusing on the family also addresses 'family overweight', important given that parental overweight is the largest risk factor for childhood overweight. (2) The developmental capacity of young children also suggests that modifying children's eating and activity patterns is best considered within broader parenting and child behaviour.

Dietitians view weight management as an important professional role; however, they identify a range of barriers to working in this area. (4) Surveys conducted with Australian dietitians in 1997 and 2002 highlighted that many do not feel well prepared to manage overweight and obese clients, particularly children. (4,5) Many feel that their capacity to work effectively in this area is limited by inadequate resources and professional development opportunities, such as time, funding, staffing and training in specialist counselling skills. (5) In addition, limited use of available practice guidelines (2) and a lack of paediatric-specific dietetic practice guidelines may also be barriers to evidence-based child weight management. Further, papers detailing the interventions evaluated in studies are scarce--another barrier to effective practice in this area. (6)

Acquiring expertise in parenting skills may provide dietitians with a useful age-appropriate child behaviour modification approach to address family lifestyle and weight-related behaviours. This paper describes the novel adaptation and use of an established and evaluated general parenting skills program, for which materials and facilitator training are commercially available, as the behaviour modification component of a family-focused child weight management program. The paper aims to provide a detailed program description, including a case study, to facilitate application of a parent-led, family-focused approach to child weight management service delivery--an area of clear need in which dietitians report limited capacity.

PROGRAM DESCRIPTION

Program overview

The program provides positive parenting skills training coupled with healthy lifestyle education. The program is underpinned by a theoretical framework that aims to facilitate and support parental capacity to initiate and maintain healthy family eating and activity behaviours conducive to changing energy balance (Table 1). Parents are defined as the 'agent of change', responsible for attending program sessions and implementing lifestyle change at the family level. Children are not directly involved in the education or program implementation process.

The program, facilitated by a dietitian, consists of 12 group sessions for parents only (12-14 parents per group; 4 parenting-focused and 8 lifestyle-focused) (Table 2). The education approach used is process-focused to promote self-management. Significant time is spent reviewing homework tasks and peer problem-solving barriers identified by parents prior to the delivery of new content. Four additional telephone sessions provide an opportunity for parents to focus on their family. These are conducted using a series of standard prompts which guide the parent, not the facilitator, to problem-solve issues.

Parenting component

The Positive Parenting Program (Triple P, Sanders et al., Brisbane, Qld, Australia) is an established and evaluated general parenting program based on social learning principles and child development theory. (7) Triple P aims to promote parental competence to facilitate appropriate child behaviour by providing parents with the skills to plan, implement and maintain behaviour change. (7,8) Self-management is fostered through self-evaluation and problem solving. Standardised Triple P facilitator training is available in most states and is designed for use by a range of health professionals (http://www.triplep.net). Although the program is widely used in Australia for general child behaviour management, there are no publications of it being combined with family-focused dietary and active lifestyle components for management of childhood overweight.

Having undertaken a three-day Level 4 Group Triple P Professional Training (http://www.triplep.net), dietitians can facilitate the standard group Triple P program with strategies modified to focus on dietary and activity weight-related behaviours (Tables 1,2), for example: developing positive relationships (Table 2, week 3) by using quality time to promote play; encouraging desirable behaviours (Table 2, week 3) through praise, role modelling healthy lifestyle habits and behaviour charts; and managing behaviour change (Table 2, week 4) by setting ground rules about TV viewing time, providing clear instructions about between-meal access to the fridge.

The 'Planned Activities Routine' (PAR) introduced in week 5 is an integral part of the program (Table 3). It provides the framework for promoting lifestyle behaviour modification and is the interface between the acquisition of parenting skills and lifestyle knowledge. (7) The PAR provides a problem-solving framework to manage situations that could jeopardise achievement of goals or rules, termed 'high risk situations' (e.g. school holidays, birthday parties, afterschool snacking). The PAR highlights the importance of identifying and preparing for potential high-risk situations, setting positive rules and limits, and having backups or consequences for times of misbehaviour. It aims to promote behaviour change by emphasising preparedness and forward thinking and reinforcing positive behaviour.

Healthy lifestyle component -- nutrition focus

The Australian Guide to Healthy Eating (AGHE) is the national food selection guide, promoting eating in line with national dietary guidelines. (9) It provides information on the type and quantity of foods to eat, with population modelling indicating that the AGHE can be used to meet the nutrient and energy requirements of children and adults. (9) Dietary modelling undertaken in the development of the weight management program demonstrated that an eating pattern consistent with the AGHE and linked to a series of food-based recommendations resulted in a reduction in the amount of saturated fat and energy in Australian children's diets (Table 4). (10) Therefore, the AGHE is an appropriate framework for use in the active treatment phase of a whole-of-family child weight management program.

Parents are encouraged to compare current eating patterns of each family member with age-appropriate AGHE food group serve recommendations. (9) Based on their findings and family eating patterns and habits, modifications required to meet AGHE recommendations are individually identified and goals for change are set. Gradual 'whole family' changes are promoted.

Healthy lifestyle component -- physical activity focus

While parents attend the healthy lifestyle sessions, children participate in supervised physical activity sessions, providing both a child-minding facility and the opportunity for the development of fundamental movement skills in a non-threatening environment with children of similar ability. These sessions were developed by physical activity experts, and were designed to be supervised by staff or students with a physical activity or education background. The sessions consist of noncompetitive and fun games, aiming to improve children's movement skills and increase their confidence to participate in physical activity. Sessions require minimal space and equipment, and are easily applicable to the home environment.

Parents observe the final minutes of the children's acitivity sessions and remain responsible for setting activity goals at home, supported by a booklet outlining the activities undertaken during each session. The activity recommendations aim to address both physical and sedentary behaviours to gradually increase child and family activity levels (Table 4). Parents consider child and family barriers to being active and plan ways to overcome these.

Program implementation

A case study illustrating implementation of the program by a family is provided in Table 5.

DISCUSSION

This weight management program for five- to nine-year-olds sits within the continuum of treatment and prevention required to address the childhood obesity epidemic. It takes an innovative family-focused approach that utilises the cornerstones of overweight treatment: diet, activity, behaviour modification and family support as recommended by Australian Clinical Practice Guidelines. (2)

Addressing lifestyle change at the family level is important given the clustering of overweight in families and shared environmental factors, such as the food supply and eating habits. Additionally, at early school age it is developmentally appropriate that parents, as the 'agents of change', have the responsibility for managing their child's health. (3) The novelty of this program is the addition of parenting strategies to traditional nutrition and lifestyle messages to support parents' capacity to initiate and maintain behaviour modification to achieve healthy family lifestyle choices. The program illustrates one approach to translate the scientific evidence within the Australian health-care context.

The program was developed for delivery by dietitians, who play a key role in supporting families to manage children's weight. It addresses barriers identified by dietitians to working in this area, by enhancing behaviour modification skills. Use of a generic parenting skills training program in conjunction with dietary advice can equip dietitians with transferable family intervention skills appropriate for the management of obesity or other common food management issues, such as fussy eating. Dietitians wishing to apply this approach but without access to Triple P are encouraged to access programs with similar strategies and theoretical underpinnings. (8)

The parenting skills training is linked to lifestyle material designed to facilitate implementation and monitoring at the family level. The program is flexible and can be tailored to meet individual family needs, appropriate for all family members. The skills potentially allow management beyond the life of the intervention and can account for changing family circumstances as the child develops, permitting use in the treatment and long-term maintenance of child weight management.

The program described increases the treatment options that dietitians can offer clients by combining standard healthy lifestyle information with parenting skills training to maximise support provided to parents to manage their child's weight. Complete 12-month data from two randomised controlled trials being conducted in Adelaide and Sydney will be available from July 2007 to determine whether the program presented here is an effective approach to child weight management.

ACKNOWLEDGEMENTS

Thanks to Kevin Norton, Professor of Exercise Science, School of Health, University of Adelaide, and Andrew Hills, Professor of Human Movement Studies, Queensland University of Technology, for developing the physical activity component of the program. Thanks also to Professor Louise Baur, Consultant Paediatrician and Specialist in Clinical Nutrition, Sydney Discipline of Paediatrics and Child Health, The Children's Hospital at Westmead, and Associate Professor Kate Steinbeck, Department of Endocrinology, Royal Prince Alfred Hospital/University of Sydney Discipline of Medicine, Sydney, for advice and input into the development of the child weight management program. This research was funded by the Australian Health Management Group Health and Medical Research Fund, and the NHMRC (Project #275526). Rebecca K. Golley was supported by a NHMRC Postgraduate Research Scholarship (#229978). Rebecca A. Perry was supported by the National Health Foods Scholarship in Childhood Obesity and currently by an NHMRC Public Health Postgraduate Scholarship (#375184).

REFERENCES

1 Magarey AM, Daniels LA, Boulton TJC. Prevalence of overweight and obesity in Australian children and adolescents. Assessment of 1985 and 1995 data against new standard worldwide definitions. Med J Aust 2001; 174: 561-4.

2 Australian National Health and Medical Research Council (NHMR). Clinical Practice Guidelines for the Management of Overweight and Obesity in Children and Adolescents. Canberra: Commonwealth of Australia, 2003.

3 Golan M, Crow S. Targeting parents exclusively in the treatment of childhood obesity: long-term results. Obes Res 2004; 12: 357-61.

4 Campbell K, Crawford D. Management of obesity: attitudes and practices of Australian dietitians. Int J Obes Relat Metab Disord 2000; 24: 701-10.

5 Collins C. Survey of dietetic management of overweight and obesity and comparison with best practice criteria. Nutr Diet 2003; 60: 177-84.

6 Summerbell CD, Ashton V, Campbell KJ, Edmunds L, Kelly S, Waters E. Interventions for treating obesity in children. Cochrane Database Syst Rev 2003; 3: CD001872.

7 Turner KM, Markie-Dadds C, Sanders MR. Facilitator's Manual for Group Triple P, 2nd edn. Brisbane: Families International Publishing Pty Ltd, 2000.

8 Sanders MR. The Triple P-Positive parenting program. Towards an empirically validated multilevel parenting and family support strategy for the prevention of behaviour and emotional problems in children. Clin Child Fam Psychol Rev 1999; 2: 71-90.

9 Smith A, Kellett E, Schmerlaib Y. The Australian Guide to Healthy Eating. Canberra: Commonwealth Department of Health and Family Services, 1998.

10 Gehling RK, Magarey AM, Daniels LA. Food-based recommendations to reduce fat intake: an evidence-based approach to the development of a family-focused child weight management programme. J Paediatr Child Health 2005; 41: 112-18.

Rebecca K. GOLLEY, Rebecca A. PERRY, Anthea MAGAREY and Lynne DANIELS

Department of Nutrition and Dietetics, Flinders University, Flinders, South Australia, Australia

R.K Golley, PhD, APD, Lecturer

R.A. Perry, B Health Sci (NutDiet, Hons), APD, PhD Candidate

A. Magarey, PhD, APD, Research fellow

L. Daniels, PhD, Head of Department

Correspondence: R.A. Perry, Block G4 FMC Flats, Bedford Park, SA 5042, Australia. Email: [e-mail]

Table 1 Parenting and lifestyle principles underpinning a parent-led,
family-focused child weight management program

Principles for parenting
sessions (7)                   Principles for healthy lifestyle sessions

* Ensure a safe, interesting   * Work as a family for children's health
  environment
* Create a positive learning   * Use the Australian Guide to Healthy
  environment                    Eating to buy, prepare and serve family
                                 meals and snacks
* Use assertive discipline     * Be active often in a variety of ways
* Have realistic expectations  * Make healthy food choices easy choices
* Take care of oneself as a    * Set good eating and activity examples
  parent                         as children learn habits from adults

Table 2 Sequence and content of a parent-led, family-focused child
weight management program utilising general parenting skills training
and healthy lifestyle education

                        Session topic and content
Week  Parent-only sessions               Child activity sessions

 1    Introductory session--a family     Supervised, fun, skills-based
        approach to child weight           physical activity sessions
        management
      * Group rules                      * Helicopter (jumping skills)
      * Factors influencing weight gain  * Eggs from basket and tops/
                                           tails (ball handling)
      * Pros and cons of being a
        healthy weight

Parenting component (two-hour sessions, parents-only) (7)
 2    Positive parenting                 Nil
      * Program overview
      * Positive parenting principles    Parenting sessions conducted in
                                           the evening to facilitate
                                           ease of child care
      * Influences on child behaviour
      * Goal setting
      * Monitoring behaviour
 3    Promoting children's development
      * Developing positive
        relationships with children
      * Encouraging desirable
        behaviours
      * Teaching new skills and
        behaviours
 4    Managing behaviour change
      * Behaviour management strategies
      * Compliance and behaviour
        correction routines
      * Behaviour charts
 5    Planning ahead
      * Family survival tips
      * High-risk situations
      * Planned Activities Routine

Healthy lifestyle component (90-minute sessions)
 6    The Australian Guide to Healthy    Parents watch last 15 minutes
        Eating (AGHE)                      of the activity session.
                                           Children demonstrate sessions
                                           games and adaptation for use
                                           at home is highlighted
      * Food groups and serve sizes
      * Nutrition recommendations
      * Monitoring food intake
 8    Nutrition skills                   Session focused on ball
                                           handling and throwing skills
      * Label reading and shopping tips  * Accuracy throw
      * Snack and lunchbox ideas         * Throwing stations
      * Recipe modification              * Run-throw-run
 9    Phone support session (20
        minutes)--content parent-
        directed facilitated by
        standard prompts
10    Being active in a variety of ways  * Parents are provided a
                                           handout of each activity
                                           session
      * Physical activity
        recommendations
      * Overcoming obstacles to being
        active
      * How to limit physical
        inactivity
12    Family food tasks and managing     Session focused on aerobic
        appetites                          fitness, ball skills, team
                                           play
      * Encouraging healthy eating       * French cricket/hungry birds
        habits
      * Responsibilities around food     * Away-away
        and eating
                                         * Hand tennis
14    Phone support session (20
        minutes)
16    Recipe modification/eating on the  Parents are encouraged to set
        run                                activity goals using games
                                           and active family leisure
                                           time
      * Healthy eating-out choices
      * Healthy eating for busy
        families
      * Food and special occasions
18    Phone support session (20
        minutes)
20    Self-esteem and teasing            Session focused on aerobic
                                           fitness, ball skills,
                                           kicking, coordination
      * Promoting self-esteem and body   * Hand tennis
        image
                                         * Knock out
                                         * Shark and Islands
                                         * Hot balloon
22    Phone support session (20
        minutes)
24    Progress review                    * Program ends with a parent-
                                           versus-children soccer match
      * Review of progress and future
        planning

Table 3 An example of the application of the Planned Activities
Routine (7) to a situation that could jeopardise achievement of family
healthy lifestyle goals

Identify the high-risk situation
* Visiting the show or holiday theme park
List any advance planning and preparation needed
* Have lunch/dinner before going to the show or theme park
* Take own healthy snacks and water from home
* Children to choose two show bags only from guide beforehand
Decide on rules or goals
* Buy show bags that were selected prior to attending
* Eat snacks brought from home
* Talk in a pleasant voice and stay happy
* Stay close to mum/dad
* Ensure appropriately occupied using non-food activities (e.g. visiting
  the pet zoo)
List rewards for new behaviours or habits
* Praise the child using specific, descriptive phrases (e.g. 'I am
  really pleased with the way you are staying close to me while we
  walk')
* Give the child positive attention (e.g. a pat on the back, a wink, the
  thumbs up)
List strategies to manage old behaviours or habits
* Remind child of the rules--used when the child forgets rule (involves
  getting the child's attention, stating the problem, explaining why it
  is a problem, and getting the child to recall rule)
* Planned ignoring (e.g. not reacting to the child's repeated requests
  for food show bags)
* Immediate consequences for disobeying rules (e.g. not being able to go
  on a certain ride)
Hold follow-up discussions and note any new goals
* Praise the child for following the rules and adjust rule to choosing
  non-food show bags

Table 4 Recommendations used throughout the program to promote healthy
eating and activity behaviours

Nutrition recommendations (9,10)
* Encourage lunch box and snack choices from breads and cereals,
    vegetable, fruit and dairy food groups
    Use cereal-based 'extras' sparingly (e.g. muesli bars, cakes,
      muffins)
* Encourage water as primary fluid
    Switch to low-joule beverages if high-sugar fluids are present in
      diet
    Limit juice to 150 mL per day
* Ensure 2-3 serves dairy per day to maintain calcium intake
    Promote 1-2% fat products
    Limit ice cream/cheese to 1-2 serves per week and use reduced-fat
      varieties

Physical activity recommendations
* Limit total 'screen time' to 7-10 hour per week
* Be active in a variety of ways (e.g. play, transport, during chores,
  family activities)
* Aim for 30-minute physical activity per day

Table 5 Case study presenting how a mother of a six-year-old girl used
the family-focused child weight management program and the
anthropometric and lifestyle results 12 months after commencing the
program

                                    Achievements and progress since last
         Goals set by mother        phone call

Week 5   Reduce TV time, cease ice  Family discussion of goals. TV
           cream after swimming       reduction PAR (a) developed. Used
           lesson.                    TV guide to plan and enforce TV
                                      time. Healthy snack taken to
                                      swimming. Facilitated consistency
                                      by reminding children of the new
                                      TV rules.
Week 6   [down arrow]TV time,       No requests made for ice cream after
           [down arrow]food           swimming. Using TV guide to plan
           rewards, healthy after-    viewing is still working. Snacking
           school snacks and          PAR developed.
           [down arrow] after-
           school grazing.
Week 7   [down arrow]TV time, and   Children eating at the dinner table
           change type and amount     after school leading to less
           of after-school snacks.    grazing. Family role modelling
                                      [down arrow]TV by switching TV off
                                      during dinner.
Week 8   Weekend TV viewing,        Feels that set goals are being
           after-school snacking,     achieved, supported by children
           preparing for the          accepting rules and family
           school holidays,           planning changes. Notes decreased
           reviewing eight-week       dependence on TV and more
           progress.                  independent play in children.
                                      Notes after-school snacks are
                                      healthier and no grazing.
Week 12  Have only one choice for   Planning meals appropriate for all
           family dinners.            family. Dinner rules discussed.
                                      Using star chart. Consistently
                                      enforcing 'same dinner' rule
                                      despite tantrums. Answering
                                      child's questions about 'healthy
                                      eating'.
Week 16  Family dinners. Christmas  Christmas event PAR worked to limit
           events PAR.                'extras' at Santa visit. Updated
                                      school holidays PAR for summer and
                                      long break.
Week 20  All the family eating the  Active Christmas gifts. Enforcing
           same dinner. Reviewing     dinner rules. Ensuring child eats
           progress made in the       one item on dinner plate.
           last six months.           Achieving exposure to a variety of
                                      foods and family modelling. Proud
                                      of achievements and consistency
                                      over six months. PAR to plan and
                                      evaluate progress was invaluable.

Changes in anthropometrics and lifestyle behaviours 12 months after
  commencing the program
Increases in height (121-130 cm) and weight (34.3-37.5 kg) over 12
  months. Body mass index (BMI) decreased from 23.4 kg/[m.sup.2]
  (4.4 kg/[m.sup.2] above the 95th percentile for BMI-for-age) to
  22.3 kg/[m.sup.2](2.5 kg/[m.sup.2] above the 95th percentile for BMI-
  for-age), using the Centres for Disease Control and Prevention BMI
  percentile charts. There was no increase in waist circumference over
  12 months (74 cm).
Screen time reduced from 220 to 64 minutes/day, and the number of AGHE
  'extras' reduced from 6 to 2 per day.
Screen time assessed using parent-reported 20-item Child Activity
  Inventory. 'Extras' intake assessed using parent-reported 54-item
  Child Food Intake Questionnaire. Tools available from authors.

         New goals set by mother for the week/month ahead

Week 5   Extend TV PAR to apply to weekends, role model [down arrow]TV
           viewing. Dad to take children to swimming as a reward.
           Develop PAR to change type of after-school snacks.
Week 6   Address attitudes to amount of parental TV viewing,
           consistently enforce TV rules on weekends and with friends,
           implement after-school snacking PAR.
Week 7   Develop school holiday PAR. Be consistent with [down arrow]TV
           time. Continue to implement after-school snacks PAR.
Week 8   Eat a wider variety of healthy foods, parental consistency with
           [down arrow] TV time.
Week 12  Continue implementing dinner PAR.
Week 16  Implement school holiday PAR.
Week 20  Maintain new eating habits. Start child in a structured sport
           and parental role modelling of active lifestyle. Use PAR as
           new situations arise.

Changes in anthropometrics and lifestyle behaviours 12 months after
  commencing the program
Increases in height (121-130 cm) and weight (34.3-37.5 kg) over 12
  months. Body mass index (BMI) decreased from 23.4 kg/[m.sup.2]
  (4.4 kg/[m.sup.2] above the 95th percentile for BMI-for-age) to
  22.3 kg/[m.sup.2](2.5 kg/[m.sup.2] above the 95th percentile for BMI-
  for-age), using the Centres for Disease Control and Prevention BMI
  percentile charts. There was no increase in waist circumference over
  12 months (74 cm).
Screen time reduced from 220 to 64 minutes/day, and the number of AGHE
  'extras' reduced from 6 to 2 per day.
Screen time assessed using parent-reported 20-item Child Activity
  Inventory. 'Extras' intake assessed using parent-reported 54-item
  Child Food Intake Questionnaire. Tools available from authors.

(a) Planned Activities Routine (PAR)--see Table 3 for detailed example.