The "Stages Towards Completion Model": what helps and hinders children with overweight or obesity and their parents to be guided towards, adhere to and complete a group lifestyle intervention

Stakeholder views of behavioral interventions for children and adolescents with obesity: Mega-ethnography of qualitative syntheses

BACKGROUND

The prevalence of overweight and obesity among children and adolescents is rising and is a recognized global health problem. This overview of reviews explored the views of children, adolescents, and parents/caregivers regarding behavioral interventions for obesity management.

METHODS

Eleven electronic databases were searched to identify reviews of qualitative research regarding the views of children or adolescents with obesity, and their caregivers, concerning behavioral interventions for obesity. Synthesis was performed using a mega-ethnography approach.

RESULTS

Eleven reviews were included. Factors associated with feasibility, acceptability, and equity were identified that influenced decisions to engage with these interventions. Children and adolescents with obesity can be encouraged to engage and participate in behavioral interventions if there is a positive environment, free from stigma; have the necessary resources needed to fully engage in the intervention; are taught holistic, practical skills that allow for long-term lifestyle change, not just short-term weight loss; and are provided with activities likely to be perceived as fun and enjoyable. Interventions are more acceptable to the child/adolescent when parents and families are able to engage with them.

CONCLUSION

Practitioners can improve engagement with behavioral interventions for obesity management for children/adolescents if they are aware of specific motivating factors.

Healthcare professionals' perspectives on the barriers and facilitators of integrated childhood obesity care

BACKGROUND

Both the causes and consequences of childhood obesity can be complex. To provide healthcare that is suitably tailored to the specific needs of children with obesity integrated care is required. The objective of this study was to explore the perceived barriers and facilitators of healthcare professionals (HCPs) in providing integrated care for children with obesity, to support them in tailoring the healthcare approach.

METHODS

In this qualitative study, semi-structured in-depth interviews were conducted with 18 healthcare professionals with experience in childhood obesity care; pediatricians, youth healthcare nurses and a youth healthcare physician. A two-phased thematic content analysis was performed: an inductive analysis with open and selective coding and a deductive analysis with axial coding using the patient-centered care model by Stewart.

RESULTS

Overall, the healthcare professionals defined the etiology of obesity as complex, and experienced the integrated care as complicated. The results fit into the four theme-structure of the patient-centered care model, with the integrated care system as an additional fifth theme. The main barriers were perceived within the sub-themes of illness and healthcare experiences, and sensitivity over talking about weight-related issues. The main facilitators were perceived within the sub-themes of conducting a biomedical, psychosocial and lifestyle assessment, tailoring the approach to families' situation and investing in a family-professional relationship. Weight stigma appeared to be an underlying barrier for healthcare professionals that impacted, both explicitly and implicitly, upon all themes.

CONCLUSIONS

Healthcare professionals providing integrated care for children with obesity, experience this type of care as complicated and comprising many barriers and facilitators regarding the four themes of the patient-centered care model and the fifth theme of the integrated care system. This paper demonstrates the patient-centered care model could prove helpful structuring a tailored approach within integrated care. This approach supports healthcare professionals in adopting a broad perspective towards individual and environmental factors and investing in the relationship, with respect to the sensitivity and complexity of childhood obesity.

Understanding parental perspectives on young children's oral health (≤ 4 years) growing up in a disadvantaged neighbourhood of Amsterdam, the Netherlands: an exploratory study

BACKGROUND

Families' understanding towards oral health problems among young children is poorly studied. More insight into parents' experiences, especially of those living in disadvantaged neighbourhoods, is needed to address persistent oral health inequalities. This qualitative study aims to explore parental perspectives on children's oral health (≤ 4 years) and the opportunities they see to improve children's oral health.

METHODS

Forty-seven mothers and five fathers with different migration backgrounds from a disadvantaged neighbourhood in Amsterdam, the Netherlands, participated in our study. Semi-structured interviews (n = 27), participant observations (n = 7) and one focus group discussion were conducted. A thematic data analysis was used.

RESULTS

Parents describe their daily life with young children as busy, hectic and unpredictable. Parents seem to be most concerned about parenting. Mothers, in particular, feel fully responsible for raising their children and managing daily complexities. While most parents value their children's oral health, they all experience challenges. Parents find it hard to limit daily candy intake and to handle unwilling children during tooth brushing. They feel limited support for these issues from their household, social network and professionals.

CONCLUSION

Parental struggles in children's oral health are complex and interrelated as they occur across family, societal, community and professional levels. Given the complex daily reality of families with young children, establishing and maintaining healthy oral health habits seems not at the top of parents' minds. They ask for advice in the upbringing of their children backed up by social support, increased attention to children's oral health within the community and professional assistance. Collaborating with parents as knowledgeable partners might be the first step in acting upon the endeavour to address oral health inequality among young children.

Development of a checklist to assess potentially effective components in combined lifestyle interventions for children with overweight or obesity

BACKGROUND

In the Netherlands, Combined Lifestyle Interventions (CLIs), offered in primary care, aim to reduce the number of children with overweight or obesity. CLIs are carried out by a multidisciplinary team and focus on dietary advice and guidance, exercise and behaviour change. These CLIs are not uniformly designed and vary in protocols to suit the local circumstances. Due to the variation in content of CLIs it is difficult to investigate their effectiveness. To enable a proper evaluation of CLIs, we first need to unravel the 'black boxes' of CLIs by identifying the various potentially effective components.

METHODS

First of all we identified potentially effective components in literature. Subsequently we organized an online consultation with experts with diverse backgrounds and asked if they could add potentially effective components. These components were then assembled into a checklist meant to determine the presence or absence of potentially effective components in CLIs for children.

RESULTS

42 experts participated. We identified 65 potentially effective components for CLIs for children with overweight or obesity that we categorized into three themes: content, organisation and implementation.

CONCLUSIONS

Based on literature and expert opinions we developed a practical 65-item checklist to determine the presence of potentially effective components in a CLI. This checklist can be used in the development of CLIs as well as evaluation of CLIs.

The development of the Dutch "National model integrated care for childhood overweight and obesity"

BACKGROUND

Childhood obesity is a chronic disease with negative physical and psychosocial health consequences. To manage childhood overweight and obesity, integrated care as part of an integrated approach is needed. To realise implementation of this integrated care, practical guidance for policy and practice is needed. The aim of this study is to describe the development of a Dutch national model of integrated care for childhood overweight and obesity and accompanying materials for policy and practice.

METHODS

The development of the national model was led by a university-based team in collaboration with eight selected Dutch municipalities who were responsible for the local realisation of the integrated care and with frequent input from other stakeholders. Learning communities were organised to exchange knowledge, experiences and tools between the participating municipalities.

RESULTS

The developed national model describes the vision, process, partners and finance of the integrated care. It sets out a structure that provides a basis for local integrated care that should facilitate support and care for children with overweight or obesity and their families. The accompanying materials are divided into materials for policymakers to support local realisation of the integrated care and materials for healthcare professionals to support them in delivering the needed support and care.

CONCLUSIONS

The developed national model and accompanying materials can contribute to improvement of support and care for children with overweight or obesity and their families, and thereby help improve the health, quality of life and societal participation of these children. Further implementation of the evidence- and practice-based integrated care while evaluating on the way is needed.

Perceived barriers in family-based behavioural treatment of paediatric obesity - Results from the FABO study

BACKGROUND

To date, few studies have investigated perceived barriers among those who participate in and drop out of family-based behavioural treatment (FBT) for paediatric obesity. Examining experienced barriers during treatment, and their role in participation and completion of treatment has important implications for clinical practice.

OBJECTIVES

To compare perceived barriers to participating in a family-based behavioural social facilitation treatment (FBSFT) for obesity among families who completed and did not complete treatment.

METHODS

Data were analysed from 90 families of children and adolescents (mean (M) age = 12.8 years, standard deviation (SD) = 3.05) with severe obesity enrolled in a 17-session FBSFT program. After completing 12 sessions or at the time of dropout, parents and therapists completed the Barriers to Treatment Participation Scale (BTPS), a 5-point Likert scale (1 = never a problem, 5 = very often a problem) which includes four subscales: 1. Stressors and obstacles that compete with treatment, 2. Treatment demands and issues, 3. Perceived relevance of treatment, 4. Relationship with the therapist.

RESULTS

Families who did not complete treatment scored significantly higher on the BTPS subscales stressors and obstacles that compete with treatment (M = 2.03, SD = 0.53 vs. M = 1.70, SD = 0.42), p = 0.010 and perceived relevance of treatment (M = 2.27, SD = 0.48 vs. M = 1.80, SD = 0.50), p < 0.001 than families who completed treatment. No other significant differences between groups were observed.

CONCLUSION

Families are more likely to drop out of FBSFT when experiencing a high burden from life stressors or when treatment is not meeting the expectations and perceived needs of the family.

Perspectives of healthcare professionals on facilitators, barriers and needs in children with obesity and their parents in achieving a healthier lifestyle

Objective

To explore the perspectives of healthcare professionals (HCPs) within an integrated care approach on the facilitators, barriers and needs in children with obesity and their parents in achieving a healthier lifestyle.

Methods

Semi-structured interviews were conducted with eighteen HCPs working within a Dutch integrated care approach. The interviews were analyzed by performing a thematic content analysis.

Results

Main facilitators identified by HCPs were support from parents and the social network. Main barriers were first and foremost family's lack of motivation, which was singled out as a precondition for starting the behavior change process. Other barriers were child's socio-emotional problems, parental personal problems, lack of parenting skills, parental lack of knowledge and skills regarding a healthier lifestyle, parental lack of problem awareness and HCP's negative attitude. To overcome these barriers, main needs that HCPs suggested were a tailored approach in healthcare and a supportive HCP.

Conclusion

The HCPs identified the breadth and complexity of underlying factors of childhood obesity, of which the family's motivation was pointed out as a critical factor to address.

Innovation

Understanding the patient's perspective is important for HCPs to provide the tailored care needed to address the complexity of childhood obesity.

Stakeholder views of services for children and adolescents with obesity: Mega-ethnography of qualitative syntheses

OBJECTIVE

The efficacy of services for children and adolescents with obesity is well researched, but this review describes what actually matters to stakeholders (children, caregivers, and professionals) in relation to such services.

METHODS

A mega-ethnography, an innovative review-of-reviews approach that uses conceptual findings as primary data, was performed. Twelve bibliographic databases (2010-2020) were searched for reviews that considered the values and preferences of stakeholders concerning services or interventions (diet, exercise, lifestyle) that targeted children and adolescents with obesity.

RESULTS

From 485 citations, 17 relevant reviews were identified. The synthesis found that the perceived need to address obesity is determined by subjective norms of weight and interactions with health professionals. Children's and caregivers' participation in obesity management services is shaped by their response to content, acceptability, and perceived benefits and demands. Whether they continue with and complete an intervention are determined by its perceived success, beyond just weight loss, including behavior change, enhanced self-esteem, and the provision of timely and relevant support.

CONCLUSIONS

Obesity management services must be promoted in a sensitive manner and must be tailored, be varied, and make positive use of family and schools if children and caregivers are to seek and actively engage with them.

Determinants of dropout and compliance of children participating in a multidisciplinary intervention programme for overweight and obesity in socially deprived areas

BACKGROUND

Children with overweight and obesity in socially deprived areas (SDAs) are less likely to complete and be compliant to a weight-loss programme.

OBJECTIVES

To identify factors associated with dropout and compliance of a multidisciplinary weight-loss programme in SDA.

METHODS

This prospective longitudinal cohort study included children (6-12 years) with overweight and obesity in a 12-week multidisciplinary intervention living in SDA in Rotterdam, the Netherlands. Potential predictive variables for dropout and compliance included were age, sex, the weight of the child and parents, quality of life, and referral status (self-registration or referral). A Cox proportional hazards model was performed to study the association between dropout and its potential predictive variables, whereas logistic regression analyses were used for the potential predictors for compliance.

RESULTS

A total of 121 children started the intervention programme. Forty-one (33.9%) children dropped out and 68 (56.2%) were compliant with the intervention. The risk of dropping out of the intervention was significantly lower for a child with overweight parents than for those with parents with normal weight (adjusted hazard ratio [HR] 0.22 [95% confidence interval, CI 0.063-0.75]), and for those with parents with obesity (adjusted HR 0.18 [95% CI 0.060-0.52]). No other potential predictive variables were associated with dropout or compliance.

CONCLUSION

Children from SDA participating in a weight-loss programme have a relatively high dropout and a low compliance rate. Parental weight seems to be an important predictor for dropout of children from SDA, where children with normal weight or obese parents have the highest risk of dropout compared with children of overweight parents.

Parents' and Children's Experiences with a Coordinating Professional in Integrated Care for Childhood Overweight and Obesity-A Novel Dutch Approach

Background: In the new integrated program of care for childhood overweight and obesity (ICCO), a Youth Health Care (YHC) nurse has the role of a coordinating professional. After a broad assessment of strengths and weaknesses in the family setting, this coordinating professional makes a plan of action with the child and parents and involves other professionals when needed. The aim of this study was to explore the experiences of parents and children with the coordinating professional in the ICCO. Material & Methods: Semi-structured interviews were conducted with eight families. Interview data were analyzed using content analysis. In addition, descriptive data on involved professionals and referrals was collected with an online questionnaire in 38 families. Results: In total, eight families (8 mothers, 2 fathers, four boys and three girls aged 10–12 yrs) were interviewed and 38 children and parents filled in (three consecutive) online questionnaires. Findings: The main themes related to the experiences of parents and children with the CP: parents and children felt supported and understood by the coordinating professional. They appreciated the broad perspective and personal approach. Contacts with the coordinating professional were not always frequent. Major points of improvement concerned the intensity of the follow-up and collaboration. Only few parents experienced collaboration between the coordinating professional and other professionals in the ICCO. Conclusions: Parents and children appreciated the personal approach of the Youth Health Care nurse as a CP. The role of the coordinating professional, however, appears not fully implemented yet. Strengthening the promising role of the coordinating professional in the ICCO is recommended.

The Side-Effects of the COVID-19 Pandemic: Increased BMI z-Score in Children with Overweight and Obesity in a Personalised Lifestyle Intervention One Year after the Start of the Pandemic in The Netherlands

Background: Early research showed weight gain in children during the COVID-19 pandemic. Objective: To compare changes in BMI z-score of children with overweight and obesity in a personalised lifestyle intervention before and during the pandemic. Methods: Changes in BMI z-score half a year (T6) and twelve months (T12) after the first lockdown were included for 71 children in the ‘2020 during COVID’ group and compared to 48 children in the ‘2019 before COVID’ group, using a marginal model for repeated measures (model 1). Model 2 corrected for lifestyle intervention characteristics, and model 3 corrected additionally for family characteristics. Results: The mean difference in BMI z-score change was significantly different at T12 (+0.07 in 2020 versus −0.09 in 2019, p = 0.022). Model 3 showed significant differences in BMI z-score change at both T6 (+0.15, p = 0.024) and T12 (+0.18, p = 0.016). This model also defined ‘having a mother with obesity’ (+0.13, p = 0.019) and the frequency of no-show consultations (+0.41 per missed consultation per month, p = 0.025) as related factors. Conclusions: Lifestyle intervention in children with overweight and obesity is less successful in decreasing BMI z-score during the COVID-pandemic. Identified risk factors for less success could contribute to identifying children with higher risks for, and possibly prevent, BMI z-score increase.

Integrating Cognitive Developmental Neuroscience in Society: Lessons Learned From a Multidisciplinary Research Project on Education and Social Safety of Youth

Integrating fundamental science in society, with the goal to translate research findings to daily practice, comes with certain challenges. Successfully integrating research projects into society requires (1) good collaboration between scientists and societal stakeholders, (2) collaboration partners with common expectations and goals, and (3) investment in clear communication. Here we describe an integrative research project conducted by a large Dutch consortium that consisted of neuroscientists, psychologists, sociologists, ethicists, teachers, health care professionals and policy makers, focusing on applying cognitive developmental neuroscience for the benefit of youth in education and social safety. We argue that to effectively integrate cognitive developmental neuroscience in society, (1) it is necessary to invest in a well-functioning, diverse and multidisciplinary team involving societal stakeholders and youth themselves from the start of the project. This aids to build a so-called productive interactive network that increases the chances to realize societal impact in the long-term. Additionally, we propose that to integrate knowledge, (2) a different than standard research approach should be taken. When focusing on integration, the ultimate goal of research is not solely to understand the world better, but also to intervene with real-life situations, such as education or (forensic) youth care. To accomplish this goal, we propose an approach in which integration is not only started after the research has been conducted, but taken into account throughout the entire project. This approach helps to create common expectations and goals between different stakeholders. Finally, we argue that (3) dedicating sufficient resources to effective communication, both within the consortium and between scientists and society, greatly benefits the integration of cognitive developmental neuroscience in society.

Behavioral Weight Loss Intervention Preferences of Adolescents with Overweight/Obesity

Background: Behavioral lifestyle interventions are the foundation of adolescent obesity treatment. Tailoring an intervention using adolescent stakeholder engagement during the development process could improve intervention effectiveness. Methods: Adolescents with overweight/obesity ages 14-19 (n = 41) participated in 11 sex-specific focus groups (girls = 6, boys = 5) and were asked their preferences regarding who should lead the intervention and be involved, what the messaging of the program should be, how to make the program engaging and maintain participation, and how to best measure nutrition intake and activity. Transcripts were coded and analyzed for emergent themes. Results: Mean age was 16.0 ± 1.8 years and participants were racially/ethnically diverse. Adolescents preferred interventions that avoid a focus on "weight loss," and instead emphasize "healthy lifestyle," which represents a more comprehensive goal of targeting physical and mental well-being. Most participants indicated preferences for a relatable instructor with prior weight loss experience. Both sexes preferred optional parental involvement, as some parents were described as helpful, while others were perceived as a hindrance to success. Boys and girls identified incentives, engaging activities, and electronic communication as core components for engagement and retention, with girls emphasizing socialization and building relationships. Sex differences in preferences were observed. Girls had more concerns about intervention participation and preferred interventions to be sex stratified. Conclusions: Behavioral interventions to treat adolescent obesity should focus messaging/content on healthy lifestyles, rather than weight loss, and be sex stratified. Development and implementation of future behavioral interventions for adolescent obesity should consider tailoring to adolescent preferences when possible to improve feasibility, acceptability, and effectiveness.

Contextual Complexities in Implementing a Family-Based Childhood Obesity Intervention: The Perspectives of Enrolled Children and Their Parents

Family interventions to treat childhood obesity are widely used, but knowledge about how family dynamics are affected by these interventions is lacking. The present study aims to understand how a family intervention impacts the context of family dynamics, and how different contexts affect the families’ implementation of the intervention. Based on qualitative interviews, we studied families with a child between 9–12 years enrolled in a family intervention to treat childhood obesity at a pediatric outpatient clinic. We conducted 15 family interviews including 36 family members. We found that the family intervention created a new context for the enrolled children. They had to navigate in different contexts and non-supportive environments and push for change if they needed more supportive environments in their attempt to adhere to healthy habits. We show the complexities experienced by parents and grandparents when trying to comply with siblings’ and/or grandchildren’s different needs. The enrolled children were often indirectly blamed if others had to refrain from unhealthy preferences to create supportive environments. These findings are significant in understanding the important role of contexts in family-obesity interventions. This knowledge is relevant to health professionals, researchers, and policymakers.

Perceived barriers/facilitators to a healthy lifestyle among diverse adolescents with overweight/obesity: A qualitative study

Objective

Effectiveness of behavioural obesity treatments in adolescents is modest. Thus, incorporating participant feedback may lead to improvement of intervention acceptability. This qualitative study's objective was to assess perceived barriers/facilitators to weight loss and healthy lifestyles among diverse adolescents with overweight/obesity (OW/OB).

Methods

Adolescents ages 14-19 with BMI ≥ 85th percentile participated in focus groups and identified perceived barriers/facilitators to weight loss and healthy lifestyles.

Results

Ten sex-stratified focus groups (n = 41; n = 13 males, n = 28 females) were conducted in 2018 and 2019. Females reported experiencing weight struggles, whereas males often stated no struggles with weight, despite all participants meeting criterion for OW/OB. Barriers included eating behaviours, family members and internal motivation, with additional barriers of physical activity, friends, time and support cited in females. Facilitators included parental, familial and peer support of healthy eating and exercise, modelling behaviours, internal motivation and organized sports. Two additional findings regarding adolescents' perceived barriers/facilitators include substantial overlap and sex differences of perceived barriers/facilitators.

Conclusions

Adolescent males and females with OW/OB experience weight status differently, affecting their perceived barriers/facilitators to weight loss and healthy lifestyles. Tailoring weight management interventions to the unique needs of adolescent females versus adolescent males has the potential to improve intervention quality and effectiveness.