HomeStyles, A Web-Based Childhood Obesity Prevention Program for Families With Preschool Children: Protocol for a Randomized Controlled Trial

Maternal Mental Health Status Is Associated with Weight-Related Parenting Cognitions, Home Food Environment Characteristics, and Children's Behaviors

Women experience anxiety, depression, and stress at higher levels than men and have more parenting responsibilities, especially establishing health practices in the home. Given children's vulnerability, this study aimed to increase understanding of how mothers' mental health status relates to maternal weight-related cognitions, home food environments, and child health via a cross-sectional survey design. In a cluster analysis, using maternal anxiety, depression, and stress assessments, we placed the sample of 531 mothers of school-age children into four clusters: Cluster 1 had the best mental health status, Cluster 2 had high stress, Cluster 3 had anxiety and moderate stress, and Cluster 4 had anxiety, depression, and high stress. Our results indicate an overall downward trend in weight-related cognitions as mental health worsened. Similarly, as mental health declined, so did home food environment characteristics, such as the greater use of non-recommended child feeding practices, fewer family meals, and greater sugar-sweetened beverage supplies. As mothers' mental health status became poorer, children's general health and mental health quality of life declined, and sugar-sweetened beverage intake increased. Our findings suggest that maternal stress, anxiety, and depression are moderately to strongly linked with mothers' cognitions, home food environments, and children's health. Our results also suggest that mental health interventions for mothers should assess cognitions and home food environments and consider the extent to which these factors are affecting family health.

Family Social Support and Weight-Related Behaviors of School-Age Children: An Exploratory Analysis

Families are a key provider of support that may encourage positive weight-related behaviors. Yet little is known about the relation of family support to children’s performance of weight-related behaviors. Mothers (N = 524) who completed an online survey were categorized as having low, moderate, or high family support for fruit/vegetable intake, breakfast intake, limiting sugar-sweetened beverage intake, physical activity, limiting sedentary screentime, and sleep. ANOVA revealed that children in families with high support for breakfast ate this meal significantly more often. Additionally, children in families with low support for limiting sugar-sweetened beverages had significantly greater intake. Surprisingly, families with moderate support for physical activity and sleep tended to have children with lower physical activity level, sleep duration, and sleep quality, and fewer days/week with set bedtimes than those with low and high support. Binomial logistic regression revealed that high family support for eating breakfast, limiting sugar-sweetened beverages, and getting sufficient sleep had greater odds of meeting recommendations for these behaviors. Findings suggest that greater family support for healthy weight-related behaviors tends to be associated with children’s performance of these behaviors. Future interventions should further examine the impact of different types of family support on weight-related behaviors to better understand this complex interplay.

Digital Health Promotion and Prevention in Settings: Scoping Review

BACKGROUND

Digital technologies are increasingly integrating into people's daily living environments such as schools, sport clubs, and health care facilities. These settings play a crucial role for health promotion and prevention because they affect the health of their members, as the World Health Organization has declared. Implementing digital health promotion and prevention in settings offers the opportunity to reach specific target groups, lower the costs of implementation, and improve the health of the population. Currently, there is a lack of scientific evidence that reviews the research on digital health promotion and prevention in settings.

OBJECTIVE

This scoping review aims to provide an overview of research targeting digital health promotion and primary prevention in settings. It assesses the range of scientific literature regarding outcomes such as applied technology, targeted setting, and area of health promotion or prevention, as well as identifies research gaps.

METHODS

The scoping review was conducted following the Levac, Colquhoun, and O'Brien framework. We searched scientific databases and gray literature for articles on digital setting-based health promotion and prevention published from 2010 to January 2020. We included empirical and nonempirical publications in English or German and excluded secondary or tertiary prevention and health promotion at the workplace.

RESULTS

From 8888 records, the search resulted in 200 (2.25%) included publications. We identified a huge diversity of literature regarding digital setting-based health promotion and prevention. The variety of technology types extends from computer- and web-based programs to mobile devices (eg, smartphone apps) and telemonitoring devices (sensors). We found analog, digital, and blended settings in which digital health promotion and prevention takes place. The most frequent analog settings were schools (39/200, 19.5%) and neighborhoods or communities (24/200, 12%). Social media apps were also included because in some studies they were defined as a (digital) setting. They accounted for 31.5% (63/200) of the identified settings. The most commonly focused areas of health promotion and prevention were physical activity (81/200, 40.5%), nutrition (45/200, 22.5%), and sexual health (34/200, 17%). Most of the interventions combined several health promotion or prevention methods, including environmental change; providing information, social support, training, or incentives; and monitoring. Finally, we found that the articles mostly reported on behavioral rather than structural health promotion and prevention.

CONCLUSIONS

The research field of digital health promotion and prevention in settings is heterogeneous. At the same time, we identified research gaps regarding the absence of valid definitions of relevant terms (eg, digital settings) and the lack of literature on structural health promotion and prevention in settings. Therefore, it remains unclear how digital technologies can contribute to structural (or organizational) changes in settings. More research is needed to successfully implement digital technologies to achieve health promotion and prevention in settings.

HomeStyles-2: Randomized controlled trial protocol for a web-based obesity prevention program for families with children in middle childhood

BACKGROUND

Parents are children's primary role models, are food and physical activity gatekeepers, and create the home structure/lifestyle environment. Thus, parents strongly influence children's weight-related behaviors and have the opportunity to cultivate a "culture of health" within the home. Yet, there is a dearth of evidence-based obesity prevention intervention programs, especially for families with children aged 6-11 years, commonly called middle childhood.

METHODS

The aim of the HomeStyles-2 online learning mode RCT is to determine whether this novel, age-appropriate, family intervention enables and motivates parents to shape home environments and weight-related lifestyle practices (i.e.,diet, exercise, sleep) to be more supportive of optimal health and reduced obesity risk in middle childhood youth more than those in the control condition. The RCT will include the experimental group and an attention control group. The participants will be parents with school-age children who are systematically randomly assigned by computer to study condition. The HomeStyles intervention is predicated on the social cognitive theory and a social ecological framework. The RCT will collect sociodemographic characteristics of the participant, child, and partner/spouse; child and parent health status; parent weight-related cognitions; weight-related behaviors of the parent and child; and weight-related characteristics of the home environment. Deliverables Enrollment for this study will begin in 2022.

DISCUSSION

This paper describes these aspects of the HomeStyles-2 intervention: rationale; sample eligibility criteria and recruitment; study design; experimental group intervention theoretical and philosophical underpinnings, structure, content, and development process; attention control intervention; survey instrument development and components; outcome measures; and planned analyses.

TRIAL REGISTRATION

ClinicalTrials.gov, Protocol #NCT04802291, Registered March 14, 2021.

Family Social Capital: Links to Weight-Related and Parenting Behaviors of Mothers with Young Children

Family social capital includes the social relationships, values, and norms shared by a family and is positively linked with children’s mental and physical health status. This cross-sectional study addresses a gap in the literature related to family social capital vis-à-vis weight-related behaviors and home environments of 557 mothers and their young children (ages 2 to 9 years). Mothers completed an online survey comprised of valid, reliable questionnaires assessing family relationships and weight-related behavioral and home environment measures. The measures that determined family social capital (i.e., supportive, engaged parenting behaviors; family cohesion; family conflict; and family meal frequency) yielded distinct tertile groups that differed significantly (p < 0.001) on every family social capital measure with large effect sizes. Analysis of variance with Tukey post-hoc test revealed greater family social capital was linked to significantly better maternal health, dietary intake, physical activity, and sleep behavior. Additionally, maternal modeling of healthy eating and physical activity, child feeding practices, and home environments was higher in groups with greater family social capital. Child mental and physical health, physical activity, and sleep quality were better in families with greater family social capital. Findings suggest greater family social capital is linked to healthier weight-related behaviors and home environments. Future intervention studies should incorporate strategies to build family social capital and compare longitudinal outcomes to traditional interventions to determine the relative value of family social capital on health behaviors.

A Comparison of Maternal Health Status and Weight-Related Cognitions, Behaviors, and Home Environments by Race/Ethnicity

This cross-sectional study compared weight-related cognitions, behaviors, and home environments of 568 mothers of young children (ages 2 to <9 years) by racial/ethnic group. Maternal health status was good and did not differ by race/ethnicity. Mothers were somewhat confident in their ability to promote healthy physical activity and eating behaviors in their children, with White and Asian mothers having greater confidence than Hispanic mothers. Mothers had low physical activity, with Hispanic mothers getting more sedentary screentime than White and Asian mothers. Mothers' dietary intake did not differ. Modeling of healthful behaviors was more frequent in White than Hispanic mothers. Asian mothers tended to use non-recommended feeding patterns more than White, Hispanic, and Black mothers. Children's physical activity and screentime did not differ by race/ethnicity. Asian children tended to drink less sugar-sweetened beverages and more milk than counterparts. All reported frequent family meals, with Hispanic mothers reporting more family meals eaten in less healthful locations. Household food environments did not differ. However, White mothers reported greater access to physical activity space and supports than Hispanic mothers. Race/ethnicity may link with maternal weight-related cognitions, behaviors, and home environments and thus can help inform the development of interventions tailored by race/ethnicity.

Interventions for preventing obesity in children

EDITORIAL NOTE

This Cochrane review is now out of date and should not be used for reference. It has been split into four age groups and updated. Please refer to the 5‐11 and 12‐18 age group Cochrane reviews which were published in May 2024: https://doi.org/10.1002/14651858.CD015328.pub2 https://doi.org/10.1002/14651858.CD015330.pub2 The 2‐4 age group Cochrane review is planned for publication in September 2024.

BACKGROUND

Prevention of childhood obesity is an international public health priority given the significant impact of obesity on acute and chronic diseases, general health, development and well-being. The international evidence base for strategies to prevent obesity is very large and is accumulating rapidly. This is an update of a previous review.

OBJECTIVES

To determine the effectiveness of a range of interventions that include diet or physical activity components, or both, designed to prevent obesity in children.

SEARCH METHODS

We searched CENTRAL, MEDLINE, Embase, PsychINFO and CINAHL in June 2015. We re-ran the search from June 2015 to January 2018 and included a search of trial registers.

SELECTION CRITERIA

Randomised controlled trials (RCTs) of diet or physical activity interventions, or combined diet and physical activity interventions, for preventing overweight or obesity in children (0-17 years) that reported outcomes at a minimum of 12 weeks from baseline.

DATA COLLECTION AND ANALYSIS

Two authors independently extracted data, assessed risk-of-bias and evaluated overall certainty of the evidence using GRADE. We extracted data on adiposity outcomes, sociodemographic characteristics, adverse events, intervention process and costs. We meta-analysed data as guided by the Cochrane Handbook for Systematic Reviews of Interventions and presented separate meta-analyses by age group for child 0 to 5 years, 6 to 12 years, and 13 to 18 years for zBMI and BMI.

MAIN RESULTS

We included 153 RCTs, mostly from the USA or Europe. Thirteen studies were based in upper-middle-income countries (UMIC: Brazil, Ecuador, Lebanon, Mexico, Thailand, Turkey, US-Mexico border), and one was based in a lower middle-income country (LMIC: Egypt). The majority (85) targeted children aged 6 to 12 years.Children aged 0-5 years: There is moderate-certainty evidence from 16 RCTs (n = 6261) that diet combined with physical activity interventions, compared with control, reduced BMI (mean difference (MD) -0.07 kg/m2, 95% confidence interval (CI) -0.14 to -0.01), and had a similar effect (11 RCTs, n = 5536) on zBMI (MD -0.11, 95% CI -0.21 to 0.01). Neither diet (moderate-certainty evidence) nor physical activity interventions alone (high-certainty evidence) compared with control reduced BMI (physical activity alone: MD -0.22 kg/m2, 95% CI -0.44 to 0.01) or zBMI (diet alone: MD -0.14, 95% CI -0.32 to 0.04; physical activity alone: MD 0.01, 95% CI -0.10 to 0.13) in children aged 0-5 years.Children aged 6 to 12 years: There is moderate-certainty evidence from 14 RCTs (n = 16,410) that physical activity interventions, compared with control, reduced BMI (MD -0.10 kg/m2, 95% CI -0.14 to -0.05). However, there is moderate-certainty evidence that they had little or no effect on zBMI (MD -0.02, 95% CI -0.06 to 0.02). There is low-certainty evidence from 20 RCTs (n = 24,043) that diet combined with physical activity interventions, compared with control, reduced zBMI (MD -0.05 kg/m2, 95% CI -0.10 to -0.01). There is high-certainty evidence that diet interventions, compared with control, had little impact on zBMI (MD -0.03, 95% CI -0.06 to 0.01) or BMI (-0.02 kg/m2, 95% CI -0.11 to 0.06).Children aged 13 to 18 years: There is very low-certainty evidence that physical activity interventions, compared with control reduced BMI (MD -1.53 kg/m2, 95% CI -2.67 to -0.39; 4 RCTs; n = 720); and low-certainty evidence for a reduction in zBMI (MD -0.2, 95% CI -0.3 to -0.1; 1 RCT; n = 100). There is low-certainty evidence from eight RCTs (n = 16,583) that diet combined with physical activity interventions, compared with control, had no effect on BMI (MD -0.02 kg/m2, 95% CI -0.10 to 0.05); or zBMI (MD 0.01, 95% CI -0.05 to 0.07; 6 RCTs; n = 16,543). Evidence from two RCTs (low-certainty evidence; n = 294) found no effect of diet interventions on BMI.Direct comparisons of interventions: Two RCTs reported data directly comparing diet with either physical activity or diet combined with physical activity interventions for children aged 6 to 12 years and reported no differences.Heterogeneity was apparent in the results from all three age groups, which could not be entirely explained by setting or duration of the interventions. Where reported, interventions did not appear to result in adverse effects (16 RCTs) or increase health inequalities (gender: 30 RCTs; socioeconomic status: 18 RCTs), although relatively few studies examined these factors.Re-running the searches in January 2018 identified 315 records with potential relevance to this review, which will be synthesised in the next update.

AUTHORS' CONCLUSIONS

Interventions that include diet combined with physical activity interventions can reduce the risk of obesity (zBMI and BMI) in young children aged 0 to 5 years. There is weaker evidence from a single study that dietary interventions may be beneficial.However, interventions that focus only on physical activity do not appear to be effective in children of this age. In contrast, interventions that only focus on physical activity can reduce the risk of obesity (BMI) in children aged 6 to 12 years, and adolescents aged 13 to 18 years. In these age groups, there is no evidence that interventions that only focus on diet are effective, and some evidence that diet combined with physical activity interventions may be effective. Importantly, this updated review also suggests that interventions to prevent childhood obesity do not appear to result in adverse effects or health inequalities.The review will not be updated in its current form. To manage the growth in RCTs of child obesity prevention interventions, in future, this review will be split into three separate reviews based on child age.

Generational Differences: A Comparison of Weight-Related Cognitions and Behaviors of Generation X and Millennial Mothers of Preschool Children

A ‘generation’ is an identifiable group sharing birth years and significant life events at critical developmental ages. There is a paucity of literature examining how parental cognitions and lifestyle behaviors differ by generation and whether generational differences are substantial enough to warrant consideration during the development of health interventions. This study compared generational differences in weight-related cognitions and lifestyle behaviors of mothers of young children who were categorized as Generation X (born 1965–1981, n = 158) and Generation Y (aka Millennials; born 1982–1999, n = 162). Survey results indicated that Generation X had significantly higher family affluence; thus, this was controlled in subsequent analyses. Analysis of covariance indicated that Millennials had more positive expectations about the benefits of engaging in healthy eating and physical activity than comparators, but not significantly so. Millennial mothers placed significantly higher value on physical activity for themselves than Generation X mothers, but both generations were neutral on the value of personal physical activity. No generational differences were noted in self-efficacy of mothers for promoting childhood obesity-prevention practices to children and self-efficacy for personally engaging in weight-protective behaviors. Millennial mothers had significantly more family meals/week, however generations did not differ on the value placed on family meals, where family meals were eaten, or whether media devices were used at mealtime. Few differences were noted between the generations for most child feeding behaviors, except that Millennials reported placing significantly less pressure on children to eat. Mothers’ modeling of weight-related behaviors as a means for children’s observational learning about healthy eating, physical activity, and sedentary behaviors did not differ by generational group. The eating behaviors of mothers differed little between generations. Millennial mothers allowed significantly more media devices in children’s bedrooms and personally engaged in more screen time daily than comparators. Overall, the two generational groups were more similar than different in weight-related cognitions as well as for personal and parenting lifestyle behaviors. The results suggest that tailoring interventions for individuals at a similar life-stage (e.g., mothers of young children) by generation may not be warranted.

"C.H.A.M.P. Families": Description and Theoretical Foundations of a Paediatric Overweight and Obesity Intervention Targeting Parents-A Single-Centre Non-Randomised Feasibility Study

Childhood obesity represents a significant global health challenge, and treatment interventions are needed. The purpose of this paper is to describe the components and theoretical model that was used in the development and implementation of a unique parent-focussed paediatric overweight/obesity intervention. C.H.A.M.P. Families was a single-centre, prospective intervention offered to parents of children aged between 6–14 years with a body mass index (BMI) ≥85th percentile for age and sex. The intervention included: (1) eight group-based (parent-only) education sessions over 13-weeks; (2) eight home-based activities; and (3) two group-based (family) follow-up support sessions. The first section of the manuscript contains a detailed description of each intervention component, as well as an overview of ongoing feasibility analyses. The theoretical portion details the use of evidence-based group dynamics principles and motivational interviewing techniques within the context of a broader social cognitive theory foundation. This paper provides researchers with practical examples of how theoretical constructs and evidence-based strategies can be applied in the development and implementation of parent-focussed paediatric obesity interventions. Given the need for transparent reporting of intervention designs and theoretical foundations, this paper also adds to the areas of implementation science and knowledge translation research.

Jump2Health Website™ for Head Start parents to promote a healthy home environment: Results from formative research

Background: In US, approximately 23% of children between the ages of 2-5 years are overweight or obese. Parents need access to information to create healthy home environments for obesity prevention, yet participation for in-person education programs is challenging. Web-based interventions are promising educational tools due to 24/7 availability. However, information is limited on their development and evaluation. Design and Methods: This study reports on a rigorous development process that included six focus group discussions (FGD) with stakeholders (three FGD each with parents and teachers) to assess education needs and inform the development of the Jump2Health Website^™ by a multidisciplinary team. After development, the Website was evaluated by telephone interviews with stakeholders (five parents and six teachers) and reviewed by an expert panel of five Registered Dietitians. Results: Twenty Head Start parents and 22 Head Start teachers participated in the FGD. To address the needs identified by these stakeholders, the Website was designed to include components that were enabling and motivating, such as descriptions of health benefits by achieving the desired behaviours, short videos on easy meal preparation, and tip sheets on how to achieve healthy behaviours in easy, economical ways. Stakeholder evaluation of the Website indicated that the information was helpful, easy to use, and would be beneficial for parents. Conclusions: The development of Jump2Health Website^™ was strengthened by FGD with stakeholders that assessed educational needs. Interviews with stakeholders and an expert panel review showed that the Website may be an effective educational method to teach parents about healthy behaviours related to obesity prevention.

The marketing plan and outcome indicators for recruiting and retaining parents in the HomeStyles randomized controlled trial

Background

Despite the critical importance of successful recruitment and retention to study integrity, reporting of recruitment and retention strategies along with factors associated with successful recruitment and retention of participants in health-related interventions remain rare, especially for health and obesity prevention programs. Thus, the purpose of this article is to retrospectively examine the recruitment and retention marketing plan used in the online HomeStyles randomized controlled trial (RCT) and discuss outcomes associated with completion of the intervention.

Methods

The HomeStyles RCT is an online intervention developed to motivate parents of young children to gain the skills and self-confidence needed to shape home environments and lifestyles to be protective against childhood obesity. Using the seven Ps of services marketing (i.e., people, place, product, physical evidence, price, promotion, and process), a comprehensive and systematic plan for recruitment and retention was implemented and outcomes assessed.

Results

A total of 489 parents with a young child aged 2 to < 6 years were eligible to participate, a final capture rate of 33%. Only 23% of Hispanic participants chose to use the Spanish-language version of HomeStyles intervention materials, below the demand anticipated. However, Hispanic enrollment overall was substantially higher than the U.S. population proportion (i.e., 17%). The number of participants prematurely leaving the study was similar in both treatment groups, indicating attrition was not differential. Completers reported high satisfaction of HomeStyles, using a 1–5 scale (strongly disagree to strongly agree) on guide attractiveness, interestingness, and usefulness. Despite all the retention efforts, the average monthly recruitment accrual rate of ~ 33 eligible enrolled participants at baseline (i.e., 489 participants/15-month recruitment period), declined to ~ 18, 11, 9, and 8 remaining recruited participants/month at midpoint, post, follow-up, and long-term follow-up surveys, respectively. In general, survey completers were significantly more likely to be female and perceived their child’s health status to be better, and they were significantly less likely to be restrictive of their child’s food intake.

Conclusions

The findings of the present study highlight the need for far-reaching, concentrated, and varied recruitment strategies; sufficient time in the research plan for recruitment and retention activities; and creative, tireless, flexible, persistent project staff for health-related interventions.

Promoting healthy home environments and lifestyles in families with preschool children: HomeStyles, a randomized controlled trial

The purpose of the HomeStyles randomized controlled trial was to determine the effect of participation in the HomeStyles intervention vs an attention control condition on the weight-related aspects of the home environment and lifestyle behavioral practices of families with preschool children. Parents of preschool children (n=489) were systematically randomized to experimental or attention control group after completing the baseline survey. Baseline and post surveys comprehensively assessed study outcomes using a socio-ecological approach incorporating valid, reliable intrapersonal (e.g., diet, activity), interpersonal (e.g., family meal frequency), and environmental measures (e.g., home media environment), and self-reported parent and child measured heights and weights. For all outcome measures, paired t-tests compared within group differences over time and ANCOVA, controlling for baseline scores and prognostic variables (e.g., parent sex), determined differences in post survey scores between groups. The final analytical sample (N=172; age 32.34±5.71SD; 58% White; 93% female) completed baseline and post surveys. The experimental group families had improved family meal and diet-related behaviors, and self-efficacy for food-related childhood obesity-protective practices. Household food supplies changed little, except for less availability of salty/fatty snacks. Within group effects indicated the control group also experienced some improvements, however these were few in number. ANCOVA revealed the experimental group parents had greater physical activity, reduced screentime, improved family mealtime behaviors, and increased self-efficacy for childhood obesity-protective behaviors and cognitions compared to the control group at post survey, though effect sizes were small. The HomeStyles program for families with preschool children promoted improvements in an array of obesity-preventive behaviors.

A Socio-Ecological Examination of Weight-Related Characteristics of the Home Environment and Lifestyles of Households with Young Children

Home environment and family lifestyle practices have an influence on child obesity risk, thereby making it critical to systematically examine these factors. Thus, parents (n = 489) of preschool children completed a cross-sectional online survey which was the baseline data collection conducted, before randomization, in the HomeStyles program. The survey comprehensively assessed these factors using a socio-ecological approach, incorporating intrapersonal, interpersonal and environmental measures. Healthy intrapersonal dietary behaviors identified were parent and child intakes of recommended amounts of 100% juice and low intakes of sugar-sweetened beverages. Unhealthy behaviors included low milk intake and high parent fat intake. The home environment’s food supply was found to support healthy intakes of 100% juice and sugar-sweetened beverages, but provided too little milk and ample quantities of salty/fatty snacks. Physical activity levels, sedentary activity and the home’s physical activity and media environment were found to be less than ideal. Environmental supports for active play inside homes were moderate and somewhat better in the area immediately outside homes and in the neighborhood. Family interpersonal interaction measures revealed several positive behaviors, including frequent family meals. Parents had considerable self-efficacy in their ability to perform food- and physical activity-related childhood obesity protective practices. This study identified lifestyle practices and home environment characteristics that health educators could target to help parents promote optimal child development and lower their children’s risk for obesity.