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1.  Overweight in Latino Preschoolers: Do Parental Health Beliefs Matter? 
Objective
To characterize the knowledge, attitudes, and beliefs (KAB) regarding childhood obesity among parents of Latino preschoolers.
Methods
Three hundred sixty-nine Mexican immigrant parents of children ages 2–5 were interviewed. Children were weighed and measured.
Results
Parents underestimated their own child’s weight status and had high levels of perceived control over their children’s eating and activity behaviors. Parents of overweight (≥95%ile-for-age-and-sex BMI) versus nonoverweight (<95%ile BMI) children did not differ in their beliefs about ideal child body size.
Conclusion
Latino parents of overweight children did not differ from parents of nonoverweight children with respect to their KAB about childhood obesity.
PMCID: PMC2804943  PMID: 20001191
childhood obesity; health beliefs; Mexican Americans
2.  Overweight, obesity, high blood pressure and lifestyle factors among Mexican children and their parents 
Objective
The objective of this study was to identify associations in the prevalence of overweight, obesity and high blood pressure between children and their parents, as well as their eating and physical patterns.
Methods
In this cross-sectional study, we obtained data on 83 pairs of school-aged children and one of their parents relating to dietary habits and various physical parameters, including the body mass index (BMI) and blood pressure of the children, which were adjusted by age and gender. Both the children and the parents were asked to complete a questionnaire aimed at providing measures of eating behavior. The questions focused on the consumption of fruit and vegetables and soda drinks as well as on physical activity patterns. Parent BMI was calculated from self-reported height and weight values.
Results
Obesity was diagnosed in 10.8% of the children, and the prevalence of overweight was 28.9%. There was a relationship between a child’s weight status and that of his/her parent according to the BMI; 45% of overweight/obese children had overweight/obese parents. In addition, a parent’s fruit and vegetable consumption was associated with his/her child’s fruit and vegetable consumption (r = 0.47, p < 0.001), and both were associated with soda drink consumption in both parents and children (r = 0.30, p < 0.001).
Conclusion
Our results confirmed that there is a relationship between the weight status, fruit and vegetable consumption and soda drink intake of children and those of their parents.
doi:10.1007/s12199-010-0151-4
PMCID: PMC2955902  PMID: 21432567
Children; Eating and physical patterns; Obesity; Parental influence
3.  Children's eating behavior, feeding practices of parents and weight problems in early childhood: results from the population-based Generation R Study 
Background
Weight problems that arise in the first years of life tend to persist. Behavioral research in this period can provide information on the modifiable etiology of unhealthy weight. The present study aimed to replicate findings from previous small-scale studies by examining whether different aspects of preschooler’s eating behavior and parental feeding practices are associated with body mass index (BMI) and weight status -including underweight, overweight and obesity- in a population sample of preschool children.
Methods
Cross-sectional data on the Child Eating Behaviour Questionnaire, Child Feeding Questionnaire and objectively measured BMI was available for 4987 four-year-olds participating in a population-based cohort in the Netherlands.
Results
Thirteen percent of the preschoolers had underweight, 8% overweight, and 2% obesity. Higher levels of children’s Food Responsiveness, Enjoyment of Food and parental Restriction were associated with a higher mean BMI independent of measured confounders. Emotional Undereating, Satiety Responsiveness and Fussiness of children as well as parents’ Pressure to Eat were negatively related with children’s BMI. Similar trends were found with BMI categorized into underweight, normal weight, overweight and obesity. Part of the association between children’s eating behaviors and BMI was accounted for by parental feeding practices (changes in effect estimates: 20-43%), while children’s eating behaviors in turn explained part of the relation between parental feeding and child BMI (changes in effect estimates: 33-47%).
Conclusions
This study provides important information by showing how young children’s eating behaviors and parental feeding patterns differ between children with normal weight, underweight and overweight. The high prevalence of under- and overweight among preschoolers suggest prevention interventions targeting unhealthy weights should start early in life. Although longitudinal studies are necessary to ascertain causal directions, efforts to prevent or treat unhealthy child weight might benefit from a focus on changing the behaviors of both children and their parents.
doi:10.1186/1479-5868-9-130
PMCID: PMC3543222  PMID: 23110748
Overweight; Underweight; BMI; Eating behavior; Feeding; Parenting; Children
4.  Economic and other barriers to adopting recommendations to prevent childhood obesity: results of a focus group study with parents 
BMC Pediatrics  2009;9:81.
Background
Parents are integral to the implementation of obesity prevention and management recommendations for children. Exploration of barriers to and facilitators of parental decisions to adopt obesity prevention recommendations will inform future efforts to reduce childhood obesity.
Methods
We conducted 4 focus groups (2 English, 2 Spanish) among a total of 19 parents of overweight (BMI ≥ 85th percentile) children aged 5-17 years. The main discussion focused on 7 common obesity prevention recommendations: reducing television (TV) watching, removing TV from child's bedroom, increasing physically active games, participating in community or school-based athletics, walking to school, walking more in general, and eating less fast food. Parents were asked to discuss what factors would make each recommendation more difficult (barriers) or easier (facilitators) to follow. Participants were also asked about the relative importance of economic (time and dollar costs/savings) barriers and facilitators if these were not brought into the discussion unprompted.
Results
Parents identified many barriers but few facilitators to adopting obesity prevention recommendations for their children. Members of all groups identified economic barriers (time and dollar costs) among a variety of pertinent barriers, although the discussion of dollar costs often required prompting. Parents cited other barriers including child preference, difficulty with changing habits, lack of information, lack of transportation, difficulty with monitoring child behavior, need for assistance from family members, parity with other family members, and neighborhood walking safety. Facilitators identified included access to physical activity programs, availability of alternatives to fast food and TV which are acceptable to the child, enlisting outside support, dietary information, involving the child, setting limits, making behavior changes gradually, and parental change in shopping behaviors and own eating behaviors.
Conclusions
Parents identify numerous barriers to adopting obesity prevention recommendations, most notably child and family preferences and resistance to change, but also economic barriers. Intervention programs should consider the context of family priorities and how to overcome barriers and make use of relevant facilitators during program development.
doi:10.1186/1471-2431-9-81
PMCID: PMC2806253  PMID: 20025769
5.  Parental obesity moderates the relationship between childhood appetitive traits and weight 
Obesity (Silver Spring, Md.)  2013;21(4):815-823.
This study examined the independent and combined associations between childhood appetitive traits and parental obesity on weight gain from 0 to 24 months and body mass index (BMI) z score at 24 months in a diverse community-based sample of dual parent families (n = 213). Participants were mothers who had recently completed a randomized trial of weight loss for overweight/obese post-partum women. As measures of childhood appetitive traits, mothers completed subscales of the Child Eating Behavior Questionnaire, including Desire to Drink (DD), Enjoyment of Food (EF), and Satiety Responsiveness (SR), and a 24-hour dietary recall for their child. Heights and weights were measured for all children and mothers and self-reported for mothers’ partners. The relationship between children’s appetitive traits and parental obesity on toddler weight gain and BMI z score were evaluated using multivariate linear regression models, controlling for a number of potential confounders. Having two obese parents was related to greater weight gain from birth to 24 months independent of childhood appetitive traits, and while significant associations were found between appetitive traits (DD and SR) and child BMI z score at 24 months, these associations were observed only among children who had two obese parents. When both parents were obese, increasing DD and decreasing SR was associated with a higher BMI z-score. The results highlight the importance of considering familial risk factors when examining the relationship between childhood appetitive traits on childhood obesity.
doi:10.1002/oby.20144
PMCID: PMC3671382  PMID: 23712985
Childhood eating behaviors; parental obesity; childhood obesity; prevention
6.  Childhood Overweight/Obesity and Pediatric Asthma: The Role of Parental Perception of Child Weight Status 
Nutrients  2013;5(9):3713-3729.
Childhood obesity and asthma are on the rise in the U.S. Clinical and epidemiological data suggest a link between the two, in which overweight and obese children are at higher risk for asthma. Prevention of childhood obesity is preferred over treatment, however, in order to be receptive to messages, parents must perceive that their child is overweight. Many parents do not accurately assess their child’s weight status. Herein, the relation between parental perceptions of child weight status, observed body mass index (BMI) percentiles, and a measure of child feeding practices were explored in the context of asthma, food allergy, or both. Out of the children with asthma or food allergy that were classified as overweight/obese by BMI percentiles, 93% were not perceived as overweight/obese by the parent. Mean scores for concern about child weight were higher in children with both asthma and food allergy than either condition alone, yet there were no significant differences among the groups in terms of pressure to eat and restrictive feeding practices. In summary, parents of children with asthma or food allergy were less likely to recognize their child’s overweight/obese status and their feeding practices did not differ from those without asthma and food allergy.
doi:10.3390/nu5093713
PMCID: PMC3798930  PMID: 24064571
childhood obesity; pediatric asthma; food allergy; parental perception
7.  The Relationship Between Child and Parent Food Hedonics and Parent and Child Food Group Intake in Overweight/Obese Children 
Many factors influence children’s dietary intake, including children’s and parents’ food hedonics (liking), and parent intake. This secondary data analysis studied the relationship between child and parent liking (CL and PL), and parent and child intake (PI and CI) of fruits (F), vegetables (V), low-fat dairy (LFD), snack foods (SF), and sweetened beverages (SB) in four- to nine-year-old overweight/obese (body mass index (BMI) ≥ 85th percentile) children presenting for obesity treatment (September 2005 to 2007) in Providence, RI. One-hundred thirty-five parent-child pairs, with complete baseline dietary (three-day food record) and food group hedonic data were included. Hedonic ratings were mean ratings using a five-point Likert scale (lower scores represented greater liking of a food group). Children were 7.2 ± 1.6 years, 63.0% female, 12.6% Black, 17.8% Hispanic, with a mean z-BMI of 2.3 ± 0.6. Total servings consumed by children over three days were: F: 2.7 ± 3.2; V: 3.4 ± 2.5; LFD: 2.4 ± 2.1; SF: 5.9 ± 4.2; SB: 2.7 ± 3.1. After demographic and anthropometric variables were controlled, PI was positively related (p < 0.05) to CI of all food groups except SB. CL was only significantly (p < 0.05) related to CI of V. In young overweight/obese children, PI was consistently related to CI. Changing PI may be important in aiding with changing young overweight/obese children’s dietary intake.
doi:10.1016/j.jada.2010.12.013
PMCID: PMC3058875  PMID: 21338743
Child obesity; parent dietary intake; child dietary intake; hedonics; food group
8.  Correlates of Parental Misperception of Their Child’s Weight Status: The ‘Be Active, Eat Right’ Study 
PLoS ONE  2014;9(2):e88931.
Objective
This study reported on correlates of parental perception of their child’s weight status. Associations between parental misperception (i.e., underestimation of the child’s weight) and parental intention to improve their child’s overweight-related health behaviors and their child meeting guidelines regarding these behaviors were also investigated.
Methods
Baseline data from the population-based ‘Be active, eat right study’ were used. The population for analysis consisted of 630 overweight and 153 obese five year-old children and their parents. Questionnaires were used to measure parental perception of the child’s weight status, correlates of misperception (i.e., child age, child gender, child BMI, parental age, parental gender, parental country of birth, parental educational level and parental weight status), overweight-related health behaviors (i.e., child playing outside, having breakfast, drinking sweet beverages, and watching TV), and parental intention to improve these behaviors. Height and weight were measured using standardized protocols. Multivariable logistic regression analyses were performed.
Results
In total, 44.40% of the parents misperceived their child’s weight status. Parental misperception was associated with lower child BMI, the parent being the father, a foreign parental country of birth, and a lower parental education level (p<0.05). Parental misperception was not associated with parental intention to improve child overweight-related health behavior, nor with child meeting the guidelines of these behaviors.
Discussion
This study showed that almost half of the parents with an overweight or obese child misperceived their child’s weight status. A correct parental perception may be a small stepping-stone in improving the health of overweight and obese children.
doi:10.1371/journal.pone.0088931
PMCID: PMC3925202  PMID: 24551191
9.  Improving healthy eating in families with a toddler at risk for overweight: A cluster randomized controlled trial 
Objective
To ascertain whether a parent education program based on Satter’s division of responsibility in feeding children (DOR) is effective in enhancing parent/child feeding interactions for children with an overweight/obese parent. The primary hypothesis was that the intervention would decrease parental pressure to eat.
Methods
Sixty-two families with a child aged 2–4 years with at least one overweight/obese parent were randomly allocated using a cluster design to either the DOR intervention or a control group. The control group focused on increasing family consumption of healthy foods and activity levels, and enhancing child sleep duration. The primary outcome was parent pressure on their child to eat.
Results
The DOR intervention was superior to the control group in reducing pressure to eat. Two moderators of pressure to eat were found: disinhibition of eating and hunger. DOR group parents irrespective of disinhibition levels lowered pressure to eat whereas control group parents with low disinhibition increased pressure to eat. There were similar findings for hunger. Gender moderated restrictive feeding with DOR parents lowering restriction more than the control group in girls only.
Conclusion
The DOR intervention was more effective in reducing parent pressure to eat and food restriction (in girls only) than the control group.
doi:10.1097/DBP.0b013e3182618e1f
PMCID: PMC3434962  PMID: 22947882
child feeding problems; pressure to eat; restrictive feeding; responsive feeding; Satter method
10.  Overweight children habituate slower than non-overweight children to food 
Physiology & behavior  2007;91(2-3):250-254.
We have shown that physiological and behavioral responses habituate to food stimuli and recover when novel stimuli are presented. In addition, physiological responses in obese adults habituate slower to repeated food stimuli than non-obese individuals, which is related to greater energy intake. The purpose of this study was to test the hypothesis that instrumental responding in overweight children habituates slower to food cues than in their non-overweight peers. Children were provided the opportunity to work for access to cheeseburger for 10 2-min trials, followed by French fries for 3 2-min trials. Results showed that children who had a body mass index (BMI) at or above the 85th BMI percentile (at risk for overweight; n = 17) habituated slower than those with a BMI percentile less than the 85th BMI percentile (non-overweight; n = 17). Response recovery to French fries did not differ between groups. Overweight children consumed significantly more grams of food and more energy than non-overweight children. When taken together, these data show that habituation may be an important individual difference characteristic that differentiates overweight from non-overweight children. Implications of this for prevention and treatment of obesity are discussed.
doi:10.1016/j.physbeh.2007.03.009
PMCID: PMC1963489  PMID: 17459429
Habituation; obesity; children; operant responding; body mass index
11.  The prevalence of obesity and the level of adherence to the Korean Dietary Action Guides in Korean preschool children 
Nutrition Research and Practice  2013;7(3):207-215.
The objective of this study was to investigate the associations between the prevalence of overweight and obesity and the degree of adherence to the Korean Dietary Action Guides for Children (KDAGC). In a cross-sectional study based on a child care center-based survey in Seoul, Korea, we collected parental-reported questionnaires (n = 2,038) on children's weight and height, frequency of fruit and vegetable consumption, and the quality of dietary and activity behaviors based on the 2009 KDAGC Adherence Index (KDAGCAI) which was developed as a composite measure of adherence to the KDAGC. Overweight and obesity were determined according to age- and sex-specific BMI percentile from the 2007 Korean national growth chart. Associations were assessed with generalized linear models and polytomous logistic regression models. Approximately 17.6% of Korean preschool children were classified as overweight or obese. Obese preschoolers had lower adherence to the KDAGCAI compared to those with lean/normal weight. Preschoolers with a high quality of dietary and activity behaviors had a 51% decreased odds ratio (OR) of being obese (highest vs. lowest tertile of KDAGCAI-score, 95% CI 0.31, 0.78; P = 0.001); the associations were more pronounced among those who were older (P = 0.048) and lived in lower income households (P = 0.014). A greater frequency of vegetable consumption, but not fruit, was associated with a borderline significant reduction in the prevalence of obesity. Our findings support the association between obesity prevention and high compliance with the Korean national dietary and activity guideline among preschool children.
doi:10.4162/nrp.2013.7.3.207
PMCID: PMC3679330  PMID: 23766882
Preschool children; obesity; dietary guideline
12.  Healthy for Now? A Cross-Sectional Study of the Comorbidities in Obese Preschool Children in the United States 
Clinical pediatrics  2010;49(7):648-655.
Objective
Examine health of preschoolers by BMI status.
Methods
A cross-sectional analysis of children 3 to 5 years old in the 1999–2008 National Health and Nutrition Examination Survey was carried out. The measured age- and sex-specific BMI percentiles were used to categorize children as very obese, obese, overweight, or healthy weight. The authors used logistic regression to examine the effect of weight status on 17 available measures of current child health potentially related to obesity.
Results
Except for very obese children, weight status had minimal effect on most measures of health for preschool-aged children (n = 2792). Parents of very obese children reported poorer general health and more activity limitations for their children. Additionally, very obese girls had more frequent/severe headaches, and overweight/obese boys had more asthma diagnoses.
Conclusions
Only severe obesity appears consistently related to immediate health problems in preschool-aged children. Parental perception that very obese children have worse health and more activity limitations may lead to decreases in physical activity, which would perpetuate obesity.
doi:10.1177/0009922810362098
PMCID: PMC2911579  PMID: 20308197
cross-sectional design; comorbidities; obesity; overweight; BMI; preschool children
13.  Associations between child weight and maternal feeding styles are mediated by maternal perceptions and concerns 
Objective
To determine whether controlling parental feeding practices are associated with children’s adiposity and test the hypothesis that any associations are mediated by maternal perception of their child’s weight.
Method
Children aged 7-9 yrs (n=405) were weighed and measured at school as part of the Physical Exercise and Appetite in CHildren Study (PEACHES). Adiposity was indexed with BMI SD-scores. The Child Feeding Questionnaire (CFQ) was completed by 53% of mothers of participating children (n=213). Mothers reported whether they thought their child was overweight, normal weight or underweight, and rated their concern about future overweight on a 5-point scale.
Results
Higher child adiposity was associated with lower ‘pressure to eat’ and higher ‘restriction’ scores. Restriction increased linearly with maternal concern about overweight, and maternal concern about overweight fully mediated the association between child adiposity and restriction. Use of pressure increased as mothers perceived their child to be thinner, but perceived weight did not mediate the association between child weight status and maternal pressure to eat. Monitoring was not associated with child adiposity, maternal perception of weight or concern about overweight.
Conclusion
Restriction appears to be a consequence of mothers’ concern about their child becoming overweight rather than a cause of children’s weight gain. Pressure may be a more complex response that is influenced by the desire to encourage consumption of healthy foods as well as ensure adequate energy intake and appropriate weight gain.
doi:10.1038/ejcn.2009.146
PMCID: PMC2875105  PMID: 20087383
BMI; feeding; concern; adiposity; parents
14.  Parental Misperception of Their Child's Body Weight Status Impedes the Assessment of the Child's Lifestyle Behaviors 
Objectives. To examine if distinct characteristics are associated with parental misclassification of underweight (UW), normal weight (NW), and overweight or obese (OWOB) children and the implications of misclassification on the parental evaluation of the child's lifestyle habits. Methods. Cross-sectional analysis (2004 sample) of the Quebec Longitudinal Study of Child Development (1998–2010) (n = 1,125). Results. 16%, 55%, and 77% of NW, UW and OWOB children were perceived inaccurately, respectively. Misperception was significantly higher in nonimmigrant parents of UW children, in highly educated parents of NW children and in NW and OWOB children with lower BMI percentiles. Erroneous body weight status identification impedes the evaluation of eating habits of all children as well as physical activity and fitness levels of UW and OWOB children. Conclusion. Parental misclassification of the child's body weight status and lifestyle habits constitutes an unfavorable context for healthy body weight management.
doi:10.1155/2010/306703
PMCID: PMC2939384  PMID: 20862382
15.  Energy and macronutrient intakes in preschool children in urban areas of Ho Chi Minh City, Vietnam 
BMC Pediatrics  2008;8:44.
Background
An increasing prevalence of overweight and obesity has been documented in preschool children in Ho Chi Minh City (HCMC), Vietnam. However, little is known about what preschool children in HCMC eat or how well their nutrient intake meets nutrient recommendations. This study aims to describe the energy and macronutrient intake and compare these nutrient intakes with the recommendations for Vietnamese children aged four to five years.
Methods
The data comes from the baseline measurement of a one year follow-up study on obesity in 670 children attending kindergartens in HCMC. Dietary information for each child at the school and home settings was collected using Food Frequency Questionnaires (FFQs), by interviewing teachers and parents or main caregivers. The average energy and nutrient intake in a day was calculated. The proportion of children with energy intake from macronutrients meeting or exceeding the recommendations was estimated based on the 2006 recommended daily allowance (RDA) for Vietnamese children in this age group.
Results
The dietary intake of the participants contained more energy from protein and fat, particularly animal protein and fat, and less energy from carbohydrates, than the RDA. Most children (98.1%) had mean energy intake from protein greater than the recommended level of 15%, and no child obtained energy from animal fat that was in accordance with the recommendation of less than 30% of the total fat intake. Nearly one half of children (46.5%) consumed less than the advised range of mean energy intake from carbohydrate (60%–70%).
Conclusion
In this preschool child population in HCMC, in which obesity is emerging as major public health problem, there is an imbalance in dietary intake. Healthy eating programs need to be developed as a part of an obesity prevention program for young children in HCMC.
doi:10.1186/1471-2431-8-44
PMCID: PMC2575195  PMID: 18928562
16.  Factors associated with parental recognition of a child's overweight status - a cross sectional study 
BMC Public Health  2011;11:665.
Background
Very few studies have evaluated the association between a child's lifestyle factors and their parent's ability to recognise the overweight status of their offspring. The aim of this study was to analyze the factors associated with a parent's ability to recognise their own offspring's overweight status.
Methods
125 overweight children out of all 1,278 school beginners in Northern Finland were enrolled.
Weight and height were measured in health care clinics. Overweight status was defined by BMI according to internationally accepted criteria. A questionnaire to be filled in by parents was delivered by the school nurses. The parents were asked to evaluate their offspring's weight status. The child's eating habits and physical activity patterns were also enquired about. Factor groups of food and physical activity habits were formed by factor analysis. Binary logistic regression was performed using all variables associated with recognition of overweight status in univariate analyses. The significant risk factors in the final model are reported using odds ratios (ORs) and their 95% confidence intervals (CIs).
Results
Fifty-seven percent (69/120) of the parents of the overweight children considered their child as normal weight. Child's BMI was positively associated with parental recognition of overweight (OR 3.59, CI 1.8 to 7.0). Overweight boys were less likely to be recognised than overweight girls (OR 0.14, CI 0.033 to 0.58). Child's healthy diet (OR 0.22, CI 0.091 to 0.54) and high physical activity (OR 0.29, CI 0.11 to 0.79) were inversely related to parental recognition of overweight status.
Conclusions
Child's healthy eating habits and physical activity are inversely related to parental recognition of their offspring's overweight. These should be taken into account when planning prevention and treatment strategies for childhood obesity.
doi:10.1186/1471-2458-11-665
PMCID: PMC3173349  PMID: 21864365
overweight status; children; recognition; parents
17.  Population-Based Childhood Overweight Prevention: Outcomes of the ‘Be Active, Eat Right’ Study 
PLoS ONE  2013;8(5):e65376.
Objective
An overweight prevention protocol was used in the ‘Be active, eat right’ study; parents of overweight children (5 years) were offered healthy lifestyle counseling by youth health care professionals. Effects of the protocol on child BMI and waist circumference at age 7 years were evaluated.
Methods
A cluster RCT was conducted among nine youth health care centers in the Netherlands. Parents of overweight, not obese, children received lifestyle counseling and motivational interviewing according to the overweight prevention protocol in the intervention condition (n = 349) and usual care in the control condition (n = 288). Measurements were made of child height, weight and waist circumference at baseline and at a two-year follow-up; parents completed questionnaires regarding demographic characteristics. Linear mixed models were applied; interaction terms were explored.
Results
The analyzed population consisted of 38.1% boys; mean age 5.7 [sd: 0.4] years; mean BMI 18.1 [sd: 0.6], the median number of counseling sessions in the intervention condition was 2. The regression model showed no significant difference in BMI increase between the research conditions at follow-up (beta −0.16; 95% CI:−0.60 to 0.27; p = 0.463). There was a significant interaction between baseline BMI and research condition; children with a baseline BMI of 17.25 and 17.50 had a smaller increase in BMI at follow-up when allocated to the intervention condition compared to control condition (estimated adjusted mean difference −0.67 [se: 0.30] and −0.52 [se: 0.36]).
Conclusion
Mildly overweight children (baseline BMI 17.25 and 17.50) in the intervention condition showed a significantly smaller increase in BMI at follow-up compared to the control condition; there was no overall difference between intervention and control condition. Future research may explore and evaluate improvements of the prevention protocol.
Trial Registration
Current Controlled Trials ISRCTN04965410
doi:10.1371/journal.pone.0065376
PMCID: PMC3669240  PMID: 23741491
18.  The irony of a rich country: issues of financial access to and availability of healthy food in the Republic of Ireland 
Objective
To determine the weekly financial cost of a diet as recommended by national policy in two parents with two children, single parents with one child and single old people with low income, and begin to identify, in a rich country context, variation in food item availability, price and household purchasing capacity.
Design
Food baskets were developed based on national dietary recommendations and purchasing patterns of these household groups. National‐level prices of each food were identified, as well as pricing across a representative selection of Irish retail outlet types. Basket costs were assessed relative to the financial capacity of household type.
Results
The types of retail outlets in which low‐income groups tend to shop do not carry many own brand items and is less likely to stock healthy options, but when they do, they are more expensive than in other outlets. Single parents with one child, two adults with two children and single older people would have to spend 80%, 69% and 38%, respectively, of their weekly household income to purchase the food basket based on economy‐line products.
Conclusions
Financial access to and availability of healthy food options must be considered through a national policy cognisant of basic human needs for healthy living. This research provides evidence on the direct costs of healthy eating for policy and planning to ensure not only financial capacity but also to guarantee that affordable healthy food choices are physically available to all groups in society.
doi:10.1136/jech.2005.041335
PMCID: PMC2465517  PMID: 17108295
19.  A family-based intervention targeting parents of preschool children with overweight and obesity: conceptual framework and study design of LOOPS- Lund overweight and obesity preschool study 
BMC Public Health  2012;12:879.
Background
As the rate of overweight among children is rising there is a need for evidence-based research that will clarify what the best interventional strategies to normalize weight development are. The overall aim of the Lund Overweight and Obesity Preschool Study (LOOPS) is to evaluate if a family-based intervention, targeting parents of preschool children with overweight and obesity, has a long-term positive effect on weight development of the children. The hypothesis is that preschool children with overweight and obesity, whose parents participate in a one-year intervention, both at completion of the one-year intervention and at long term follow up (2-, 3- and 5-years) will have reduced their BMI-for-age z-score.
Methods/Design
The study is a randomized controlled trial, including overweight (n=160) and obese (n=80) children 4-6-years-old. The intervention is targeting the parents, who get general information about nutrition and exercise recommendations through a website and are invited to participate in a group intervention with the purpose of supporting them to accomplish preferred lifestyle changes, both in the short and long term. To evaluate the effect of various supports, the parents are randomized to different interventions with the main focus of: 1) supporting the parents in limit setting by emphasizing the importance of positive interactions between parents and children and 2) influencing the patterns of daily activities to induce alterations of everyday life that will lead to healthier lifestyle. The primary outcome variable, child BMI-for-age z-score will be measured at referral, inclusion, after 6 months, at the end of intervention and at 2-, 3- and 5-years post intervention. Secondary outcome variables, measured at inclusion and at the end of intervention, are child activity pattern, eating habits and biochemical markers as well as parent BMI, exercise habits, perception of health, experience of parenthood and level of parental stress.
Discussion
The LOOPS project will provide valuable information on how to build effective interventions to influence an unhealthy weight development to prevent the negative long-term effects of childhood obesity.
Trial registration
ClinicalTrials.gov NCT00916318
doi:10.1186/1471-2458-12-879
PMCID: PMC3538526  PMID: 23072247
Overweight; Obesity; Preschool; Child; Parent; Intervention study
20.  Away-from-home food intake and risk for obesity: Examining the influence of context 
Obesity (Silver Spring, Md.)  2008;16(5):1002-1008.
Objective
This study examined socio-demographic and cultural determinants of away-from-home food consumption in two contexts and the influence of frequency of away-from-home food consumption on children’s dietary intake and parent and child weight status.
Research Methods and Procedures
Parents of children (N=708) in grades K-2 were recruited from 13 elementary schools in Southern California. Parents were asked through a questionnaire the frequency with which they eat meals away from home and the restaurant they frequented most often. The height and weight of the parents and their children were measured to calculate body mass index (BMI).
Results
Consuming foods at least once a week from relatives/neighbors/friends [RNF] homes was associated with children’s dietary intake and children’s risk for obesity. For example, children of parents with weekly or greater RNF food consumption drank more sugar sweetened beverages. Parents of families who ate at restaurants at least weekly reported that their children consumed more sugar sweetened beverages, more sweet/savory snacks and less water compared with families who did not frequent restaurants this often. The type of restaurant visited did not impact diet intake or obesity. More acculturated families exhibited less healthy dietary behaviors than less acculturated families.
Discussion
Restaurants remain an important setting for preventing child and adult obesity, but other settings outside the home need to be considered in future intervention research. This may especially involve eating in the homes of relatives, neighbors and friends.
doi:10.1038/oby.2008.34
PMCID: PMC3758884  PMID: 18309297
Children; eating behaviors; family behavior; Hispanics; weight
21.  Perceived and desired weight, weight related eating and exercising behaviours, and advice received from parents among thin, overweight, obese or normal weight Australian children and adolescents 
Background
Thin children are less muscular, weaker, less active, and have lower performance in measures of physical fitness than their normal weight peers. Thin children are also more frequently subjected to teasing and stigmatization. Little is known about thin children's weight perceptions, desired weight and attitudes and behaviours towards food and exercise. The study aimed to compare perceived weight status, desired weight, eating and exercise behaviours and advice received from parents among thin, overweight, obese or normal weight Australian children and adolescents.
Methods
The sample included 8550 school children aged 6 to 18 years selected from every state and territory of Australia. The children were weighed, measured and classified as thin, normal, overweight or obese using international standards. The main outcome measures were perceived and desired weight, weight related eating and exercising behaviours, and advice received from parents.
Results
The distribution of weight status was - thin 4.4%; normal weight 70.7%; overweight 18.3%; and obese 6.6%. Thin children were significantly shorter than normal weight, overweight or obese children and they were also more likely to report regularly consuming meals and snacks. 57.4% of thin children, 83.1% of normal weight children, 63.7% of overweight and 38.3% of obese children perceived their weight as "about right". Of the thin children, 53.9% wanted to be heavier, 36.2% wanted to stay the same weight, and 9.8% wanted to weigh less. Thin children were significantly less likely than obese children to respond positively to statements such as "I am trying to get fitter" or "I need to get more exercise." Parents were significantly less likely to recommend exercise for thin children compared with other weight groups.
Conclusions
Thin children, as well as those who are overweight or obese, are less likely than normal weight children to consider their weight "about right'. Thin children differ from children of other weights in that thin children are less likely to desire to get fitter or be encouraged to exercise. Both extremes of the spectrum of weight, from underweight to obese, may have serious health consequences for the individuals, as well as for public health policy. Health and wellness programs that promote positive social experiences and encourage exercise should include children of all sizes.
doi:10.1186/1479-5868-8-68
PMCID: PMC3132157  PMID: 21703026
22.  Supporting parents of preschool children in adopting a healthy lifestyle 
BMC Nursing  2012;11:12.
Background
Childhood obesity is a public health epidemic. In Canada 21.5% of children aged 2–5 are overweight, with psychological and physical consequences for the child and economic consequences for society. Parents often do not view their children as overweight. One way to prevent overweight is to adopt a healthy lifestyle (HL). Nurses with direct access to young families could assess overweight and support parents in adopting HL. But what is the best way to support them if they do not view their child as overweight? A better understanding of parents’ representation of children’s overweight might guide the development of solutions tailored to their needs.
Methods/design
This study uses an action research design, a participatory approach mobilizing all stakeholders around a problem to be solved. The general objective is to identify, with nurses working with families, ways to promote HL among parents of preschoolers. Specific objectives are to: 1) describe the prevalence of overweight in preschoolers at vaccination time; 2) describe the representation of overweight and HL, as reported by preschoolers’ parents; 3) explore the views of nurses working with young families regarding possible solutions that could become a clinical tool to promote HL; and 4) try to identify a direction concerning the proposed strategies that could be used by nurses working with this population. First, an epidemiological study will be conducted in vaccination clinics: 288 4–5-year-olds will be weighed and measured. Next, semi-structured interviews will be conducted with 20 parents to describe their representation of HL and their child’s weight. Based on the results from these two steps, by means of a focus group nurses will identify possible strategies to the problem. Finally, focus groups of parents, then nurses and finally experts will give their opinions of these strategies in order to find a direction for these strategies. Descriptive and correlational statistical analyses will be done on the quantitative survey data using SPSS. Qualitative data will be analyzed using Huberman and Miles’ (2003) approach. NVivo will be used for the analysis and data management.
Discussion
The anticipated benefits of this rigorous approach will be to identify and develop potential intervention strategies in partnership with preschoolers’ parents and produce a clinical tool reflecting the views of parents and nurses working with preschoolers’ parents.
doi:10.1186/1472-6955-11-12
PMCID: PMC3489519  PMID: 22852762
Overweight; Childhood; Preschool; Parental opinion; Health promotion; Action research
23.  The ALADINO Study: A National Study of Prevalence of Overweight and Obesity in Spanish Children in 2011 
BioMed Research International  2013;2013:163687.
The aim of the study was to determine the prevalence of overweight and obesity in children in Spain using different sets of cut-off criteria, through a community-based cross-sectional study. The study was conducted in a representative sample of Spanish children between 6 and 9 years, recruited in Spanish schools, between October 2010 and May 2011. 7,569 boys and girls were selected. All were weighed and measured, and their parents were asked about their socioeconomic background, food habits and physical activity. The BMI of each was calculated, and the prevalence of overweight and obesity was determined by age and sex using Spanish reference tables (SPART), IOTF reference values, and WHO growth standards. The prevalence of overweight in boys ranged from 14.1% to 26.7%, and in girls from 13.8% to 25.7%, depending on the cut-off criteria. The prevalence of obesity in boys ranged from 11.0% to 20.9%, and in girls from 11.2% to 15.5%. The prevalence of obesity was the highest among those same children when using the SPART or WHO criteria. Overweight and obesity remain widespreading among Spanish children; a consensus on the definition of overweight and obesity cut-off criteria is necessary.
doi:10.1155/2013/163687
PMCID: PMC3780583  PMID: 24089663
24.  Maternal BMI and migration status as predictors of childhood obesity in Mexico 
Objective
To assess the association of maternal migration to Baja California, body mass index (BMI) status, children’s perceived food insecurity, and childhood lifestyle behaviors with overweight (BMI > 85% ile), obesity (BMI > 95% ile) and abdominal obesity (Waist Circumference > 90% ile).
Methods
Convenience sampling methods were used to recruit a cross-sectional sample of 4th, 5th and 6th grade children and their parents at Tijuana and Tecate Public Schools. Children‘s and parents’ weights and heights were measured. Children were considered to have migrant parents if parents were not born in Baja California.
Results
One hundred and twenty-two children and their parents were recruited. The mean age of the children was 10.1 ± 1.0 years. Forty nine per cent of children were overweight or obese. Children with obese parents (BMI > 30) had greater odds of being obese, Odds Ratio (OR) 4.9 (95% Confidence Interval (CI), 1.2–19, p = 0.03). Children with migrant parents had greater odds of being obese, OR= 3.7 (95% CI, 1.6–8.3), p = 0.01) and of having abdominal obesity, OR = 3.2 (95% CI, 1.4–7.1, p = 0.01). Children from migrant parents have greater risk of higher consumption of potato chips, OR = 8.0 (95% CI, 2.1–29.1, p = 0.01). Children from non-migrant parents had greater odds of being at risk of hunger.
Conclusions
Parental obesity and migration are associated with increased risk of obesity among Mexican children. Children whose parents were born in Baja California have greater odds of being at risk of hunger. Further studies should evaluate the role of migration on risk for childhood obesity.
PMCID: PMC3139543  PMID: 21519746
Childhood; Obesity; Migratio; Food intake; Hunger
25.  Parental perceptions of weight status in children: the Gateshead Millennium Study 
Objectives
To investigate parents’ perceptions of weight status in children and to explore parental understanding of and attitudes to childhood overweight.
Design
Questionnaires and focus groups within a longitudinal study.
Subjects
536 parents of Gateshead Millennium Study children, of which 27 attended 6 focus groups.
Main outcome measures
Parents’ perception of their child’s weight status according to actual weight status as defined by International Obesity Taskforce (IOTF) cut-offs. Focus group outcomes included parental awareness of childhood overweight nationally and parental approaches to identifying overweight children.
Results
The sensitivity of parents recognising if their child was overweight was 0.31. Prevalence of child overweight was underestimated: 7.3% of children were perceived as ‘overweight’ or ‘very overweight’ by their parents, 23.7% were identified as overweight or obese using IOTF criteria. 69.3% of parents of overweight or obese children identified their child as being of ‘normal’ weight. During focus groups parents demonstrated an awareness of childhood overweight being a problem nationally but their understanding of how it is defined was limited. Parents used alternative approaches to objective measures when identifying overweight in children such as visual assessments and comparisons with other children. Such approaches relied heavily on extreme and exceptional cases as a reference point. The apparent lack of relevance of childhood overweight to their child’s school or own community along with scepticism towards both media messages and clinical measures commonly emerged as grounds for failing to engage with the issue at a personal level.
Conclusion
Parents’ ability to identify when their child was overweight according to standard criteria was limited. Parents did not understand, use or trust clinical measures and used alternative approaches primarily reliant on extreme cases. Such approaches underpinned their reasoning for remaining detached from the issue. This study highlights the need to identify methods of improving parental recognition of and engagement with the problem of childhood overweight.
doi:10.1038/ijo.2011.106
PMCID: PMC3154641  PMID: 21673651
Qualitative Research; Parents; Child; Perception; Overweight; Obesity

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