Running Head: PARENTAL FACTORS IN PEDIATRIC OBESITY 1 Parent al Factors A ssociated with Pediatric Obesity Jovana Obradovic University of Florida
PARENT FACTORS IN PEDIATRIC OBESITY 2 Abstract Background: A bout one third of children are considered overweight or obese. Despite a higher prevalence in rural communities, pediatric overweight research has mostly concentrated on families from metropolitan areas. The purpose of this study was to examine whether parental factors, such as parent weight status, diet ary intake physical activity, family functioning, parent psycho logical functioning and motivation we re associated with child weight status Methods : Parents of 146 rural children who were overweight or obese completed questionnaires. Weight and height of children and parents were measured. Bivariate Pearson correla tions and regression analyses were utilized to determine associations between parent factors and child weight status Results : Correlation analyses revealed a significant positive correlation between Child BMI z score and Parent BMI ( r (143) = .20, p = 0.016), indicating that higher parent weight status wa s associated with higher child weight status. R egression analyses indicated similar results where Parental BMI was a significant predictor of child BMI z score Conclusions : This study indicates tha t parent weight status is an important factor to consider when examining the weight status of rural children. F uture studies are needed examining other parent factors that impact the weight status of obese children, as well as children with a healthy weigh t.
PARENT FACTORS IN PEDIATRIC OBESITY 3 Parent Factors A ssociated with Pediatric Obesity Overweight and obesity are currently one of the most important preventable threats to hu man health in the United States. Both overweight and obesity are known to be major risk factors for diabetes, cancer, cardiovascular disease, as well as numerous other chronic diseases ( U.S. Department of Health and Human Services, 2001) Current estimates report that about 32% of childre n are considered overweight or obese (Ogden et al., 2012 ). This number has increased in the last two decades; with the largest increase being among adolescents from poor and minority households. Adolescents from poor households are twice as likely to be ov erweight as adolescents from middle and high income households ( U.S. Department of Health and Human Services, 2001). Several factors related to childhood overweight and obesity, including genetics and sedentary lifestyles have been studied ( Tremblay & Willins, 2003). Place of residence specifically rural versus urban, has been identified as a risk factor for increased weight status (Patterson et al., 2004) In addition, some studies have examined parental characteristics associated with pediatric obesi ty. Few pediatric obesity researchers have focused on parental factors related to pediatric obesity in children living in rural areas even though overweight and obesity rates are highest in these populations (Patterson et al., 2004) Parent psychological functioning as well as family functioning have been found to be associated with outcome s of weight management treatment s for obese and overweight children (Wrotniak, Epstein, Paluuch, & Rowmmich, 2004). Specifically, low levels of conflict and high level s of cohesion and support within families are positively correlated with the degree of adjustment and management of chronic health conditions for adolescents (Drotar, 1997; Wysocki, 1993) Conversely mothers of overweight children reported higher levels of familial
PARENT FACTORS IN PEDIATRIC OBESITY 4 conflict and lower levels of family unity when compared to mothers of normal weight children (Zeller et al., 2007). Likewise, according to Kirschenbaum, Harris and Tomarken (1984), child ren of parents that reported a chaotic home environment benefited less from weight management interventions than families with less disorganized home environments In addition, reported psychological distress by parents, specifically mothers, has been show n to increase the risk of poorer psychological and physical health outcome s in their children and is associated with disruption in the parent child relationship (Burke, 2003) However, all of these studies concentrated on families from urban or sub urban environments making it difficult to generalize these findings to families from rural areas where obesity rates are higher. Focusing on children and families living in rural areas is important due to economic and social issues that may impact engagement i n health y lifestyle behaviors. Average weekly earnings for rural workers have been found to be about 80 percent of those of workers in urban areas ($543 compared to $685; need reference) which translates to an average rural income of about $34,000 compared to approximately $45,000 of the metropolitan average (United States Department of Agriculture, 2003). A bout 14% of rural residents are considered poor while the rate in metropolitan areas is about 11% ( U.S. Department of Health and Human Services, 2001) and a greater number of rural children live in poverty compared to children in metropolitan areas (20.2 percent compared to 15.4 percent respectively) (United States Department of Agriculture, 2003). Therefore, residents of rural areas are typically of lower socioeconomic status (SES) than those of metropolitan areas which places them at higher risk for overweight and obesity (U.S Department of Health and Human Services, 2001) It is suggested that this increased risk in lower SES families is due to the low quality food environments caused by increased distance to supermarkets (Ford & Dzewaltowski 2008) L imited economic resources may also cause
PARENT FACTORS IN PEDIATRIC OBESITY 5 families efined grains, added sugars, and added fats sources of energy but higher in fat and calories ( McCarthy 2004) R ural obese youth are more likely to be white, female, uninsured, and have not received health care in the past year ( Lufiyya et al., 2007). In fact, in a national study Lufiyya et al. (2007) foun d a higher prevalence of obesity among rural youth compared to metropolitan youth. These findings suggest that previous studies focusing on pediatric obesity in metropolitan areas may not generaliz e to rural children and families due to demographic and social difference s D ifferences in obesity rates between urban and rural areas may be related to poverty, lack of insurance, lack of preventative care, and li mited access to physical activity ( Lufiyya et al ., 2007) However, more research i s needed in order to examine parental factors that may be related to obesity in rural children. weight status but taken together, the results of previous studies strongly suggest that parental lifestyle behaviors and functioning affect the behavior of children (Davis et al 2008) especially among girls ( Jargo et al., 2010; Jargo et al. 2005) As overweight and obesity are associated with numerous health risks (Dietz, 19 99), additional research evaluating factors that may impact weight status is important for designing and implementing future interventions targeting weight management and the development of healthier lifestyles in children from rural areas The main purpo se of this study wa s to examine parent al factors that may be associated with the weight status of rural children It is hypothesized that parental factors, specifically parent weight status, diet ary intake physical activity, family functioning, psychological functioning and motivation score such that parents who have a higher weight status, a higher calorie diet lower physical activity and lower family
PARENT FACTORS IN PEDIATRIC OBESITY 6 functioning psychological functioning and motivation will have children with a higher BMI z score Method Participants Participants included 146 overweight and obese children 8 to 12 years of age ( M = 9.89, SD = 1.453) and their parents living in rural counties in North Central Florida. Families participating in this study were taking part in a larger project examining the effectiveness of three family based healthy lifestyle weight management interventions (se e Janicke et al., 2011 for information about recruitment and the interventions) The mean BMI z score for child participants was 2.16 ( SD = .398). Mean parent BMI was 34.5 ( SD = 7.90). There were slightly more girls than boys who participated ( n = 81, 55.5 %) and children were most often accompanied by their mothers ( n = 124, 84.9%). The majority of parent participants were Caucasian ( n = 102, 69.9%), with 26 ( 17.8% ) indicating African American, 1 (. 7% ) American Indian, 4 ( 2.7% ) were Biracial, and 11 ( 8.9% ) with either an unknown race or not responding. F amily income ranged from 1 (Below $19,999) to 6 (Above $100,00 0 ), with the median family income at 3.0 which ranged from $40,000 59,999. Mean family income was 2.89 ( SD = 1.43) Measures Dietary Intake. wa s assessed using Th e Block Brief 2000 Food Frequency Questionnaire (Block et al., 1994) Parents were asked to indicate how often in the past year they ate each food item and the amount they consumed by volume, in one day They w e re provided with pictures to help choose the amount of food, with choices ranging from cup, cup, 1 cup, and 2 cups. Total calories from all food groups was the value used in primary analys e s.
PARENT FACTORS IN PEDIATRIC OBESITY 7 Physical Activity. P wa s measured using The Block Physical Activity Screener (Block et al., 2009) Parents we re asked to record how often in the past year they engaged in specific type s of physical activity (running, walking, etc.) and the amount of time each day they engaged in that activity The total physical activity score which is the amount of energy exerted in all reported physical activities, was used for analys e s. Family Functioning. In order to measure family functioning, parents completed t he Family Assessment Device ( FAD; Epstein, Baldwin, & Bishop, 1983 ). The FAD uses a 4 point Likert Sca le with choices ranging from 1 = Strongly Agree to 4 = Strongly Disa gree for each statemen We express tenderness We are able to make decisi ability to solve family problems experience certain emotions while in the company of other family members, as well as determine the values placed on the thoughts an d concerns of other family members. The FAD consists of the following subscales: family problem solving, communication, affective regulation, affective involvement, roles, behavioral control, and global family functioning. For the purposes of this study g lobal family functioning wa s the main family functioning variable examined. Psychological Functioning Parental psychological symptoms such as depression and anxiety, were assessed using the 18 item Brief Symptom Inventory ( BSI 18; Leonard, Derogatis & Melisaratos 1983). Parents were asked to indicate how often in the past week they experienced a specific symptom, with their choices being Not At All, A little bit, Moderately, Quite a bit, and Extremely. A total score is obtained from the BSI 18, with h igher scores indicat ing poorer psychological functioning.
PARENT FACTORS IN PEDIATRIC OBESITY 8 Motivation. To assess parent motivation to chang e their exercise and eating habits, as well as their perception of these changes, parents complete d the Paren t Opinions on Healthy Behaviors measure This measure asked participants to answer and was created for use in this study Demographic Information. Parents also complete d demographic information, including child and parent age and race, as well as parent marital status, education, occupation, and family income. Anthropometric Data Child and parent height and weight we re measured by trained res earch staff at the time of their appointment Weight was measured in kilograms to the nearest 0.1 kg using a digital scale (Tanita) Height wa s measured in centimeters using a stadiometer (Seca) to the nearest 0.1 cm Procedure Families participating in this study we re taking part in a larger project examining the effectiveness of three family based healthy lifestyle weight management interventions Data for this project is from the pre treatment screening and baseline assessment visits which families complete d before the start of the treatment programs. Participants were recruited using direct solicitation methods distribution of brochures through schools, churches, social organizations, local businesses, as well as community p resentations Once parents provided consent and children gave asset to participate they completed questionnaires and anthropometric measurements were taken by trained research staff. Trained research assistants instruct ed
PARENT FACTORS IN PEDIATRIC OBESITY 9 families how to complete each que stionnaire and we re available to answer questions and read items to children and parents if needed Results Preliminary Results First, d escriptive statis tics were conducted on demographic variables including age, gender, and BMI z score of the child participants and parent BMI race, and family income. Means a nd standard deviations of the main study variables were then obtained and are displayed in Table 1. Second, c orrelations were conducted to examine statistically significant associations between c hild BMI z score and parent BMI, d ietary intake p hysical a ctivity, p sychological f unctioning f amily f unctionin g and motivation. As shown in Table 2, t here was a significant positive correlation between Child BMI z score and Parent BMI ( r (14 3 ) = .20, p = 0. 016 ) indicating that higher parent weight status is associated with higher child weight status A nalyses also revealed a significant positive correlation between par ent s psychological functioning and o verall f amily f unctioning ( r ( 124 ) = .279 p = 0.0 02 ), indicating that parents who reported more positive family functioning were more likely to report negative psychological symptoms There was a significant positive association between parent dietary intake and physical activity ( r (142) = .199, p = 0.0 17 ) indicating that parents who consume more calories also spend more time in physical activity There was also a significant positive association between physical activity and parent BMI ( r (145) = .225, p = 0.0 06 ) suggesting that parents with a higher weight status spend more time in physical activity In addition, there was an association between parent and child motivation ( r (126) = .309, p < 0 .00 1 ) where parents with high motivation to change their habits
PARENT FACTORS IN PEDIATRIC OBESITY 10 also perceive d their child There w ere no significant association s among the other variables. Primary Analyses A regression analysis was conducted to examine the effect of parent al factors ( BMI, dietary intake, p hysical a ctivity, p sychological f unctioning, f amily f unctioning, and motivation ) on child BMI z score Table s 3 and 4 summarize the analysis which produced a statistically significant model ( R = .100, F (6 118) = 2.191, p =.049). Parent BMI was a significant predictor of child BMI z score ( = .247, p =.007) indicating that higher parent BMI is associated with higher child BMI z score. In addition, parent dietary intake approached significance in predicting child BMI z score ( .161, p = .078) suggesting that parents that consume m ore calories from food may be more likely to have c hildren with a lower BMI z score The other variables did not significantly contribute to the multiple regression model. Discussion This study examined whether parent factors, such as weight status, diet ary intake physical activity, family functioning, psychological functioning and motivation, a re associate d with child BMI z score. Overall, our hypotheses were only partially supported P arental factors such as p arent BMI and parent dietary intake are associated with or predict a higher BMI z score in rural children. In accord with other published studies, parent BMI was positively correlated with and serve d as a predictor for child BMI z score, thus supporting previous finding s that there is a strong relation between parent and child weight status (Garn et al., 1989 ; Whitaker et al ., 2011 ) However the finding that parent dietary intake approached significance in predicting child BMI z score s in a negative direction is contradictory to results of prev ious studies. Two studies
PARENT FACTORS IN PEDIATRIC OBESITY 11 examining behavioral modeling where the child learn s by imitating their parents without verbal direction, found there is an association between parent and child food preference, eating frequency as well as eating motivation (Brown & Ogden, 2004 ; Clark et al., 2007) Thus if parents are consuming a large number of calories it is likely children will also be doing so and higher caloric intake would cause both the child and parent to gain weight an d lead to increase d weight status (U.S. Department of Health and Human Services, 2001). Furthermore we found a positive association between parent physical activity and p arent BMI suggesting that parents who participate in a greater amount of physical activity tend to have a higher BMI. As above, these findings are counterintuitive and contradict previous studies (Lahti Koski et al. 2002 ; Ruiz et al., 2006) suggest ing that physical activity burns excess calo ries and therefore leads to reduced body weight Th e discrepanc ies between our study and others may be due to a variety of reasons While other studies sample d primarily from metropolitan populations, this one is specific to families from rural communities Rural residence has been found to impact engagement in lifestyle behaviors, which may have impacted our results. In addition, past research has found that overweight and obese people may underrepresent their dietary intake (Heitmann & Lissner ,1995 ), adding to the variation in results. Along with this, participants of the previous studies and this one were aware that they we re participating in a study weight status. This knowledge m a y lead them to be more sensitive about the ir dietary intake and physical activity lead ing to underrepresent ing their caloric intake and over represen ting their physical activity in order to decrease stigma and to demonstrate healthier habits Limitations of this study are important to consider. Including only parents of overweight or obese children may have narrow ed the range of responses making it difficult to detect
PARENT FACTORS IN PEDIATRIC OBESITY 12 relations between variables In order to get a full range of res ponses, a stu dy including both overweight, obese and healthy weight children and parents should be conducted. In addition, the participants of this study were not randomly selected and consisted of families that were interested in join ing a weight management program i n the hope s of improving weight status and therefore may want to present themselves favorably. This lack of random selection can lead to responder bias and responses that imply that the participants have healthier eating and physical activit y habits However, a strength of this study is that both child and parent weight were measured by trained personnel in a similar manner for all participants reducing a chance for measurement bias. Henc e, future studies should concentrate on both the overwe ight and normal weight population and randomly select from it t hus reducing potential error. In addition, these studies should develop methods to more accurately record dietary intake as well as physical activity of participants and therefore reduce resp onder bias. For example, 24 hour dietary recalls may be a better way to assess dietary intake and accelerometers may be a good option for measuring physical activity be cause they are more objective than self report methods As stated above, parent BMI was found to be a predictor of child BMI z score and it is speculated that this is due to modeling (Brown & Ogden, 2004 ). Parents with a higher BMI are more likely to participate in less physical activity ( Lahti Koski et al., 2002 ) and have a higher caloric in take ( U.S. Department of Health and Human Services, 2001), which may expos e their children to a similar sedentary lifestyle. These children in turn are more likely to engage in similar sedentary lifestyle behaviors, leading them to develop a higher BMI z s core compared to children of parents with BMI scores in the healthy range (U.S. Department of Health and Human Services, 2001) F uture research should also focus on what role parent weight status may pl ay, for instance modeling learned helplessness or if there is a difference in the weight status of
PARENT FACTORS IN PEDIATRIC OBESITY 13 children who have parents who have a history of dieting compared to those whose parents do not have this history The findings from this study regarding the relation between child and parent weight status provide support for utilizing b ehavioral f amily i nterventions for rural families Providing interventions only at the level of the child or the parent leaves the uninvolved party unaware of their importance i n the success of the intervention. With both children and parents involved in modifying lifestyle behaviors it is possible to identify behaviors that put them at risk for a higher weight status. In addition, interventions can help children and parents wor k together to make small, gradual changes to diet ary intake and physical activity to reduce th ese risk s in the hope of model ing and supporting engagement in healthy lifestyle behavior s f or each other.
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PARENT FACTORS IN PEDIATRIC OBESITY 18 Table 1 Descriptive Statistics of Main Study Variables Measure Mean SD Minimum Maximum n Child BMI z score Parent BMI 2.15 34.46 0.40 7.90 0 .948 21.2 00 3.005 2.155 145 145 Overall Family Functioning 21.17 5.21 12 .000 39 .000 126 Parent Total Calories from Food 1662.04 884.92 497.260 8527.700 145 Parent Total Calories from PA 1531.64 1297.06 106.410 9251.170 145 Psychological Functioning 4.72 6.73 0 35 127 Parent Motivation 13.37 1.97 7 15 126 Child Motivation 10.74 2.66 3 15 126 Note: PA = physical activit ies Table 2 Intercorrelations of P arental F actors and C hild BMI z score Measure 1 2 3 4 5 6 7 8 1.Child BMI z score 2.Parent BMI .200* 3.Overall Family Functioning .074 .0 84 4.Total Calories from Food 114 .14 4 .033 5.Total Calories from PA .031 225** .022 .199 6. Psychological Functioning .009 .034 .279** .115 .032 7.Parent Motivation .110 .162 .146 .122 .030 .073 8. Child Motivation .095 .101 .170 .171 .111 .037 .309* Note s : PA = Physical Activities; p < 0.05. ** p < 0.01
PARENT FACTORS IN PEDIATRIC OBESITY 19 Table 3 Regression Model Summary Measure R 2 0.1 12 F Change 2.1 15 Sig. F Change 0.04 7 Table 4 Summary of Multiple Regression Analysis Note: PA = physical activities Measure Beta t Sig. Parent BMI .247 2.723 .007 Overall Family Functioning .026 .291 .772 Parent Motivation .073 .783 .435 Child Motivation .070 .741 .460 Total Calories from Food .161 1.776 .078 Total Calories from PA .041 .454 .651 Psychological Functioning .007 1.262 .209
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