Parents as Agents of Lifestyle Change for Obese Children: A Call to Action

There is growing consensus that the environment in which the child lives, including the family, school, community and society at large, should be taken into consideration when developing effective childhood obesity prevention and treatment initiatives.¹ Families play a critical role in the development and maintenance of eating and activity behaviors in youth, and parents have considerable influence over what, when, where and how children eat. As parent involvement² and modeling of healthy behaviors³ have been identified as crucial components of effective interventions, most child weight control programs are family-based. Moreover, parent weight loss predicts child weight loss,⁴ suggesting that adult behavior change favorably affects child outcomes. Therefore, it is commendable that the AHA Scientific Statement systematically addresses the topic of parents and adult caregivers (PACs) as “agents of change” for treating obese children.

One goal of the Scientific Statement is to review core behavior change strategies used in family-based childhood obesity treatment programs. Behavioral weight control is based on the premise that the proximal mediators of body weight--eating and physical activity--are learned behaviors that can be modified by changing the environmental cues that precede them and the consequences that follow. Behavioral interventions are multi-faceted and incorporate sound information, diet, and physical activity, and teach a variety of skills to help individuals implement and sustain lifestyle changes. During the last several decades, obesity interventions have come to include a compendium of behavioral techniques that include, but are not limited to self-monitoring, goal setting, stimulus control, positive reinforcement, problem solving, social support, cognitive restructuring and relapse prevention (see^5-8 for reviews). Like evidence-supported programs for adults, childhood obesity treatment programs include the strategies summarized in the Statement, which represent the current state-of-the-art.

It is important to underscore, however, that there is wide variability in how the broad behavior change strategies included in the Statement can be implemented by PACs in real-world settings. For example, self-monitoring is the cornerstone of behavioral weight control, but accurately tracking food and beverage intake, amount consumed, and associated caloric content is a complex and sometimes daunting task for children and parents. Similarly, recording the type, intensity and duration of physical activity poses challenges, and more information is needed on adapting behavioral tools for use by families. It also is important to keep in mind that PACs’ efforts to facilitate child self-monitoring may take many forms. Not only can PACs provide direct assistance to children, but also they can establish a supportive home environment and serve as role models by recording their own behaviors. Within a single household, more than one PAC may be engaged as an agent of lifestyle change, and more than one child may be obese. Additionally, many children divide their time between households. Thus, many important questions remain regarding implementation of specific techniques by PACs, and the Scientific Statement begins to identify just some of the gaps in our knowledge base.

Although there has been general agreement that family involvement enhances the outcome of behavioral weight control programs targeting school-aged children,^9-11 the Statement notes that most research studies were not planned with the objective of examining the level of PAC involvement. Thus, the studies reviewed shed some light on whether greater PAC involvement and adherence are associated with better child weight loss, but do not address these issues directly. Therefore, readers should be cautious in evaluating the statement that the “balance of results from randomized clinical trials provides mixed support for the notion that greater PAC involvement leads to better child weight control.” Although we do not yet know the minimum threshold or best ways to engage PACs as agents of change, PAC involvement is key. Clearly there is a need for research studies specifically designed to test the mechanisms for child weight loss and to determine the optimal type and amount of PAC participation.

Although the issue of whether childhood obesity treatment will be equally effective without the child’s participation in intervention sessions is not directly evaluated in the Scientific Statement, some investigators have questioned whether childhood obesity interventions should target parents only.^12,13 Indeed, parenting programs have high potential to positively impact social, emotional and behavior problems in children.¹⁴ Parent-only treatments have been used for child behavioral issues such as tantrums, self-destructive behaviors, verbal aggression, excessive crying, thumb sucking, school phobia, and oppositional behavior.¹⁵ Parent-only interventions also have been utilized for child weight control¹³, and provide for more flexibility, and less burden and cost, relative to a model targeting both parents and children.^16,17 Golan and colleagues^18-20 showed that involving parents only was superior to targeting parents and children, whereas other studies have yielded comparable results for approaches that do and do not include children.^21-24 Overall, these data suggest that working exclusively with PACs yields child weight outcomes that may be equivalent to (or better than) interventions that include both PACs and children.

PAC-only childhood obesity interventions may be most appropriate for pre-school or younger school-aged children. There has been relatively little research on family-based treatment of obese children outside the age range of 8 to 12, but it stands to reason that it may be developmentally appropriate for older youth to assume primary responsibility for behavioral self-management than younger children. Child severity of obesity and weight-related health problems, household composition, family finances, motivation and other factors noted in the Statement may also play an important role.

The AHA Scientific Statement should serve as a call to action to mobilize PAC as agents of lifestyle change for obese children and stimulate novel work on this important topic. However, simply questioning whether greater parental involvement yields incremental benefits to children is of limited utility. Childhood obesity is treated in the context of the family, and it will be critical to initiate rigorous clinical studies to determine what kind of PAC involvement is most helpful to youth at different stages of development and with particular family characteristics. Obese children tend to have obese parents, and engaging PACs in childhood obesity treatment will likely confer health benefits to PACs as well. Future work ultimately may facilitate a paradigm shift where PACs are exclusively targeted for implementation of child weight management in some families.