Julia Clark

It's a balance of just getting things right: mothers' views about pre-school childhood obesity and obesity prevention in Scotland

BackgroundThe high prevalence of childhood obesity is a concern for policy makers and health professionals, leading to a focus on early prevention. The beliefs and perspectives of parents about early childhood obesity, and their views and opinions about the need for weight management interventions for this age group are poorly understood.MethodsA formative qualitative focus group study with parents of pre-school children took place in eight community-based locations throughout North-East Scotland to explore their ideas about the causes of early childhood obesity, personal experiences of effective weight management strategies, and views about the format and content of a possible child-orientated weight management programme. Study participants were recruited via pre-school nurseries.ResultsThirty-four mothers (median age 37 years) took part in the study, but only two believed their child had a weight problem. Participants (who focussed primarily on dietary issues) expressed a strong sense of personal responsibility to ‘get the balance right’ regarding their child’s weight, and were generally resistant to the idea of attending a weight management programme aimed at very young children. At the same time, they described a range of challenges to their weight management intentions. These included dealing with intrinsic uncertainties such as knowing when to stop ‘demand feeding’ for weight gain, and judging appropriate portion sizes - for themselves and their children. In addition they faced a range of extrinsic challenges associated with complex family life, i.e. catering to differing family members dietary needs, food preferences, practices and values, and keeping their ‘family food rules’ (associated with weight management) when tired or pressed for time.ConclusionsThe findings have important implications for health professionals and policy makers wishing to engage with parents on this issue, or who are currently developing ‘family-centred’ early childhood weight management interventions. The challenge lies in the fact that mothers believe themselves to be the primary (and capable) agents of obesity prevention in the early years – but, who are at the same time, attempting to deal with many mixed and conflicting messages and pressures emanating from their social and cultural environments that may be undermining their weight management intentions.

Development and piloting of a food-based intervention to increase vitamin E intake in pregnant women in a randomized controlled trial

Abstract Low maternal vitamin E intake during pregnancy is associated with childhood asthma and a trial is required to test whether increasing maternal vitamin E intake reduces childhood asthma. This study investigated whether such a trial is possible using food to increase vitamin E intake. Three soup varieties with enhanced vitamin E content (16–19 mg/can) from food ingredients were developed. Near identical retail versions (vitamin E 1–4 mg/can) acted as placebo. In a pilot double‐blind randomized controlled trial, pregnant women were randomized 1:1 to enhanced or placebo soups (three tins/week) from 12 weeks gestation to delivery. Vitamin E intake was quantified at 12, 20, and 34 weeks gestation. Qualitative interviews were conducted. 59 women were randomized (29 enhanced, 30 placebo), 28 completed the trial, (15 enhanced, 13 placebo). In women completing the trial, vitamin E intake of the placebo group remained unchanged; 7.09 mg/d (95% CI 5.41–8.77) at 12 weeks, 6.41 mg/d (5.07–7.75) at 20 weeks, and 6.67 mg/d (5.38–7.96) at 34 weeks gestation; vitamin E intake of the enhanced group increased from 6.50 mg/d (5.21–7.79) at 12 weeks to 14.9 mg/d (13.3–16.4) at 20 weeks and 15.2 mg/d (12.9–17.5) at 34 weeks, P < 0.001. Qualitative interviewing provided clear guidance on improving adherence. Although 31 women withdrew at median 19 weeks gestation (interquartile range 16–25), the intervention was consumed by women for 80% of weeks between 12 and 34 weeks gestation and for 63% of weeks between 12 weeks gestation and delivery. In a pilot double‐blind randomized controlled trial (RCT) it is possible to increase maternal vitamin E intake using food ingredients, a further food product is required to improve adherence.

A formative study exploring parents' and health visitor's perspectives of the relevance and acceptability of weight management programmes targeting preschool children in Grampian, Scotland

The UK Child Health Surveillance Programme (CHSP) reported that 8.6% of children born in Scotland in 2001 were obese (BMIP95th centile of the UK 1990 reference data) at 3.5 years of age compared to 7.9% of those born in 1995. There is growing policy maker and health professional interest in preschool weight management interventions to halt or reverse this trend. In 2012, NHS Grampian commissioned formative research to inform the development of a pre-school weight management intervention planned for the region. Qualitative research was conducted with parents of pre-school aged children and health visitors (as the group of health professionals considered best placed to deliver such a programme) to explore their respective views and perceptions about the problem of obesity and overweight in this age group, and, the acceptability and feasibility of possible interventions. This paper presents the results of research which explored these issues with 34 parents and 15 health visitors based in the north-east of Scotland. The study took place between May 2012 and February 2013. Parents of preschool aged children were recruited by invitation through preschool nurseries, and health visitors were invited to participate through the community nursing service. Ethical approval was sought from and granted by the North of Scotland Research Ethics Committee. Nine focus groups were held with parents preschool children. The health visitors took part in individual in depth telephone interviews. Both the focus groups and interviews lasted between 45–90 mins, were audio-recorded, transcribed verbatim and analysed thematically. The research has revealed a rich picture of the variety of sources of information parents and healthy visitors use to make judgements about a pre-school age child’s weight status, and the large areas of overlap and divergence that exist in those different perspectives. It also reveals interesting insights regarding parents’ and health visitors’ perspectives about the legitimacy and relevance of growth centile reference data and BMI charts in the context of ‘real world’ circumstances for this age group, and, the general resistance that exists amongst parents to the idea of programmes or health professional interventions targeting them about this issue. Despite parents’ questioning of the relevance of a weight management programme for their preschool children, parents in this study described dealing with many significant challenges and pressures both within and from outside the family environment, as they struggle to ‘get the balance right’ in raising a healthy weight child. Furthermore, all parents who took part in this study expressed concern about their child’s weight in the future. In particular parents described struggling with aspects of weaning and infant feeding.(e.g. deciding on portion size and over feeding), dealing with different perspectives within their families about appropriate foods and portion sizes for their children, managing different dietary preferences and energy requirements at family mealtimes and ‘sticking to the healthy eating rules’ when tired or feeling time pressured. This research also suggests that the development of (separate) visually-based resources for parents and health visitors, both to help assess a child’s weight status may assist with problem recognition, and to depict age appropriate portion size for toddlers and infant, could be useful adjuncts to programmes intended for parents of children in this age group, and for health visitors attempting to work with parents in this area.

Focus group discussions to inform the design of a weight loss programme suitable for overweight and obese women treated for breast cancer

Women who are overweight or obese at the time of breast cancer diagnosis and/or who gain weight after diagnosis are at higher risk for adverse clinical outcomes. Therefore, improving the quality of life and reducing the risk of recurrence for this population group has become very important. Only a few interventions have been conducted targeting weight loss for women already treated for breast cancer. The present study used qualitative research to inform the design of a weight loss intervention for women treated for breast cancer. As part of the development of the intervention, 15 women were recruited from a local female cancer support charity, who had previously undergone treatment for breast cancer. Three focus group discussions were held, led by a dietitian (JC) in a local cancer support centre. Topics addressed in the focus groups included post diagnosis weight issues, eating and exercise patterns, barriers to maintaining a healthy weight, and their past experience of and future preferences for a weight loss programme. All meetings were recorded and transcribed verbatim by a trained typist. The data was analysed using Framework analysis. The protocol was approved by the North of Scotland Research Ethics Committee. Analysis of the data revealed that majority of the women had put on weight during their treatment and/or post treatment. The most commonly reported causes for their weight gain were lifestyle changes, side-effects of treatments and the menopause, though some women thought it was difficult to isolate the cause of their weight gain. Although a number of women had tried different diets and joined various health clubs and slimming clubs, they discussed a number of barriers towards weight loss including lack of energy and selfesteem, lack of knowledge and self-motivation, lack of guidance from health professionals and disability due to arm, hip and muscle pain. But many would have liked to join a weight loss programme to improve their self-confidence. Their preference was for a programme delivered three to six months after completion of hospital treatment either in a group of women treated for breast cancer or one-to-one sessions followed by a small group. They would have liked this programme to be delivered in a non-clinical setting e.g. a cancer support centre or a community centre. Their preference was for gentle exercises such as slow dance with music, yoga, walking, swimming and also any healthy dietary advice which would stop the cancer recurring. The findings from these focus group discussions, along with results from a questionnaire survey in a larger more representative sample informed from these discussions, will aid in the design of a weight loss intervention suitable for women treated for breast cancer.

Evaluation of NHS Grampian's child healthy weight programmes: Engagement and impact

Participating parents and children were generally positive about the programmes, but also identified a range of modifications that they felt would improve effectiveness and encourage more families to engage. The personal characteristics and attributes of staff delivering the programme emerged as crucial factors regarding engagement and satisfaction with the programme. The main barrier to engagement identified by parents and health professionals was associated with notions of parents failing to acknowledge or accept that their children had been assessed as overweight. This view was particularly evident amongst parents whose child’s BMI was just above the cut-off point for overweight. There was also some evident confusion amongst parents about children’s BMI classification. Some parents also believed there was a general lack of knowledge about the programmes within their school community. Both issues might explain the lack of engagement amongst some families with overweight children. Some staff were anxious about raising the issue with parents, while other more experienced staff, who believed they had good existing relationships with the families concerned, were less anxious about it. It was not possible to ascertain whether dietary or physical activity changes claimed by parents or children, as a result of the programmes, had actually occurred. Moreover, many staff members expressed doubt that families would be able to sustain any changes in the longer term without further support from a professional. Given current concern over childhood weight trends, this research provides insights into the experiences and views of parents, children and health professionals involved with child healthy weight programmes, and identified possible improvements for existing programmes in Grampian. However, it also suggests that the problem of childhood obesity is not perceived by many parents in the same way as policy makers or health professionals, and further research is required to understand their perspectives in more depth.

A survey to inform the design of a weight loss programme for overweight and obese women treated for breast cancer

Overweight or obesity is an established negative prognostic factor for a poorer outcome in patients treated for breast cancer. The average weight gains during treatment usually range from 2.5–6.2 kg. As part of a programme of work to design a weight loss intervention for women treated for breast cancer, a survey was conducted targeting this population of interest, to determine their attitudes, beliefs and future preferences for a programme for its successful design and implementation. The questionnaire was developed following on from focus group discussions and re-drafted following pre-testing with seven women using the ‘think-aloud’ technique. The survey was conducted (April–June 2011) with women attending follow-up appointments in the outpatient breast clinic at the Aberdeen Royal Infirmary (ARI). An invitation letter was posted out two weeks prior to their clinic appointments, along with a consent form and a study information sheet. The women were then approached in the clinic by the researchers who discussed the study, measured height and weight and gave out the questionnaire with a stamped addressed envelope for return. A reminder was sent to all non-responders after 2 weeks. A subsample of the women who returned the questionnaires were also interviewed (telephone or face-to-face) to explore their views in further depth. The interview sample was selected depending on their responses to the questionnaire and their socio-demographic characteristics to provide a broad range of views and sample size was determined by reaching saturation in the responses. The survey achieved a good response rate (128/138, 93%). Most of the respondents were either overweight (n = 50, 38.8%) or obese (n = 34, 26.4%). The majority (n = 110, 85%) had never received any information from any health professionals on ‘how to maintain a healthy weight’ since diagnosis but they would have liked to receive it (n = 58, 45%) either straight away (48%) or within 3 months (26%) of their initial treatment (surgery, chemotherapy and radiotherapy). The preference for receiving any information varied by BMI category (69% obese vs 47% overweight, p = 0.006). Those who wanted information would have preferred to receive it in a hospital setting (41%), at a cancer support centre (38%) or GP surgery (38%) either one-to-one (63.8%) and/or in a group setting (48.3%). Among women who would have liked to do more physical activity (n = 52, 40.3%) following their initial treatment, 48% would have preferred to do this in a group of other women with breast cancer, 42% in a group of any women and 58% preferred on their own. Moreover, 50% and 37% would have liked to attend a group session once a week or twice a week respectively. The most popular physical activities were walking (85%), swimming (39%), yoga (37%) and pilates (37%). The interview data revealed a preference for a supervised weight loss programme (incorporating both diet and physical activities) for at least three months in a group setting, preferably delivered by a dietitian, with different learning and interactive sessions, and some encouragement and guidance for physical activity specific to their needs. There were mixed feelings about being regularly weighed and whether this should be done in the group or in private. Some women would have liked to involve their partners in the programme. These findings will be used in the design of a weight loss programme suitable for women treated for breast cancer.

Views of parents on routine measurements of children’s growth in schools

In England, as part of the NCMP, every year children in reception (4–5 years old) and year 6 (10–11 years old) are weighed and measured and parents receive their child’s results, regardless of their weight status, unless they request otherwise. In Scotland, all NHS Boards provide a Child Health Surveillance Programme (4) , where all children are routinely offered a health check on entry to primary school including height and weight measurements. These data are used to produce national obesity statistics. However, unlike England these measurements are not routinely fed back to parents. The aim of the present study was to elicit the views of parents in Grampian, Scotland on providing results of children’s height and weight measurements in primary school. Twenty-one schools in Grampian distributed study information to parents of Primary 2 children. Consent was implied by the completion and return of a short questionnaire. Parents were also invited to participate in focus groups to explore opinions in greater depth and seek views on a range of feedback information formats. Six hundred and thirty questionnaires were distributed and 153 (24 %) returned. Sixty five percent of parents felt that all children should have their growth measured in school; 23 % felt it should only be done if parents agree and 7 % only if a health professional thought that there was a problem. Only 3 % felt children’s growth should not be measured in school. Eighty eight percent of parents felt that growth measurements in schools should be carried out only by a health professional. Seventy-three percent felt it would be useful for written results to be given to all parents; 23 % felt that written results should only be provided if the child was overweight or underweight and 3 % felt it would not be useful for parents to receive written information. Fiftyfour percent felt that the information provided should include a chart for parents to monitor growth in the future; over 70 % felt there should be a statement on whether the child’s height or weight were in the normal range and over 80 % felt that advice on what to do if the child’s height or weight were not within the normal range and the opportunity to discuss results with a health professional should be available. Initial results from focus groups suggested that parents thought that receiving feedback would be useful but there were some concerns over the sensitivity of the topic and they would like a named contact for further information. There were mixed opinions on mentioning health risks in feedback information and also on whether or not to include a simplified colour-coded BMI chart. However, parents felt it would be useful to include tips for changing behaviour and discussing the subject with the child. The majority of parents in this sample thought that children’s growth should be measured in school by a health professional with written information and further advice fed back to parents, along with the opportunity to discuss the results with a health professional. Further focus groups are in progress to obtain a more representative cross-section of parents’ views.