Preventing the development of obesity in children is an international health priority [1
]. Current estimates suggest that the prevalence of overweight and obesity in all age groups is rapidly increasing worldwide [2
]. In Australia approximately 25% of children are overweight or obese and that estimate is growing with data highlighting that these increases begin in early childhood [3
]. An Australian sample of 114,669 pre-schoolers showed the prevalence of overweight and obesity increased from 16.3 to 27.2 per cent in girls and from 13.4 to 21.4 per cent in boys between 1995 and 2002 [4
Overweight and obesity are recognised to have numerous negative impacts on children's health and wellness during childhood and through to adult life [5
]. Further, research has shown that adiposity within the childhood period is a stable trait [7
] and that parents are often poor at identifying fatness in their children [8
]. In addition, obese children tend to become obese adults and treatment is difficult and costly [2
]. Cochrane reviews have established that opportunities for prevention are poorly understood [9
]. Overall there is an urgent need for research on the capacity to influence the development of children's obesity- promoting behaviours in early life.
Overweight in early childhood is determined in part by eating, physical activity and sedentary behaviours learnt at home in the first five years of life. The intervention outlined is informed by the understanding that (a) obesity-promoting behaviours are established early in life, (b) parents play a primary role in shaping these behaviours in infancy, (c) intervening before these behaviours (and parents responses to them) are established is likely to be effective, and (d) that the social milieu provided by parent groups is likely to facilitate and support the uptake of health promotion messages.
Obesity-promoting behaviours are established early in life
Recent evidence highlights that obesity-promoting dietary habits, such as high consumption of energy-dense foods and fluids, previously documented in children [10
] are also evident in infants and toddlers [12
]. Australian data using 3-day weighed food records (n = 538), shows 90% of 18-month old children consumed energy-dense snack foods on the recall days and 70% consumed sweetened non-milk drinks (e.g. soft drinks) [13
]. Overall, foods considered as "extra" or "non-core" provided 27% of the total energy intake in that sample. In addition, the nutritional quality of diet is known to continue to decline throughout childhood and adolescence [14
These early dietary patterns couple with evidence of high levels of sedentary behaviours in early childhood. For example, 17% of 0–11 month and 48% of 12–23 month old children in the US watch more than the recommended two hours of television per day, and this proportion increases throughout childhood [16
]. Further evidence suggests that viewing television for more than two hours per day is positively associated with obesity-promoting dietary behaviours and low levels of physical activity in young children [17
]. Little physical activity trend data during infancy and early childhood is available, however it appears that physical activity levels fall throughout this period [19
In addition to population trend data, there is evidence of tracking of children's dietary [21
], sedentary and physical inactivity behaviours [22
] from childhood to adolescence and adulthood, which appear to impact on adult health [23
]. Thus, the obesity-promoting behaviours learned and supported during these early years may establish lifestyle behaviours that will track throughout the lifespan. Given this, it is reasonable to posit that early childhood provides a unique and circumscribed opportunity within which to establish lifestyle behaviours that will promote health and minimize the risk of the development of obesity.
The role of parents in the promotion of children's behaviours
One of the most powerful predictors of weight management in overweight children is parental involvement, yet there remains an urgent need to examine opportunities to prevent childhood overweight and obesity via parental involvement in the early years [24
]. Children's eating, physical activity and sedentary behaviours are learnt and sustained in the home and there is evidence that this environment impacts on children's weight [27
]. Parents have the capacity via their nutrition knowledge, parenting style, modelling and the food environment to impact on children's emerging food choices [27
]. Evidence has shown that in a young population (2–6 year olds, n = 564) the strongest predictor of children's fruit and vegetable consumption was parent consumption [29
]. In addition, child rejection of fruits and vegetables (negative association) was modifiable with repeated exposure to rejected foods.
In terms of parents' involvement in physical activity with their children, one study reports that parents spend 13% of their child's play time in active play with their infant and that the remainder of time is spent in object play [30
]. The use of parks and outdoor spaces is reported by less than half of parents with 5–12 year olds [20
]. Children whose parents are active with them are reported to have higher levels of physical activity [31
]. However, family rules are reported to be inversely associated with children's physical activity [26
]. Similarly, rules prohibiting television viewing during mealtimes are reported to be inversely associated with children's television viewing time, and frequency of parent's watching television with their child has been found to be positively associated with children's television viewing [33
Despite these trends, first-time parents may be particularly receptive to knowledge and skill development around parenting and the promotion of healthy family eating and physical activity behaviours. First-time parents regularly seek advice during their child's first year of life. In Victoria Australia, families make approximately 35 visits to health care providers for their infants during this first year [34
]. Importantly, most visits to health service providers are not related to child illness, but rather reflect parental need for support and information during this period of rapid transition. In addition, parents indicate high levels of concern regarding children's appetite, eating patterns and growth, and regularly express the need for more comprehensive guidance in these areas [35
]. It is likely that messages delivered to first-time parents may be preferentially received if delivered at times in their child's development when they are actively seeking strategies to manage emerging behaviours, an approach known as anticipatory guidance.
Utilisation of anticipatory guidance
Anticipatory guidance is heralded as a promising approach by which health practitioners might support parents to promote healthy weight in their children by being proactive, informing parents about what to expect and how to manage behaviour, as opposed to supporting parents to manage events after they occur [36
]. Anticipatory guidance has been shown to be effective across a range of domains, including parent-infant interactions, sleep patterns, injury prevention and reading at home [39
Despite the promise of anticipatory guidance as an educative approach, just one study utilising this approach in the area of childhood eating has been published [40
]. That study involved guidance of parents of new-borns regarding delaying introduction of solids. Compared to controls, the intervention resulted in positive differences in the types of foods introduced and increased confidence in health professionals as primary providers of information.
A randomised-controlled trial targeting overweight indigenous mothers of 1–3 year olds focused on parenting skills to promote improved child eating and physical activity patterns [41
]. That study found intervention group infants had decreased relative weight, total energy intake, and improved parent-child interactions around food over 16 weeks. This high quality US study highlights that parents are willing and capable of making positive changes to improve their child's health and body weight.
INFANT: preventing childhood obesity and promoting healthy life-style choices
The INFANT project will employ an anticipatory guidance approach to support first-time parents attending a new parents' group to be skilled in their approaches to their infant's emerging dietary, physical activity and sedentary behaviours. The intervention will be delivered by an experienced dietitian during infants' first 18 months of life at first-time parents groups held within Maternal and Child Health (MCH) centers. Evidence supports the proposition that education regarding lifestyle behaviours is feasible within existing MCH infrastructures and that it is likely to be effective [42
]. Victoria's 80 MCH Centres (across 39 regions) are a cornerstone of service provision with 96% of all first-time parents attending [34
]. MCH nurses routinely establish first-time parents' groups through which education sessions are delivered. A recent prospective study [43
] reported that 2/3rds of eligible first-time mothers joined these groups and that of these groups, 2/3rds were still meeting 18 months after the formal sessions had concluded. Drop out from such groups was estimated to be between 10 and 15%. That study also documents the important social environment that first-time mothers' groups provide throughout this early period of parenting. Given the stability of these pre-existing groups and the well-documented capacity of groups to support and reinforce the uptake of knowledge and skills we propose that these groups will provide an important vehicle by which we may deliver an intervention. In addition, our pilot work and engagement with local government areas has demonstrated that access to these groups via MCH nurses is feasible and that willingness of mothers within these groups to participate in research is high.
While this intervention utilises professional support beyond that currently existing in MCH Centres, it remains modest in terms of total cost of implementation and is designed for long-term sustainability, with skills required easily transferable to MCH nurses and other comparable health professionals.
The intervention draws on parenting support theory [44
], which emphasizes children's psychological and behavioural goals, logical and natural consequences, mutual respect and encouragement techniques. Emphasis will be placed on parents' understanding of how improved parenting skills can facilitate the development of appropriate eating and activity behaviours in children. In the feeding domain, these approaches have been operationalised by Satter who promotes the 'Division of Responsibility in Feeding' [45
] This approach has also been adopted in the US Start Health Feeding Guidelines for Infants and Toddlers [46
]. Havery-Berino et al [47
] report, in one of the only relevant studies in this age group (age 9 to 36 months), a positive impact on children's dietary intakes using similar approaches.
The intervention will use an anticipatory guidance framework, to coincide with opportunities to support parents regarding feeding, physical activity and sedentary behaviour issues for infants prior to their evolution. In addition, it will utilise the dynamics of existing first time parents' groups to support and reinforce the messages delivered in the intervention.