Interventions for childhood overweight and obesity: a place for parenting skills.

(See the paper by Golley et al., pages 144-50)

Concern about levels of obesity (1) could almost be described as a current panic in child health in our community. After a period in which it seemed impossible to obtain funds for obesity research, particularly for projects looking at overweight and obesity in children, the subject is now 'hot'; it is hard to look at the media without a mention of the topic and gratifying to see funds available for both prevention approaches and intervention trials. There is still a long way to go for the answers to be in place, and a single approach may never be suitable for a multidimensional problem. (2) This emphasises the need for long-term support to promising interventions and to evaluate all strategies for effectiveness, reach and cost. (3)

The program for child weight management described by Golley et al. (4) embraces a number of useful approaches--a parent-led intervention alongside that of teaching general parenting skills with a focus on behaviours relevant to childhood overweight. For younger children, the approach of directing intervention strategies at parents with little or no direct child contact has been successful in achieving more impressive weight changes than a parallel program involving children along with parents; this was reflected in lower attrition rates and less negative consequences. (5) A model using a parenting skill training approach, targeting behaviours relevant to overweight, has shown promising effectiveness in families of Native American low socioeconomic status (SES) backgrounds, with children considered high risk assessed on maternal body mass index (BMI). The program was controlled against a general parenting skills program. (6) These approaches not only appeal because of the early signs of efficacy, but because of the benefits of offering parents strategies and skills which can be applied in other situations. Those who work regularly with parents share comments on the difficulties parents experience in application of advice--no doubt, a factor in the decision to include parenting in the intervention under discussion.

It is not just in the context of overweight and obesity that families relate their difficulties as 'I know what he should do, but how I can make him do it?' Many parents seeking advice for issues around children's eating report their awareness of the behaviour required but their inability to know how to effect change. (7)

As exploration of the contributors to the increases in overweight and obesity continues, and of the promising and less promising approaches, increasingly there is a need for parenting skills for the application of strategies. No single approach has provided the way to successful outcomes and probably will not, and some programs which seem useful at the time may turn out not to be so. (8,9) It is therefore particularly important that the approaches we try do no harm and may perhaps confer useful benefits in other arenas; even if not effective in making significant change in weight status, there may be supportive positive outcomes.

There has been ongoing interest in the relationship between hours of exposure to television and screen-based activities to child overweight and obesity. In a review of 31 possible early-life risk factors, (10) television viewing withstood the rigours of review and was identified as one of eight early-life risk factors associated with increased risk at seven years. The mechanism of television viewing on obesity is not clear (10) but usefully, reduction of television hours appears a promising intervention. (11) Interestingly, the effect on risk of obesity of a television set in the bedroom outweighs the impact of hours of TV alone. (12) In a study on TV in children's bedrooms, after controlling for SES, hours of reported viewing and physical activity, the children in the study, aged 9-12 years, were more likely to have a BMI >95th centile; the mechanism offers interesting possibilities. High amounts of TV have a number of negative outcomes other than that on weight--poor scholastic performance, poorer food choices and less sleep. (13,14) Hours of sleep has raised interest as a risk factor for overweight in childhood. Sleep duration at 30 months was found to be inversely related to overweight at seven years. (10) In a provocative paper on the plausible contributors to the rising obesity numbers, in addition to the Big Two, (15) the role of sleep debt was examined; in both children and adults, there is an inverse relationship in cross-sectional and longitudinal studies. There are a number of hypotheses for the mechanism, but data do indicate that the average amount of sleep has steadily decreased over several decades. In considering the limiting of TV access, there are possible positive outcomes from increased social interaction and better academic achievement. (15) Parents report difficulties in limiting TV access, and difficulties with sleep and bedtime ring true among practitioners in the area of childhood overweight and obesity, so assistance with a parenting approach may be helpful here.

Using snacking practices as the setting, Ogden et al. discuss the complexity of parental control over children's eating and the ways in which differing approaches to parental control are reflected in intake of differing foods. (16) The discussion goes some way to shed light on the way in which parental body weight is influential on a child's weight, and the apparent confusion in the literature around the effects of parental attitudes and control of a child's eating environment on long-term eating behaviours.

It has been observed that children 'no longer play'; this is suggested as a serious issue with consequences well beyond the impact on obesity. (17) Play is an important aspect of children's emotional, social and cognitive development--it fosters attention skills, social interaction and connection, is sometimes described as offering the first practice in negotiation, and can offer happiness and mood enhancement. Conveying the message about the importance of play must sometimes be directly conveyed to parents, who, for various reasons, sometimes limit a child's access to play and particularly to the special benefits of outdoor play. Some of the barriers to play may of course be beyond parents, and need community and environmental support. In efforts to encourage play, the messages should be around the traditional benefits of joy and fun, rather than simply on energy expenditure.

With all this emphasis on overweight and obesity, let us remember that children have many needs in life--both those children who are overweight and the majority of children (fortunately, still a majority) who are not. All children need play and creative opportunities, to have fun, adequate sleep, to enjoy the benefits of good nutrition on wellbeing, and to enjoy eating simply because it is a pleasure.

Too often a family's ability to effect change is blocked by a defensive stance, because parents feel blamed or held accountable for their child's overweight or obesity, or impacted by a previously unsuccessful try at making change. Being able to offer a practical support which offers general benefits would be helpful, outside any association of 'bad parenting'. There are numbers of behavioural links where parenting skills would offer flow-on benefits; perhaps offering anticipatory parenting assistance is something our community could offer or encourage for all parents.

Kay Gibbons, FDAA 

Manager Nutrition Services, Royal Children's Hospital 

Melbourne

REFERENCES

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